Profile analysis of managers of Basic Health Units in Criciúma Análise do perfil de gestores de Unidades Básicas de Saúde de Criciúma

This paper aimed to analyze the profile of managers of Basic Health Units in Criciúma. This is a descriptive, qualitative and quantitative study. After approval by the Research Ethics Committee (CEP), data collection was developed through a semi-structured questionnaire and focus group from April to June 2016 with 84 participants. Information from the National Register of Health Facilities subsidized the construction of the profile of managers and the qualitative analysis of the municipality of Criciúma in the light of the national panorama. In Brazil, there are managers in 6% of establishments in general and in 13% of the Units. In Criciúma, 1% of the facilities and 2% of the Units. The results of the managers’ profiles show that they have an average of 30,5 years, 76% are women, with a nursing education, having an average of 3 years in the public service, 0,7 years in average as the manager of the current unit. Regarding the education level, 74% are post-graduated, 32% said they have already done or are doing some postgraduation. The profile of the managers of the Units of Criciúma coincides with that presented in the literature. The complexity of the health sector requires powerful management approaches, extra-sectoral resources and interaction of the various actors involved in the situation.


Introduction
This article aims at bringing to light a subject that is not valued in Primary Care (PC), which is the profile, as well as the characteristics and distribution of the manager of the Basic Health Unit (BHU). The motivation for the study is due to the perception that this professional can enhance or hinder the development of health actions and services in PC.
From the twentieth century, organizations become complex, and systematic studies on management contribute to the development of their own field of knowledge. The analysis of managerial work shows a correspondence between its improvement and the evolution of the market and organizations, whether public or private 1 .
Especially after the 1988 Constitution and the creation of the Unified Health System (SUS), there was a process of decentralization of health services to the municipalities, which started to perform mostly the services of PC. When assuming the planning, management and services, the municipalities required the performance of a progressively larger number of health managers in their staff 2 .
In the organization model of health services in Brazil, PC has developed with increasing complexity in its conformation and increased financing. In addition to family health teams, a priority model for the organization of Brazilian PHC, new and specific models of professional teams and performance have been increasing their resoluteness. These professionals work in the community and at the user's home, but their main place of work is BHU.
The analysis of the profile and distribution of BHU managers was anchored to authors who discuss the planning and strategic management of health services 3-7 .
For Motta 3 , managerial work differs from other technical and administrative activities in which functional attributions are likely to receive clear definitions, generating routine behaviors. For the author, a rough definition for management can be described as the art of thinking, deciding and acting, making it happen, and achieving results in constant human interaction.
At the BHU, the work is based on the complexity and interdependence of its members. For Rivera 4 and Artmann 5 , the following are characteristics of these organizations: primacy of the operational center that encompasses a large number of independent, highly specialized units that recognize a differentiated environment; preponderance of the relational with work coordination through mutual adjustment that presupposes spontaneous and informal relationships between those responsible and the standardization of the professions; weakness of the technostructure with weak interference power over the operational core; importance of logistics due to the expansion of typically medical logistics means and absence of rigid hierarchy, with management having no capacity or competence to direct workers directly, acting indirectly through the technostructure. For Mintzberg 6 , managers play important roles of aggregating information for the above managers and feedback to improve the performance of the units in which they operate. Thus, these flow up the problems, difficulties, proposals for change and decisions that require prior authorization; and down to the resources, rules, and plans to be adopted, and they often make decisions in accordance with the authority granted them. For André 7 , the BHU manager bridges the gap between care and management, needing both skills to be recognized by colleagues as an effective manager, to dialogue with professionals, and eventually, in specific situations, to be able to act even with your professional knowledge. Thus, it concludes that the ideal training profile for the basic unit manager would be one with academic education in health sciences and specific training in health service management.

