Repercussions of the Covid-19 pandemic on referral services for viral hepatitis care

Abstract

Study carried out with the objective of analyzing the repercussions of the Covid 19 pandemic on reference services for viral hepatitides in the state of Mato Grosso from the perspective of managers and health professionals. This is an evaluative research with a descriptive approach of qualitative data through semi-structured interviews. The thematic analysis resulted in two categories: “Covid-19 pandemic and weaknesses in viral hepatitis care” and “Management challenges in viral hepatitis care aggravated by the pandemic”. The study found difficulties in organizing and implementing care strategies during the pandemic due to the reduction in the state administrative service, in addition to the absence of guidelines to perform the services and limitation in the number of professionals; also, due to the need for relocation to face the Covid 19 pandemic. Management challenges include prioritizing strategic actions in order to increase testing and provide access to reference services. The turnover of managers and the number of professionals have repercussions on coping with hepatitides. It is necessary to organize the care network with the objective of advancing actions and services that allow faster responses in care flows.

Keywords:
Human viral hepatitides; Health services; Pandemic; Health systems; Health assistance; Health management

Resumo

Estudo com objetivo de analisar, segundo a perspectiva de gestores e profissionais de saúde, as repercussões da pandemia por Covid-19 para os serviços de referência às hepatites virais no estado de Mato Grosso. Trata-se de pesquisa avaliativa, em abordagem descritiva de dados qualitativos, coletados por meio de entrevistas semiestruturada. A análise temática resultou em duas categorias: “Pandemia de Covid-19 e fragilidades na atenção às hepatites virais” e “Desafios da gestão na atenção às hepatites virais agravados pela pandemia”. Constatou-se dificuldades de organização e implementação de estratégias para favorecer o cuidado, durante a pandemia, por ter redução no serviço administrativo na gestão estadual, ausência de diretrizes para os serviços e limitação no quantitativo de profissional, além da necessidade de remanejamento para atendimento a Covid-19. Os desafios postos pela gestão incluem a prioridade de ações estratégicas para aumentar a testagem e oportunizar acesso aos serviços de referência. Entretanto, a rotatividade de gestores e quantitativo de profissionais repercute no enfrentamento às hepatites. A organização da rede de atenção precisa avançar na governança das ações e serviços e em rearranjos organizacionais capazes de permitir respostas mais rápidas nos fluxos da atenção.

Palavras-chave:
Hepatite viral humana; Serviços de saúde; Pandemia; Sistemas de saúde; Assistência à saúde; Gestão em saúde.

Introduction

In the health system, the uncertainty of defining flows and actions requires quick and timely direction from the management to guide the coordination of care and minimize possible barriers that directly affect access to health services and the commitment of health problems of the users.

In addition to the attention paid to the Covid-19 pandemic, which required extensive resources of different natures, the health sector was faced with the discontinuity of campaigns and actions for the detection of several injuries, partial or total interruption of treatments for other diseases already recurrent in the health system, such as chronic non-communicable diseases (CNCD) and communicable diseases (BRASIL, 2020a).

The discontinuity of care in services that meet demands for sexual health, in countries that have social vulnerability, in the pandemic, has had a negative impact (HALL et al., 2020), a situation that worsens access to services and the living conditions of these people. Studies (BASHH, 2020; JEWELL et al., 2020) present the impact resulting from the pandemic on the attention to the human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). In particular, with regard to HIV treatment, more than seventy countries have expressed a risk of lack of antiretrovirals (OPAS, 2020a).

The Pan American Health Organization (PAHO) recommended that essential services for the prevention and treatment of viral hepatitides maintained actions during the pandemic (OPAS, 2020b), since hepatitides are among the diseases with the highest morbidity and mortality in the world (STANAWAY et al., 2016) and have become a public health problem whose epidemiological, diagnostic and therapeutic peculiarities, especially in vulnerable populations, require the adoption of strategies for coping and continuity of care.

In Brazil, in relation to HIV testing, according to the Department of Chronic Diseases and Sexually Transmitted Infections (DCCI), Ministry of Health (MH), there was a reduction in prevention actions, in addition to the concern of specialists with the interruption of the continuous treatment of STI (THERRIL, 2020). Regarding viral hepatitides, the DCCI published a note that refers to a guarantee of supply of medicines until the first quarter of 2021 (MH, 2020).

