ESTRATÉGIA SAÚDE DA FAMÍLIA MEETINGS : AN INDISPENSABLE TOOL FOR LOCAL PLANNING

Objective: to demonstrate the structure, functioning and contributions of the Estratégia Saúde da Família work meetings regarding local health planning. Method: a single case study with five integrated units of analysis, represented by the coordinator of the Health Centre and four Estratégia Saúde da Família teams. Data collection was performed through semi-structured interviews, non-participant observation and documentary research from October to December 2014. Data were triangulated, organized with MaxQDA®Plus software, and analyzed according to the explanatory construction technique. Results: three analytical categories were identified: Structure and functioning of the Estratégia Saúde da Família work meetings; Participation of professionals in the Estratégia Saúde da Família work meetings for local planning; Processes that contribute to local health planning. Conclusion: work meetings are essential for the construction of local health planning. They provide professional integration through discussions, and facilitate decision-making and information exchange. DESCRIPTORS: Primary health care. Family health strategy. Health planning. Nursing. Health management.


INTRODUCTION
Primary Health Care (PHC) is defined as the gateway to the health system and the user´s first point of contact with the health system.It includes a set of actions in the individual and collective scope, understanding the person as a singular being, inserted in a sociocultural context. 1 PHC is guided by the principles of universality, accessibility, connection, longitudinality, integrality of care, co-responsibility, humanization, equity and social participation.] The health actions of PHC are focused on the democratic practices and participatory care and management, and directed at populations of defined territories which assume sanitary responsibility.Considering this set of actions, PHC in Brazil is carried out by Estratégia Saúde da Família (Family Health Strategy -FHS) teams, which provide integral and continuous actions with families and their physical and social environment.Its actions are aimed at health promotion and disease prevention, as well as the treatment and rehabilitation of health issues. 3he FHS teams consist of a physician, nurse, nurse auxiliary or nurse technician and a community health agent.Focused on establishing a link between professionals and the community, these teams occupy strategic places, bringing health care closer to the citizen. 1,4rom a managerial point of view, the FHS team identifies adverse situations and/or needs of the community, and promotes the local planning process and planning of strategic actions in order to promote positive changes in the given reality.] Thus, local health planning is performed based on the demands and needs of the population, but also those directly evidenced by health professionals.8] In addition, local planning is an integral part of something systemic that involves the entire institution, considered an important part of the instrumentalization of institutional planning.
At a local level, planning is used as an administrative tool that offers the possibility to program actions that involve reasoning, reflection and analysis of the actors involved in the process.] Regarding this process, it is fundamental to favor expression, communication and agreement between different actors and interests, with a view to sharing their experiences and knowledge in search of solving problems and creating new strategies that contribute to the accomplishment of local planning. 6mong the main scenarios of the activities performed at the local level, work meetings are important tools for structuring and organizing planning, information exchange, establishment of guidelines and decision-making. 9he meetings can be defined as opportunities for dialogue, in which it is possible to elaborate care plans for each individual and each family, clearly defining the actions and those responsible.0] In addition, meetings contribute to the readjustment of the work process, based on available data and information.

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Regular team meetings for joint discussion on the planning, monitoring and evaluation of health actions are attributed to professionals working in the FSH teams, defined by national and local regulations.
In the city of Florianópolis, Santa Catarina, the place of this study, the prefecture regulated a period of two hours per week, for each FSH team, for action planning meetings, work process organization, case discussion and permanent education.In addition, each Health Center (HC) has four-hour monthly time slots for joint planning meetings with all professionals from all FSH teams.The coordinator must disclose the date and time of the monthly meeting to the public in advance, and provide information on another nearby health center in cases of spontaneous demand as well as information regarding the provision of basic services such as vaccination, medication delivery, dressings, among others. 11dopting the theoretical proposition that the periodic meetings of the FHS significantly contribute to the local health planning process, this study sought to answer the following research question: How do The Family Health Strategy work meetings contribute to local health planning?Based on the above, the objective was to highlight the structure, functioning and contributions of the Family Health Strategy work meetings to local health planning.