Material and methods
This is a case study, descriptive, of quantitative and qualitative approach 8 . Official data and research on BHU managers in Brazil were used, as well as public information analysis, such as the assessment of PC in Santa Catarina 2006, from the National Register of Health Facilities (CNES), from the PHC Census conducted in 2012 and the National Program for Access and Quality Improvement in Primary Care (PMAQ-AB), conducted in 2012 and 2014 by the Ministry of Health, which presents data from the Criciúma units discussed in conjunction with state and national data. All information is public and available on publicly accessible websites.
The analysis were compared with the results found in national and international databases by searching the Virtual Health Library (VHL), Latin American and Caribbean Health Sciences Literature (Lilacs), Medline, Scopus and Web of Science, using Mesh and Desh descriptors as keywords: gestor, gestão and saúde, avaliação de competência, atenção básica, atenção primária, health manager, administrative personnel, primary healthcare, primary care, primary health care, and health center.
After authorization by the Municipal Secretary of Health, coordinator of the PC, municipal ethics committee and the Sergio Arouca National School of Public Health, opinion 1.417.075, contact was made with the municipal secretary of health, the coordinator of PC and the managers of the Criciúma Health Districts, to invite them to participate in the research and authorize the researcher to contact the managers of BHU, also inviting them to participate. This research did not receive any financial support.
To define the profile of the Criciúma BHU managers, a questionnaire with 19 open and closed self-assessment questions, with a friendly interface, was produced according to the guidelines proposed by Gil 8 . For the comparability purpose with the research carried out in 2007 by the Ministry of Health and the Santa Catarina State Department of Health, the same questions were reproduced in the questionnaire plus those pertinent to the research.
The managers were invited to sign the Informed Consent Form and to respond to the printed questionnaire that made it possible to draw the profile of this manager. Data were collected during April and June 2016. The focus group members were selected through the analysis of the questionnaires, the criteria were criticality and completion of the open questions of the semi-structured questionnaire. Thirty-four BHU managers from the city of Criciúma participated in the research, totaling 71% of the total managers. The focus group consisted of 14 participants from all health districts of Criciuma. Statistical analysis was performed with simple frequency, and the narrative production of the Focal Group subsidized the qualitative analysis.

Profile of the BHU managers
There are no objective national data concerning the number of BHU managers operating in Brazil Data from the municipality of Criciúma, from December 2016, show that there are 534 health facilities. Of these, 48 are BHU. Regarding managers of health facilities in Criciúma, there are records of 3 people as administrative managers and 2 people as managers of health services, in a total of 5 records. This means that for 534 health facilities there are 5 manager records, totaling 1% of managers per facility, assuming that all facilities have only one manager.
In relation to the BHU, there are 48 of them, 1 administrative manager and no health services manager, totaling 1 manager, which corresponds to 2% of establishments with managers.
Based on Criciúma data, where BHU managers are not registered with CNES as managers, but as nurses, other than a single case in which the unit manager is not a nurse, it is assumed that this same reality may occur in other municipalities of Brazil. This can be explained by the fact that the professional, as in the case of Criciuma, does not act exclusively as a manager, but also as the nurse of the health team. Compared with the state of Santa Catarina and Brazil, the municipality of Criciúma has a lower percentage of managers of basic units (2%) than the state of Santa Catarina (4.4%) and Brazil (13.5%). This can be explained, among other factors, by the organization of PC services in the state of Santa Catarina and Criciúma, where health units predominated with only one family health team, in which the nurse usually assumes the role of manager.
Another secondary data source that can help to understand the management of BHU in Brazil is the assessment of PMAQ-AB, which was articulated, since January 2011, within the framework of a set of PC development policies in Brazil, such as infrastructure of BHU, computerization, provision of professionals, among others. The first PMAQ-AB assessment cycle took place in 2011, and more than 17,000 PC teams participated in the Country. The second cycle, which began in 2013, involved more than 30 thousand 10 .
The data provided by the second cycle of PMAQ-AB, in which the external evaluation (data collection directly at the BHU) took place in 2014, bring some information that supports the discussions about the BHU manager. This is because there were no direct questions related to the BHU manager in PMAQ-AB, just some approximations.
The survey conducted in 2008 by the Ministry of Health, in partnership with some states of Brazil, in which the state of Santa Catarina participated in the collection and organization of the research in which some questions directly related to the BHU manager were present. There are no published data available by municipality, only state and health region. Thus, we present data from the State of Santa Catarina and from the Carboniferous region, where Criciúma is located 11 .