The impact of the Covid-19 pandemic on health systems and the need to maintain essential services, considered a priority, including services for the prevention and treatment of communicable diseases, sexual and reproductive health care, care for vulnerable populations (OPAS, 2020c) with guidance on adapting the workforce for the detection, prevention and treatment of other diseases (OPAS, 2020d), the weaknesses of strategic actions in the fight against viral hepatitides, justified this investigation. In this sense, this study aimed to analyze, from the perspective of managers and health professionals, the repercussions of the Covid-19 pandemic for reference services for viral hepatitides in the state of Mato Grosso.

Method

This is an evaluative research (ARREAZA; MORAES, 2010), descriptive and with qualitative data, extracted from the doctoral thesis "Evaluation of access to viral hepatitis care services in the state of Mato Grosso-MT" (GLERIANO, 2021). It was developed in the state of Mato Grosso, which is the third largest state in the country in territorial extension, a situation that affects geographical issues for mobility, distribution of health services, including limitations on access (GLERIANO et al., 2021). Regarding the federative units of Brazil, the state of Mato Grosso occupies the sixteenth position in the incidence of hepatitis A cases, the twelfth for hepatitis B and D and the thirteenth for hepatitis C (BRASIL, 2020b).

The state of Mato Grosso is divided into six macro-regions and 16 Health Regions (HR), and its choice is justified by the characteristics of decentralization of management and the regionalization process (SES, 2012; GLERIANO et al., 2021), of geographical and demographic issues and the condition of the distribution of services that may limit access. To select the HR to be studied, in the first four months of 2020, in consultation with the data from the National Registry of Health Establishments (CNES), the reference services for viral hepatitis care distributed in the six macro-regions and 16 HR in the state were mapped. For the selection of the region, the one with the highest number and heterogeneity of reference services was taken into account, namely, the Testing and Counseling Center (TCC) and/or the Specialized Assistance Service (SAS), understood as the capacity to offer actions and services. The southern region of Mato Grosso, which is also a health macro-region, met the selection criteria; it is noteworthy that this HR has the highest population density.

This HR has seven services for attention to viral hepatitides, six participated in the study. The exception was the service for the population deprived of freedom, which is in the penitentiary, whose conditions of organization of care require a specific approach to the flow and provision of resources (BRASIL, 2014).

Participants were responsible for managing the viral hepatitides area of the Mato Grosso State Health Secretariat (SHS); also the professionals responsible for the reference services and/or health professionals indicated by the former, with the justification that the health professionals had been caring for patients with viral hepatitides for a considerable time. It is noteworthy that the intentional inclusion of these participants is justified because they have an activity articulated/integrated with state management, whose responsibility includes aspects related to the organization of the system and health services to enable access and care - therefore, they are considered key informants. The inclusion criterion was to be, for at least six months, developing the function in the service and, the exclusion criterion was professionals absent from the service for any reason.

Participants were contacted via email and phone call in June and July 2020, and were invited to participate in the survey. After formalizing the acceptance by email and sending the Informed Consent Form (ICF) signed, the interview was scheduled on a date, digital platform (WhatsApp, Google Meet or Zoom) and time indicated by the participant.

For data collection, an interview was used, guided by a semi-structured script, composed of two parts: one related to professional characterization and the other requesting that the interviewees, based on situations experienced in their daily management, report experience on positive and negative aspects, limitations and potentialities, the organization and articulation of services and the access of users to viral hepatitis care services. The script was submitted to face validation and pre-testing.

The interviews lasted a mean of 50 minutes, and were carried out by the researcher in charge, during the months of August and September 2020. The material was transcribed by the researcher, identified by the letter P (indicative of participant) and by the Arabic numeral, according to the increasing chronological order of the interviews, in order to preserve anonymity.

The data were systematized and content analysis in its thematic aspect was used for analysis (MINAYO; ASSIS; SOUZA, 2010). Among the general weaknesses and challenges, the current situation of the Covid-19 pandemic strongly emerged, which justified the particularized look. Thus, the corpus of the analysis was organized into two categories: Covid-19 Pandemic and weaknesses in the attention to viral hepatitides and Management challenges in the attention to viral hepatitides aggravated by the pandemic.