METHOD
A qualitative single case study with five integrated units of analysis, qualitative approach HC are represented by the coordinator of the studied HC and four FSH teams.
This study was developed in a HC in the municipality of Florianópolis, Santa Catarina, which has four teams for a region with 16,705 inhabitants.It has 58 permanent professionals and a traveling staff from the Núcleo de Apoio à Saúde da Família (Family Health Support Center -FHSC), including the following professional categories in these two groups: doctors, nurses, nursing technicians, dentists, community health agents, psychologists, nutritionists, pharmacists, physiotherapist, and speech therapist.This HC was intentionally selected, based on information provided by the Municipal Health Department and the analysis of reports on the management of health plans, goals and public policies.According to the municipal managers, the site is a reference location due to the monthly monitoring of the planning indicators which are developed annually, with good results in PHC.
In this study, the five integrated units of analysis included the participation of ten professionals working in the FHS, including nurses, doctors and dental surgeons.Higher education was used as a criterion of participant inclusion, since the competences for management and administration of health services, leadership, communication and decision making are contained in the national guidelines regarding the education of these professionals.
Triangulation was used in data collection by means of semi-structured interview, non-participant observation and documentary research.The semi-structured interviews were performed in October 2014, recorded on a digital medium and transcribed at later time; each interview had an average duration of 30 minutes.The non-participant observations were carried out in four weekly team meetings, one per FHS team, with an average duration of two hours each meeting and in a monthly general meeting, with an average duration of four hours during the months of October and November 2014.The documentary research was performed through reading and systematization of the contents of the minutes of the monthly general meetings, from January 2014 to January 2015, made available by the coordination of the Health Center.
The MaxQDA®plus software was used for data processing and organization.The analysis was developed using the explanatory construction technique, which explained the structure and processes related to the case. 12

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The construction of the explanation is a special type of standard combination, with the purpose of analysing the data by constructing an explanation about the case, thus developing the proposed propositions and the ideas for future studies.The essential element of explanation is to explain the phenomenon under study, to stipulate the causal links of "how" and "why" things happen.The final explanation is the result of a series of interactions. 12he study complied with the recommendations of Resolution 466/2012 of the National Health Council on research involving human beings.This study is part of research project which was funded by the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).

RESULTS
Three analytical categories emerged through the combination of codes extracted from the participants' statements: Structure and functioning of the FHS work meetings; Participation of professionals in the FHS work meetings for local planning; and Processes that contribute to local health planning.

Structure and functioning of Family Health Strategy work meetings
The HC's monthly general meetings are used to accompany the annual planning, they are planned at the beginning of each year, and show the different stages of this planning, the main schedules of the meetings and the registers of the discussions.The general meetings take place monthly in the HC, and last for four hours, alternating between the morning and afternoon periods each month.During this period, the service is closed to the population.At each beginning of the year, the dates for these meetings are established and each month, posters are put up inside the CS, informing the date and time of the meeting in order for the users of the HC to schedule their appointments before or after the meeting.
The most frequently discussed topics in a general meeting are the planning stages of the HC, which involve the definition, monitoring and evaluation of actions, as well as user embracement, and scheduling of appointments and consultations.However, the extraordinary agendas involve topics that are rarely addressed in ordinary meetings, eventualities and specific problems identified by professionals.The educational agenda includes health education topics, chosen among professionals, due to needs or difficulties presented on a certain subject.Professional training is also included in this list, which is administered by professionals from the Sanitary District.The administrative agendas are usually raised by the coordinator and involve issues relating to the organization and management of the unit, such as records in the time sheets, strikes and assemblies, employee health plans, vacations and recess.
In the agenda pre-established by the coordinator, in agreement with the professionals, the needs of the debate and the main problems that occur in the place at that moment are identified.However, such agendas are flexible and new topics are often added to the meeting according to demand or questions presented by professionals.
The weekly FSH team meetings are related to the planning meetings of the specific activities of each team, and the performance of different stages, such as identification of the problems, decision making for action programming, monitoring and evaluation of activities.
The weekly team meetings last for two hours, and are on different days of the week.In the four FSH teams working in this HC, the meetings are coordinated either by a nurse or a doctor.In some situations, if the discussion is specific to a particular subject, such as the Programa Saúde na Escola (Health School Program -HSP), the professional responsible for the program leads the discussion.At that moment, professionals who work in teams such as doctors, nurses, nursing technicians, 6/14 community health agents and dental surgeons participate.In addition, FHSC professionals, nursing residents, social workers, nutritionists and psychologists also participate.They report that the opinions of community agents are very important because of their greater proximity to the community.The participation of nursing technicians is more restricted due to the small number of these professionals and the greater difficulty in scheduling meetings.
The teams perform an area diagnosis to identify the needs and priorities to be discussed at meetings.The teams occasionally used a checklist, which included discussion points in order to guide the meetings.The weekly team meeting agenda cover issues such as monitoring markers of coverage areas, case discussing, defining actions such as active searches and home visits.Administrative matters related to vacations and professional recess are also discussed.They discuss and organize themselves in order to adjust the work of the area for those periods.
During the period when permanent education activities were carried out more frequently, these meetings were used as opportunities for improvement, however due to the lack of time and high demand, this is no longer a reality.At each meeting, topics were chosen according to the needs of the team, all the professionals studied the theme and participated in the discussion.They always sought to include community agents at these times, aiming to achieve adequate communication with the community.
The teams establish priorities according to the high number of agendas.The priority actions are discussed among the professionals and some criteria are adopted.The first criterion is the clinical condition of the people, clinical evaluation of the case that needs to be immediately resolved.Actions that involve the main markers of the area, pregnant women, hypertensive and diabetic users are also priorities.
Weekly team meetings are always recorded in a minute book.Each team has their own book.In most teams, there is no fixed writer; alternation occurs at each meeting, according to those that are pronounced or according to an already established order.The book is written in by hand and all information about the meetings is recorded including: date, participants, agendas, planned activities, activity leaders, execution time and goals/objectives.At the end, all the participants sign the meeting minutes which are filed in the coordination room and can be consulted at any time.