Profile of the BHU managers
Regarding the question, if there is a professional exclusively hired for the managerial function at BHU, the state results were that only 12.4% of BHU have this professional. In the Carboniferous region, no unit surveyed had an exclusive manager. The following questions were asked only for managers acting exclusively in the managerial role. Thus, the data presented refer to the whole state, since the Carboniferous region has no exclusive manager for the management of the BHU.
Regarding education, 58% of managers have a higher education degree; 18%, technical degree; 26%, secondary education; and 2%, primary education. Among those with a college degree, 61% have a postgraduate degree. For 48% of the exclusive managers, the selection was by public tender, and 51% have a statutory contract. Asked if they have already taken or are taking a course in planning and management, 42% reported yes; and 58%, no 11 .
The results of managers' profiles show that they have an average of 30.5 years, ranging from 24 to 45 years. Women account for 76%, they are practically all nurses, except one manager who has a degree in aeronautics, they have an average of 3 years in the public service, with a minimum of 3 months and a maximum of 14 years as a manager and 0.7 years on average, in addition to a minimum of 3 months and a maximum of 6 years as manager of the current unit.
This characteristic of BHU managers in Criciúma can be seen in the statements collected during the focus group:  This measure forced the mayor of Criciúma to send to public tender all the professionals and dismiss the old ones, a difficult process for the whole city and that brought, among other consequences, a whole new network, as can also be observed in the speeches of managers during the focus group: That's why they have to invest, because they will be there tomorrow, later, then they will be in a work routine, so we will continue, we have to continue in ten, 15  According to André and Ciampole 13 , BHU managers unprepared to assume their role, as observed, are an important critical node of the public service, as they provide discrepancies in the leadership needed to conduct change processes and implement health policies, leading to maintenance of projects that need to be overcome. Building competencies for BHU is still an individual project of some managers, without conduction by the federal, state and municipal government.
Ximenes Neto and Sampaio 14 , evaluating the continuing education spaces offered to the managers of family health teams, note that of the 28 managers interviewed, 27 did not receive any training at the time of appointment, and even regarding the qualifications that the manager has experienced, there is the absolute predominance of continuing education activities, focused on care practice, and not on management. For Santric' Milicevic et al. 15 , in a case study in Serbia, training for health facility managers showed that it was possible, through training, to reduce the skills gap.
Mintzberg 16 , in his book 'Managing: unraveling the day to day management', reflects that a few decades ago asked managers what happened on the day they became managers, and they say 'nothing'. Generally, managers do not receive training or mentoring, having to learn the art of management on their own.
In relation to the selection of the manager of the basic unit in Criciúma, it was found that, when asking the form of this selection, 47% answered that it was by public tender, and 53% reported that it was in other ways. Among the most reported are the automatic, by imposition and the public tender for nurses.
In the municipality of Criciúma the managers of basic units are necessarily nurses of the family health team or traditional PC, so there is no selection or alternative to the nurse not taking office.
For Hill 17 and Loch 1 , the odyssey of individual contributor to manager is, often, difficult, filled with horror stories about careers that have failed. Even though they are excellent individual contributors, some workers never successfully adjust to managerial work and managerial responsibilities. Top-notch management is a very stressful activity, full of conflict; and for those who fail to do so, the costs are high. For André and Ciampone 13 , the rise to managerial position should be due to meritorious evaluation, not political indication, friendship or trust.
Regarding the exercise of unit management to be exclusively by nurses in Criciúma, the positions differ in the focus group: In the research developed by Hill 17 , the subordinates evaluated as essential the importance of the manager to be someone with technical education in the area that is managing and deep knowledge of the work process. Mintzberg 6 , when discussing the power of the administrator/manager in professional bureaucracies, states that due to the nature of the highly specialized and autonomous professional nucleus, there is a collective search for control over the managerial decisions that affect them and the demand that these administrators be empowered by the governing bodies they represent and which are preferably elected by such bodies.
In assessing the managers of a medical work cooperative, Roquete 18 concludes that, for managers, knowledge of the profession is fundamental to support their work with the professional class and users. For Elina et al. 19 , managers who are doctors have difficulty inserting themselves in management activities, being closely linked to clinical knowledge and acting more as consultants than as managers. According to the same author, primary care physicians can better play the role of managers.
It is observed that in studies that bring the profile of managers of BHU, there is a predominance of nursing, but there is no exclusivity. In Brazil, the nurse's role in management is very significant, unlike other countries, where nurses have a greater role in care, care with chronic and palliative diseases. According to Carvalho et al. 20 , the important contribution of nursing in the management of PHC points to its commitment to individuals and communities, administrative capacity and to satisfactorily relate to other members of the multiprofessional team.
However, it is also related to its outstanding position in favor of order fulfillment and maintaining the status quo. For Ximenes Neto and Sampaio 14 , the BHU manager position should not be centered on nursing professionals and women, but rather on the individual and collective competencies necessary for good management, based on the analysis of the professional profile of team members.
In the present research, when asked if the manager receives any bonus to act as such, 97% answered that they do not receive any bonus, only one manager said that he receives a bonus of R$ 500,00 from PMAQ-AB. Regarding the name given to their position, 70% said they are called managers, 9% coordinator, and 21% administrator.
During the focus group, the specific issue of whether or not to gain financial gratification for exercising BHU management became a controversial topic: André and Ciampone 13 point to the need to value the managerial development of the manager, and Ximenes Neto and Sampaio 14 report that the complexity of the management of PC services needs social and financial recognition by the municipal management. In the author's research in Sobral (CE), the gratification that managers received was negligible and incompatible with the position and responsibilities.
Regarding the organization of work, the managers evaluated in this study reported that 82% work 40 hours per week, 9% work 30 hours and 1 manager work 44 hours per week.
Regarding workers under their responsibility, there is an average of 10 workers and 5.915 people assisted to each manager.
In the focus group, a divergence was explicit regarding the need for a professional exclusively to act as manager of BHU: It is good to have one manager and one in care, because the work will work much better, well qualified, will be able to give more assistance to the patient, to work more in prevention, [...]. (G14). About the exclusivity of work as a manager of BHU, Ximenes Neto and Sampaio 14 propose in their research that, in territories where epidemiological and social indicators are more critical, with dense list of socio-sanitary needs and high population, that managers are exclusive for managerial activity.
McConnell 21 , examining the balance between two careers, specialist and manager, that health professionals can take on, finds that there are major difficulties for professionals in keeping the two careers in parallel; that the expert's knowledge does not automatically enable him to be a good manager, since management has its own body of knowledge and disciplines, and that some professionals, when taking over management, for lack of training as a manager, are very uncomfortable in their role.
Some findings of this study, such as: a) the preponderance of females among the coordinators; b) predominance of nurses in management, except for two publications in which doctors predominate; c) have a higher education degree, d) more than 60% with graduate degree studies; e) up to 5 years in the position of manager; f ) less than 45 years old and less than 50% have a postgraduate degree in management; are also corroborated by other research 13,14,20,22-28 .