This study was approved by the Research Ethics Committee (REC) CAAE: 01481918.0.0000.5393 and co-participant institution CAAE: 01481918.0.3001.5164.

Results and Discussion

Of the eleven invited to participate in the research, nine technical professionals from the state management of the SHS and the reference services participated, with a higher frequency of females, seven (77.7%); hired by the statutory regime, seven (77.7%), four (44.4%) nurses. The time of experience in management/technical responsibility varied between one year and ten years.

Covid-19 pandemic and weaknesses in viral hepatitis care

This category groups meaning cores related to the difficulties of organizing and implementing strategies to favor care during the pandemic, especially in prevention and monitoring actions. These aspects refer to the fragmentation of care, including the limitation in the number of personnel who deploy in different functions to enable actions in reference services and in support of the demand forwarded by Primary Health Care (PHC) to these services, as can be seen in the following statements:

It needs at this time of quick articulation of support to the manager, because the problem bursts in the municipality, now with another demand, that of Covid. It is different to face the pandemic in a municipality that has infrastructure or that can get a place to refer. The manager has to answer for the assistance, especially in an election year, if he does not have the vacancy, this will not be easy, it is worrying, so the urgent need for institutional support. (P2)

Because it is not clear here who is responsible for the attention in the reference services for hepatitides, we end up having to play the role that is not ours. The articulation, integration, between surveillance and care it practically does not exist, this is perhaps the greatest difficulty here in the management of the State Health Secretariat (SHS) to treat hepatitides. (P1)

We have not yet been able to issue guidelines for the attention to hepatitides at this time of pandemic. It is necessary that internally we can articulate surveillance with attention to promote these guidelines, but here it is still flawed. (P1)

The Ministry of Health needs to guide us in this pandemic moment, we cannot leave it up to the municipality to make a decision, here we had problems that bumped into the issue of hemodialysis, of patients referred for testing, we suspended, what could we do? (P4)

If someone comes to the family health unit and asks, can I take the hepatitis test, or someone else who wants to do a quick HIV test, the question here today is who is doing it? Because the TCC stopped, the only person who does the test is away and there is no one to do it, so we tell to the users to wait for the pandemic to pass. (P5)

A big problem now is that in the family health unit they are not focused on this, even if the month is the hepatitides campaign, the focus is Covid, they themselves have not sought the units. (P7)

The statements show the need for decision making of the manager and guidelines to guide the organization of the care network, which, when not provided in time, amplify the weaknesses in the provision of attention to viral hepatitides and in the integration strategies in the HR that could suppress the lack of assistance in the reference services.

Strategically, both the state management and the referral services for hepatitides manifested the position of the MH as an articulator of guidelines to support local decisions. However, the pandemic revealed the fragility that the MH itself had been going through, due to an absence of articulation with the collegiate entities that work in the elaboration of guidelines and support decision making, in addition to its low capacity to guide the coordination of the health system, both for the pandemic and for the other diseases already faced by the System (GLERIANO, J. S. et al., 2020).

It is considered that, from a regional perspective, care management is an important tool in the work process to strengthen communication between different actors. In the Health Care Network (HCN), care management aims to provide comprehensive care to loco regional demands, therefore, managers must understand the dynamics of the territory, to organize care in a network, in line with coping with needs (SANTOS; GIOVANELLA, 2016). Advancing care management requires that the coordination of care organizes and favors actions to share information and assistance between the points of attention, to encourage strategies and actions that enable an integral response (ALMEIDA; MARIN; CASOTTI, 2017).

Before the pandemic, it was already possible to observe limitations to articulate the coordination of federal entities, especially for medium and high complexity care (BASTOS et al., 2020), an issue that was aggravated by Covid-19 due to the disorganization caused in health systems, further weakening the coordination of attention to other diseases (MENDES, 2020).