Participation of professionals in the work meetings for local planning
At the general meeting, led by the HC coordinator, the following professionals from the FSH teams are involved: doctors, nurses, nursing technicians, dental surgeons and community agents; as well as FHSC professionals such as social workers, pharmacists, nutritionists, psychologists, geriatricians and paediatricians.There is also collaboration from residents of the Multiprofessional Residency program of The Prefecture of Florianópolis, undergraduate students who carry out their training in the HC, administrative technicians and, when necessary, professionals from the Sanitary District Centre.The only employees who do not attend the meeting are the cleaning professionals who take advantage of this moment to perform a general cleaning of the unit.
The professionals discuss the problems identified in the day-to-day routine during the meetings.In general, the same professional who initiated the discussion offers possible solutions to the problem and organizes the discussion.The professionals keep a monthly record of the meetings.
The interviewed coordinator confirmed that the objective is for everyone to participate and contribute with opinions and suggestions regarding planning.In some meetings, conflicts and disagreements among professionals have occurred during collective decision-making.In such cases, there is a need for the unit coordinator to intervene and, in doing so, seek to take into account the opinions and evaluate the best option for both the user and the worker.

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The interviewed professionals mentioned that, in addition to general monthly meetings and weekly team meetings, it is necessary to attend shorter meetings, usually at the end of the day, with specific groups of professionals in order to solve specific problems.These meetings do not always have a pre-set time and date to take place.They depend on the available time of each professional and the urgency to solve the problem.

Processes that contribute to local health planning
The annual planning of the unit is among the processes that contribute to local health planning.This is drawn up during the first meetings of the year and is consulted during all monthly meetings.According to the reports, the planning of the unit involves all the professionals, which demands the participation and contribution of each one in the general planning.The annual general planning is based on an instrument used by the Municipal Health Department.This instrument is completed at the general meeting.First, the self-assessment is completed and then the unit chooses the standards/ objectives that will be worked on during the year and, afterwards, the goals and objectives are defined.Based on these goals, the professionals develop actions and strategies, as well as electing responsible members for each.The action plan is performed in the unit and is monitored during the monthly meetings throughout the year.The results of finalized actions are also evaluated in monthly meeting.
The coordinator prepares a spreadsheet with the planned actions and discusses what is in progress, how the action is going, if it was not possible to execute, what the obstacles are, and how to improve the action.This monitoring is mainly performed by the coordinator and the leaders of the actions.If the action has already been completed, the evaluation of the results will occur.An evaluation of the annual planning is always performed at the beginning and the end of the year.Often, what was not performed during the year ends up being transferred to the following year.
Team decisions taken at meetings consist of more timely decisions regarding the need for home visits, cases of social vulnerability, the organization of doctors ' and nurses' agendas, and defining group visits.They are decisions related to the teams, which do not have to go through the large groups (general meetings) and that can be defined in each team, according to the needs and characteristics presented by the coverage areas In particular, Doctors and nurses identify needs during individual consultations and group activities and take them to meetings along with data and information, for example, user charts, indicator/ marker tables.The community agents bring the requests, doubts and complaints of the community and individuals to the meetings which are collected in their daily activities with families and active searches of specific cases.
Based on these problems, the diagnosis of the situation of the area is made.As part of the planning stages, the teams go beyond the identification of problems, through the use of information and the definition of actions and activities, information from weekly meetings in order to monitor the activities that are in progress and to evaluate the completed activities.
The monitoring of the actions is carried out by the nurses.At the end of a particular action, practitioners seek to make quicker and simpler assessments, different from the more detailed and complex annual planning assessments of the unit.
The other process that contributes to local planning is active searches, which are among the main actions organised by professionals in weekly team planning.In general, while monitoring the markers, the nurse or the doctor identifies absentees, delayed vaccinations, undelivered exam results, among others.These cases are discussed with community agents in order to identify whether these users still reside in the community.
Agents actively search for these users and seek to reconnect them to the service.In addition to the active searches, the home visit is another action that is among the most included in the planning 8/14 during team meetings.When professionals identify that there are users who are not able to come to the CS due to physical constraints and require health care, home visits are scheduled by professionals so that care can be provided to these people.