Final considerations
The BHU in Brazil form a health services network that regularly serves more than 150 million Brazilians and has the capillarity of being present in all municipalities of the Country, in a ratio of 1 basic unit for every 5 thousand people. The scope of services offered by the basic units has been sophisticated and complex, with the performance of other professional teams, in addition to family health teams or basic health teams.
This process of aggregation of services by the basic units and recognition of BHU as the preferential door, ordering and organizing health services generates a set of political, organizational and articulation demands that require the need for a manager of these services, present in everyday life of the unit. For this manager to be successful in the management activities of the BHU, he/she needs to have a set of competencies focused on health services management.
National, state and municipal data from the BHU manager point to two possibilities: either most health facilities do not have managers, or these managers are not correctly registered in the information system. It is noteworthy that the registration of the health facility manager or BHU is not mandatory nor linked to any type of financial incentive by the federated entities. This demonstrates the need to stimulate or create specific policies so that we have the correct information about these managers and their professional profile.
The results of the Criciúma managers' profiles conclude that they are young women and nurses. This result is supported by the literature and is related to the high turnover of these professionals in health services and, in particular, in the municipality of Criciúma, with the recent competition in which health workers, especially from PC, previously hired on a precarious basis, were replaced by tenderers.
Despite having a significant percentage of managers holding a graduate degree, during the focus group, in the speeches, it was evident the lack of preparation on the part of the managers to act according to the function, which can be explained by the distance and fragility of the postgraduate courses in relation to the practice of health services and the lack of training in services in the places where managers operate. This finding is supported by the literature, as the books and articles repeatedly cited bring this difficulty on the part of managers.
Regarding the form of selection for the position, they reported that it was imposed, since they are nurses, work in care and management and do not receive any kind of financial reward for the role of manager. These findings are corroborated by what is present in the literature and demonstrate little recognition of the manager's role, as the choice is not related to the profile and competences nor is there any financial return for this specific assignment.
The constitution of national, state or municipal policies aimed at valuing and consolidating the management of BHU is proposed. This includes the institutionalization of the position of manager of BHU in municipal administrative structures, financial incentive for the exercise of manager assignment, workload reserve for management activities and units with the largest number of teams, exclusivity of the professional for the position of manager, selection of professionals according to the management profile for the manager position.
It is recommended that the Ministry of Health, the Secretariats of State and Municipalities, as well as the Universities, can offer specialization and qualification courses aimed at the development of the necessary competences for the managers of BHU. However, it is necessary that the content and format of these training courses be adequate in order to prepare managers for the creative confrontation of the problems related to the management of BHU. A first concept to be addressed is the very notion of planning as a calculation that precedes and presides over everyday action. This broadening beyond calculation incorporates management aspects, organizational aspects and an emphasis on conjuncture planning and the constant updating of the plan/actions/activities. Well-prepared and strategically supported institutional support teams at the Municipal Health Departments to which BHU managers are linked can also contribute to solving the concrete cases found in the services, promoting continuing education, reflection and broadening the scope of competencies of BHU managers.
The complexity of health work, which requires coping with problems for which there is no previously known or normative solution, imposes powerful management approaches and managers' ability to articulate, in a sector in which problems must always be addressed in their multiple dimensions -political, economic, social, cultural etc. -and in its multi-sectoriality, because its causes are not limited to the interior of a specific sector or area and its solution often depends on extra-sectoral resources and the interaction of the various actors involved in the situation.

Collaborators
Henrique F (0000-0002-6363-6730)*, Artmann E (0000-0002-8690-5964)* also contributed to the conception and design of the article, to analysis and interpretation of the data and in to writing and final revision of the text. Lima JC (0000-0001-9132-1253)* contributed to the writing and final revision of the article. s *Orcid (Open Researcher and Contributor ID).