In this study, it was found that the pandemic reduced the administrative service in the state management, in addition to interrupting and/or reducing the service of reference centers, whose location, especially in cities with low population density, presented discontinuity of actions, as can be seen in the statements:

In fact, this year could be the year of hepatitides, it has been a while since the staff has deployed in actions and for this year we would have proposed an increase in testing. We left this because of the guidelines; most of the servers here have moved away, they are working on reduced journeys or at home (P2)

In the face of Covid, we had a lot of obstacles. It hasn't been taking any action from the hepatitides. Everything is locked, because you can't do an action, you can't go to a place, everything is kind of stopped, everything is Covid now, so you have to do actions that seek the patient without bringing risk. (P8)

To ensure the safety of patients because of the pandemic, we interrupted consultations and hepatitides testing. (P6)

We stopped collecting viral load, we do not have the structure to meet, and we are now working on strategies to meet the follow-ups. (P4)

The pandemic decreased the service, we had to reduce care, now only if it is an emergency priority, and we are asking to the patients to wait. (P3)

Small town, a lot of people in the Covid risk group, the best thing to do was to suspend hepatitis care activities. (P7)

The statements show the absence of guidelines and strategies by the state management, specifically to the Health Surveillance Secretariat responsible for coordinating the hepatitides program, to the care services, an issue that expanded the challenges and reflected in the discontinuity of actions of attention to viral hepatitides.

Considering the risk of going to health services or due to their closure due to Covid-19, there was a significant reduction in access to viral hepatitides tests worldwide (WINGROVE et al., 2020). The underdiagnosis of hepatitides is a limiting factor in achieving the elimination target set out in Agenda 2030 (LANCET, 2020).

In the United Kingdom and Italy, countries that are on the way to achieving the WHO goals of eliminating viral hepatitides, projections have shown worsening in the condition of patients due to the interruption or decrease in attention in health services (KONDILI et al., 2020). Specifically in Italy, the pandemic caused a reduction, partial or total interruption of activities, in addition to the postponement of treatment in hepatology units, including a reduction in the care of new cases and complications of viral hepatitides, such as cirrhosis and cancer (AGHEMO et al., 2020).

The ease of access to diagnostic services, the support of health management and the location of specialized units are fundamental for the engagement in the treatment of viral hepatitides (POURMARZI et al., 2020). Therefore, strengthening the coordination of care by recognizing the care trajectory of the users in the planning of care is essential, in the pandemic it has become an indispensable requirement to ensure assistance in the health care network.

The speeches of the participants did not mention technical notes by the different managers of the state and HR to advance in the testing and/or prevention campaigns of viral hepatitides during the pandemic, a fact that also shows limitations of care management. In line with this finding, it is noted that the state management sought support in ministerial guidelines to issue its considerations, but as mentioned, this point is a structural weakness of the Ministry of Health, which focused only on the continuity of treatment with emphasis on medication. Despite highlighting the review of flows, it did not advance in state management as expressed by the participants.

It is noteworthy that, although at the state and local levels, no specific measures or guidelines were adopted in March 2020, the DCCI of the Ministry of Health advised the expansion of the antiretroviral dispensing for up to three months to users already diagnosed, recommended the spacing of follow-up consultations, depending on the clinical conditions of the patients (BRASIL, 2020c) and signaled the need to review the flows of HCV genotyping tests (BRASIL, 2020d). However, these documents did not present guidelines on strategies for approaching new cases and prevention measures, ensuring care in compliance with the precepts of physical distancing. It should be noted that in December 2020, through Informative Note 02/2020 (BRASIL, 2020e), the MH suspended the collection of samples for Hepatitis C Virus exams.

It is understood that the actions of the Ministry of Health and the collegiate entities that are responsible for promoting debates and pointing out implementation proposals to face the pandemic, in the different scenarios, were considered divergent and poorly articulated (TCU, 2020). This finding also applies to the confrontation of viral hepatitides and aggravates the scenario of collegiate articulation for the confrontation of other diseases that were on the agenda in the health system.

In Brasil, Non-Governmental Organization, Optimism group to support people living with viral hepatitides, an affiliate of the Aliança Independente de Grupos (AIGA), recognized the absence of specific guidelines for this population (ANH, 2020). In the cities of Salvador-BA and São Paulo-SP, during the pandemic, to continue providing care services to users with HIV and STI, telehealth was used to provide care and telemonitoring for user recruitment, in addition to using other sources to disseminate information such as text messages on smartphones and online social media (Instagram and Facebook) (DOURADO et al., 2020).

In the United Kingdom, to ensure the treatment of hepatitides, the expansion of monitoring by telemedicine and delivery of medicines at home was carried out (LANCET, 2020). The French Association for the Study of the Liver (AFEF) advised that, during the pandemic, tele or video consultation should be used to care for patients with stable liver disease, suggesting that people at higher risk should be removed from work and perform teleworking (GANNE-CARRIÉ et al., 2020). In Turkey, the use of telemedicine through online platforms has broadened the discussion of experts on the health status of patients with liver disease (SAHIM; AKBULUT; YILMAZ, 2020).