DISCUSSION
In order to carry out the work of the FHS teams, it is necessary to join and integrate different health professionals together. 13Multiprofessional teams are considered fundamental for the development of joint actions in which all workers are involved, and that each professional acts according to their level of competence, in order to carry out work that addresses the complexities and health problems of individuals and the community.] The findings of this study showed that the meetings are dedicated times for the planning and organization of health care actions.During the meetings there are opportunities for professionals to exchange information and to clarify any possible doubts.Both general monthly meetings and weekly team meetings are important places for multi-professional dialogue.They offer the opportunity to promote the integration of active categories in order to make more assertive decisions for unit and team planning.
Meetings can be considered as planning tools, i.e., they are mechanisms aimed at obtaining a certain objective.On these occasions, the professionals exchange information for the purpose of decision making and relate, despite singular characteristics and specificities, as actors from different contexts.Thus, meetings are important places for the effective construction of work, as they favor the discussion of cases, the expression of opinions and interdisciplinary dialogue. 15he practice of routine meetings helps to verify the progress of actions, to remind professionals of their tasks and responsibilities, to discuss ways to deal with difficulties, to define changes that need to be implemented, and to agree on new action strategies to confront the current problems.They allow a readjustment of the actions to achieve the objectives sought in the annual planning of the HC, making participation and collective contribution fundamental.A study performed in Rio de Janeiro (Brazil) regarding teamwork at the FHS, showed that professionals recognize the work of others and share objectives, which results in a more communicative and cooperative practice in a network model of conversations. 16owever, the meetings can be long and drawn out, and can create conflicts and disagreements regarding decisions.A study carried out in Rio Grande do Sul (Brazil) 15 revealed that it is common for professionals to complain about tiring meetings, difficulties regarding decision-making, considering them a waste of time.In addition, complaints about disagreements can be characteristic of failed and unsuccessful meetings. 15oexistence among several professionals, with their characteristics and singularities, can result in conflicting points of view, since their perceptions will not always be convergent.Conflicts are conscious phenomena that, in organizational life, constitute observable or covert noises. 17The conflicts generated due to the different opinions are processes inherent to human nature, with their existence being a question of recognition and confrontation, revealing professional maturity, especially for the resolution of situations that may compromise the effectiveness of the service.
The findings of this study revealed that the weekly team meetings are mainly used for the discussion and matricial practices of clinical, community or territorial cases.The monthly general meetings are held for the planning, organization and follow-up of annual actions involving the entire health unit.
The theme of reception is frequently found in the agendas of team meeting agendas This is because user reception is one of the practices that involves dialogue, posture and reorganization of 9/14 health services.A study carried out with managers, health professionals and users in Florianópolis revealed that, from the perspective of good practices, user embracement becomes a point of intersection between different subjects and practices of care in PHC, unfolding in the dimensions of reception and dialogue, reception-positioning and reception-reorganization of services. 18he perception of good practices is directly related to the context and interactions established by managers, health professionals and users, who elaborate their positions based on their experiences and positions in health services. 3s a general rule, the most used markers in local action planning are those said to be priorities, such as pregnant women, children, hypertensives and diabetics.Routine use of these markers is confirmed as they offer the FSH team information on frequently monitored groups, through monthly visits, as well as by responding to the majority of the population seeking the CS. 19he records of all meetings are held in the minute books, key documents that preserve the decisions and agreements made between professionals.They are also instruments that evaluate and monitor the progress of the planned actions, as well as giving support to professionals in situations of doubts or when they have questions regarding the decisions taken at the meetings.Not all teams read or use the minutes.One study revealed resistance and lack of professional interest regarding their use.The professionals investigated in the study believed that the minutes were only valid for people absent from the meeting, as a way for them to be aware of the decisions and events that occurred. 15oubts and questions about decisions made during meetings cannot depend on the memory of professionals alone.The book is used to avoid gaps and unnecessary friction.
Both monthly general meetings and weekly teams meeting contain permanent health education activities.It is possible that there may be a lack of encouragement regarding the development of educational initiatives for workers.To this end, it is necessary to articulate the areas of education and health, which are based both on health actions, as well as on the organization and management of health services and training institutions. 20he accomplishment of a diagnosis of the area allows the identification of needs and priorities to be discussed at a later time, facilitating the planning of the activities, the prioritization of the problems and optimizing the meeting time.This diagnosis would be fully effective if the difficulties regarding provision and updating on health indicators and markers of the population were overcome.Outdated information causes the system to be less reliable to support planning.A study that analyzed the use of indicators of the Sistema de Informação da Atenção Básica (Primary Care Information System -PCIS) in the planning of local health actions showed that these indicators are restricted and limited, and that it is necessary to use other data sources to supplement health information.In addition, it would be useful to create a regionalized instrument that could adequately meet the unique requirements of the community. 19he community diagnosis is a tool which supports the construction of planning and programming of local actions, representing the technology needed to organize the work of multiprofessional teams.It gives teams opportunities to reflect on daily routine and the reality of the service, seeking to establish priorities, guidelines and observe factors that limit action development.This diagnosis is based on data and factors that demonstrate the problems and needs presented by the community.
There are several strategies for its construction and among them is the use of health information systems. 5,192] Despite the recognized importance of PCIS, a study showed that the applicability of PCIS was restricted to completing the files and reports for monthly production delivery, which is not always used by the team. 23In the studied municipality, a study identified that the although PCIS is limited, it has been used in conjunction with other instruments and data sources to complement and further investigate data that this system does contain/cover. 19