Despite the limitations and challenges, managers and health professionals use strategies to favor the continuous monitoring of viral hepatitides, as well as actions to not empty the care agenda for such diseases. However, the use of telehealth, video consultation and other communication channels with users were not reported in the HR studied, mechanisms that could have been explored as support to professionals to qualify care for users.

In this study, another relevant aspect to weaken the attention to hepatitides was found, which concerns the reduction in the number of personnel, as a measure to protect the health of workers and users, which reflected in the care of spontaneous demand, with prioritization of severe cases, as can be seen in the statements:

We work here well closed, following strict sanitation of areas that have movement of people, with availability of tests and consultation to patients who really need. We distribute alcohol gel, in addition to having placed signs and reports throughout the unit; we improved the sterilization of equipment. Whoever comes here already has one problem and doesn't need another. (P4)

We tailor the demand, giving priority to patients with severe cases who are undergoing treatment for hepatitis, changes of prescription. We need to attend to what is possible in order not to leave this patient without assistance, but we greatly reduced our care. (P8)

Professionals who met the demands of hepatitides were relocated to readjust the supply of services to face the pandemic; others needed to be removed because they were from the risk group and/or had a positive test for Covid-19, reflecting on the operation of services, according to reports of the participants:

An employee of the unit was diagnosed with Covid-19, so everything here closed for fifteen days. (P5)

I had to share my work, I spend part time in the Covid center and in the surveillance giving support; the other part time is that I go to the SAS, but as only I do a test for hepatitis, the testing is stopped for a while. (P7)

The thing became intense with Covid, had an impact on the staff of health professionals, had to relocate, we ended up having to go somewhere else, and where there is only one professional for hepatitides, so the service no longer has, right? (P3)

I am the team that does the hepatitis tests here in the municipality (P5)

For now I am responsible for hepatitides, as I stopped going to the SHS because I am in the risk group, so it was up to the superintendence, which responds promptly to the demands. (P3)

I took a vacation, came back, the pandemic started and now I'm more with activities in the basic unit. This year, I did not attend any case of viral hepatitides so far. (P8)

In the context, the fragility of the number of personnel to perform the actions of attention and monitoring in the TCC/SAS is added to the responsibility of the units to divide their resources with the demand of the pandemic. It appears that this situation may indicate limitations in strategic management aspects for the composition of teams and prioritization of attention to viral hepatitides, which often does not assume a leading role in the programmatic management agenda.

It should be noted that, in the pandemic, this fact is not restricted to viral hepatitides, since to guarantee and/or expand the responsiveness of the health system, it has been necessary to reprogram measures for patient care, a situation that requires management of personnel, resources and inputs (HO; MORAIS, 2020). It is understood that the situation may be even more serious in municipalities with low infrastructure, both due to the need for professional relocation to reinforce care in other sectors, as well as the contamination of these professionals (CRUZ et al., 2020), in addition to the possibility of removal of servers from risk groups (FIOCRUZ, 2020).

The management of people has proven to be a challenge, not only due to the possibility of professionals becoming ill, but also due to the recrudescence of chronic aspects. Issues related to the dimensioning and distribution of personnel, overload and qualification, precariousness of the workforce in the Unified Health System (SUS); working conditions, including elements of physical structure, inputs for the care and safety of the professionals, approaches to reduce occupational stressors; low recognition and professional appreciation are central elements of the management of people who are exacerbated in the pandemic (DAL BOSCO et al., 2020; JÚNIOR et al., 2020; MORAES et al., 2020; JÚNIOR; SILVA, 2020; TEIXEIRA et al., 2020; LOURENÇO; BERTANI, 2007).

With regard to viral hepatitides, the low number of disease specialist physicians who are heterogeneously distributed increases the difficulties of ensuring timely treatment (MARQUES; CARVALHEIRO, 2017; ABRÃO et al., 2014). The complexity and multiplicity of factors inherent to management, consolidated by the pandemic, impose leadership strategies on managers, in actions capable of responding to the emerging demands for (re)organization of services, in the dimension of health surveillance, to minimize possible complications and lapses in attention to other diseases.

The marginalization of the viral hepatitides theme from the investment priority agendas can be one of the biggest challenges, which in times of pandemic has a direct impact on the consolidated progress in the expansion of the testing network to develop a program that allows achieving the goals for the 2030 Agenda.

Management challenges in the care of viral hepatitides aggravated by the pandemic

This category adds aspects of the core of meaning that constitute challenges to management to advance in the fight against viral hepatitides, including the agenda of priorities, profile of managers, establishment of collegiate management spaces and weaknesses of care regulation, permeated by questions about the little space for dialogue and technical support between state managers and reference services.

Viral hepatitides were considered isolated in the strategic action agendas, representing a challenge to list it as a management priority, as verified in the participants' statements.

I believe that the challenge remains to show the manager how important hepatitides are. (P3)

The manager has to be committed to this issue, if not the focus is only where they scream and in the case of hepatitides they are quieter, right, it is silent. HIV screamed, so it succeeded; now who is screaming is Covid, so focus is Covid. (P5)

If the manager does not buy this cause, if he does not have a commitment to actions that make the manager recognize that he needs to invest in the fight against hepatitides, this is left out. (P6)

Hepatitides have never been a priority. It's like tuberculosis and leprosy, years and years there in the face of public health and nothing; it seems that people have become accustomed to the disease and want to do more action for new diseases, now everything is aimed at Covid. (P8)

The statements show the chronic situation of little emphasis on management in coping with viral hepatitides, which was aggravated in the pandemic. It is noteworthy that this finding has an unfavorable impact on meeting the goal of increasing testing and providing access to reference services, international goals that are proposed by the World Health Organization (WHO)/PAHO (OPAS, 2019) and by the Ministry of Health through the Hepatitis C Elimination Plan (BRASIL, 2019), that is, it requires changes in the direction and conduct of policies and management strategies.

Faced with so many demands, it is necessary to recognize the dispute of different interests for centrality and emphasis on different priorities in the management agendas, but it is imperative to act considering sanitary and epidemiological aspects that, in the study scenario, justify favoring the confrontation of viral hepatitides. In this sense, establishing innovative approaches to improve and expand care programs, making them more accessible (HEFFERNAN et al., 2018) can represent a challenge and an alternative of action.

The limitations of response of the secondary level of care are a basic challenge in the SUS, exacerbated in the pandemic, due to the low investment in a robust network of infrastructure, resources and inputs capable of systematically meeting regional demands (GLERIANO et al., 2020). The organization of the care network favors access to prevention, diagnosis and treatment; however, it is considered that epidemiological, socioeconomic and population criteria need to be used by health management, only in this way, it will be possible to start structuring an organization of the care network that suits loco regional needs. In this sense, it is emphasized the urgent need to advance in the governance of actions and services to expand and qualify attention (PADILHA et al., 2018), prioritizing the processes of regionalization resuming this space within the collegiate bodies.

In order to make health care happen, there is a need for healthcare professionals and managers qualified to do so. However, the turnover of managers and the inadequate sizing of personnel in technical areas result in new disputes to analyze the fight against viral hepatitides that, in the context of the pandemic, are more intense, given the need for organizational rearrangements necessary to allow rapid responses from the health system.

It spent a long time without a surveillance superintendent here at the SHS, at the time of a pandemic it is necessary that the positions, especially those that are essential to sign a decision are filled, both a security of the area, and so that this does not stand still, waiting for the decision of a larger manager, who sometimes is not aware of the subject (P2).

Epidemiological surveillance now seems to be Covid surveillance, so any information about hepatitis or a problem the patient will have to be very ill to focus, get in line at the service, because the reference has stopped, they are not doing confirmatory tests, elective consultation is rare to get, lack of professional, many people away, because they are a risk group. (P4)

Even with administrative structures to regulate care, both in state and municipal management, there was no mention of their contribution to articulate the flow of care and provide opportunities for treatment follow-up.