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The interviewees consider that the number of workers in the HC problematic, as it increases the work demands and causes difficulties related to holding weekly meetings with the entire team.In this HC, the lack of professionals is due to internal rotation, professionals constantly change the work unit within the municipality itself.
In this study, it was identified that adverse factors, such as the lack of professionals in the HC and the difficulties of the community agents in relation to the use of technologies, result in the information system becoming a failed action.Thus, the data and information used for planning are not always up to date and may cause uncoordinated and inconsistent organization in relation to community priorities.
must consider the importance of human resources for good work performance in PHC and that precarious employment relationships are considered hugely problematic for the satisfactory performance of health actions.As well as harming the longitudinal work of the FSH teams, professional turnover also requires more public resources for the training and hiring of new professionals. 24The high turnover rate has a direct relationship with the quality of filling in the SIAB records, not only due to the assimilation of the collection routine, but also due to the difficulty the professionals have in relation to completing the records, familiarity with the printed documents, and the need for computing knowledge.It is necessary that professionals are familiar with the program in its entirety, so that they can adequately fill out the files in order to produce and analyse the report .25In this particular HC, the professionals use an instrument adapted from the Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB).This program is one of the SUS management strategies which aims to increase the population's access to primary health care and improve the quality of care provided in these services.It involves the monitoring and evaluation of the infrastructure of basic health units, equipment, the availability of medicines and citizen satisfaction.] Community health workers were considered key actors for team meetings, because in addition to their closeness and attachment, they identify community problems and contribute to the discussions.In a study performed in São Paulo (Brazil), the agents reported the meetings as beneficial strategies for the construction of interpersonal relations between them and the health team.In addition, they considered such meetings as opportunities to alleviate concerns and to address their doubts. 28imilarly, in Rio de Janeiro (Brazil), a study showed that meetings can have two paths: facilitate interaction among professionals and enable the dialogue and information exchange between team members and simultaneously be a polarized moment, a concentration of power that tends to hinder collective participation. 29t is important to remember that, in order for meetings to happen with co-responsibility and organization, it is necessary to horizontalize the work process of the teams.

CONCLUSION
This study evidenced the structure, functioning and contributions of the FSH work meetings regarding local health planning, revealing that such meetings are important moments in health care planning.Professionals organize themselves to attend monthly general meetings and weekly team meetings.The monthly general meetings are moments of collective participation, in which the main topic discussed is the annual planning of the HC, as well as the stages of monitoring and evaluation of the activities previously planned at the beginning of each year.The weekly meetings count on the participation of only the professionals who work in each FSH team and are configured as moments 11/14 for the discussion of cases and matricial practices.They are reserved for solving problems related mainly to the user and their social environment, promoting planning that is more focused on the characteristics and needs presented by the population of each coverage area.
It should be emphasized that work meetings should be held in a democratic manner and with collective participation.It was observed that in the accomplishment of these meetings, there are professional categories that stand out due to the organization and leadership and that the lack of adequate quantitative professionals negatively influences points that guide the meetings, such as the data input and information used in planning.Finally, it should be noted that the meetings held in this establishment are in accordance with the duties of the professionals of the FSH defined in the municipal and national scope, and the recommendations of the National Primary Health Care Policy.