Our patients are regulated by SISREG, but as the tests stopped in Rondonópolis we are waiting for a resumption statement to organize. (P4)

In case any patient needs a consultation now in the pandemic for the hepatitides the guidance is to go to the epidemiological surveillance or directly seek the service in Rondonópolis. (P-5)

An important obstacle in the coordination of care is the interruption and/or absence of regulatory flows that integrate care networks (ALMEIDA et al., 2010). The pandemic was able to reinforce the disarticulation of flows of specialized care, a situation that exposes the vulnerability of management in the regulation of care, both for the diagnosis of hepatitides and for its treatment. In the care of viral hepatitides, it is imperative to carry out joint actions, with different approaches, in the care network to strengthen the institutional work with a view to regional specificities (ALMEIDA et al., 2019). It is vital to adopt the perspective of integrality, to direct a set of institutional arrangements that respect the geographical landmarks of regionalization, the health response capable of subsidizing planning and collaboration between organizations, services, social and political actors.

The current scenario exposes the need for managers to understand HR governance to define the planning of service reorganization measures in the midst of the pandemic (TASCA; MASSUDA, 2020). The moment of pandemic, in addition to the many challenges and problems, can be a possibility to advance in the strengthening of collegiate management and in the governability of projects in each federated entity, in the establishment of continuous spaces for debate and decision making, in short, actions that have the potential to impact on guidelines that advance regional planning and institutional support for the monitoring of other diseases, such as hepatitides. Establishing an agenda of dialogues with non-governmental organizations and fighting entities in defense of the right of the persons with hepatitis can enable the implementation of strategies and actions.

The international experience presents the possibility of joining forces through an ambitious combination of Covid-19 surveillance in screening with tests for viral hepatitides and other diseases (LANCET, 2020), that is, using the challenges posed by the pandemic as an opportunity to add new ways of facing other public health dilemmas. However, only with management capable of recognizing these possibilities can new work fronts be installed, an issue that involves the qualification of managers and a strategic vision of action.

In this sense, a proposal for inter-federative cooperation presented by QualiRede projects the production of work plans that favor a set of activities with the State Viral Hepatitides Program (PNHV) (NEMES et al., 2019).

In short, the challenges exposed are due to the fragmentation of coordination within the scope of management, in the PNHV, and more than a limitation, they may represent the possibility of revisiting the guidelines that guide the PNHV to advance in the confrontation of hepatitides in a health system such as the SUS. The capillarity of services and decentralized management strengthen coping strategies, but a manager committed to the different health surveillance folders is needed.

This study had the limitation of not including the service aimed at persons deprived of liberty whose approach is differentiated and of concentrating participation on managers and professionals who, even considering the power and influence in the organization of care, do not show the evaluation from the perspective of users. On the other hand, a relevant contribution of the study concerns the possibility of documenting, in a timely manner, the repercussion of the pandemic in facing a serious public health problem.

Final considerations

There were failures in conducting guidelines both managers and services to articulate strategies to provide a response for the coordination of hepatitis care. Condition that triggered minimization of health promotion actions, prevention, diagnosis and treatment of hepatitides due to access limitations both by the redirection of the organization of many services and by the adoption of physical distancing.

Although the research was conducted months after the announcement of the pandemic, with some progress in the Brazilian territory, the finding allows us to reaffirm the need to promote the coordination of care to address the segmentation of attention to the diagnosis, treatment, monitoring and prevention of viral hepatitides. However, it is noteworthy that PHC was not positioned as an opportunity to advance in the fight against viral hepatitides in the pandemic.

In the experience lived in the SUS by the Covid-19 pandemic, one cannot fail to reaffirm the importance of the MH and the SHS as formulators and supporters in the elaboration of guidelines and strategies that make the best possible conditions to meet the different demands that emerge in local health systems, in addition to possibilities to strengthen links in the teaching-service integration to seek solutions, based on scientificity, to the problems that are recurrent in management.²

Acknowledgements

To the National Council for Scientific and Technological Development (CNPq) for the PhD scholarship granted to the first author.

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• 2
  J. S. Gleriano and L. D. P. Chaves: study design; collection, analysis, interpretation and discussion of results; collection of material for analysis; writing and critical review; review and final approval of the version; agreement with all aspects of the manuscript. J. B. B. Ferreira: analysis, interpretation and discussion of results; collection of material for analysis; writing and critical review; review and final approval of the version; agreement with all aspects of the manuscript.

Publication Dates

• Publication in this collection
  06 Jan 2023
• Date of issue
  2022

History

• Received
  24 Feb 2021
• Accepted
  01 Apr 2022
• Reviewed
  30 Sept 2022