Brazilian Breast Cancer Care Network: the perspective of health managers

To analyze the organization of the Brazilian Breast Cancer Care Network, according to the perspective of managers of the Coordenadoria Regional de Saúde Sudeste (Southeast Regional Coordination of Health) of the city of São Paulo.

Method:

A descriptive study, with a qualitative approach, carried out with seven managers of this Coordination. The interview data were analyzed based on the components of the operational structure of the Brazilian Health Care Network: Communication Center; Secondary and Tertiary Care Points; Support Systems; Logistic Systems; and Network Governance System.

Results:

There is heterogeneity in the operationalization of the Care Network and the obstacles to its integration and comprehensiveness were: fragility of the bond with the users; high turnover of professionals in Primary Health Care; lack of standardization of the reference system and counter-referral, and low cooperation between municipal and state health services.

Final considerations:

The organization of the Brazilian Breast Cancer Care Network is fragmented, thus compromising the comprehensiveness of care.

Descriptors:
Breast Neoplasms; Primary Health Care; Health Management; Women's Health; Health Evaluation

Thematic Category	Subcategories	Speeches of individuals
Communication center - Primary Health Care "O centro de comunicação das Redes de Atenção à Saúde é o nó intercambiador no qual se coordenam os fluxos e contrafluxos do sistema de Atenção à Saúde, sendo constituído pela Atenção Primária à Saúde" (The communication center of the Health Care Networks is the interchange node in which the flows and counterflows of the Health Care system are coordinated, being constituted by the Primary Health Care)⁽⁸8 Mendes EV. As redes de atenção à saúde. Organização Panamericana da Saúde, 2a ed. Brasília: 2011.⁾.	First contact: accessibility and use of the service	[...] for the person to make the first appointment at the Basic Health Unit can take from two to three months. (M1) [...] I know I have a three-month waiting line. (M6)
	Coordination of flow and counterflow of the system	The professional is oriented towards the protocol, but does not acquire the knowledge to make a correct flow. So often does not request the mammogram or referral, and this delays the start of treatment very much. (M2) Another limitation would be the difficulty of dialogue with the secondary network, the lack of counter-referral. (M1) One obstacle that we have is the fragmentation of the network, because the hospital does not provide this response to Primary Care. (M3) When you go to the treatment service you lose that contact. It still needs to ensure this monitoring with Primary Care. (M5) In referral and conterreferral, the clinician talks to the mastologist who talks to the hospital and that user returns to the clinician. This turn is a big knot. The referral and counter-referral does not exist. (M2) Is there a flaw in communication between services, because while you are being treated you are being followed up and then, when you fall into the network, under what conditions? [...] So we started well and lost data on the way. (M3)
	Profissionals availability	[...] we have a very large turnover of these professionals… (M1)

Thematic Category	Subcategories	Speeches of individuals
Secondary and Tertiary Care Points "São pontos de atenção secundários e terciários, os nós da rede onde se ofertam determinados serviços especializados, gerados através de uma função de produção singular. Se diferenciam por suas respectivas densidades tecnológicas" (Secondary and tertiary attention points are the nodes of the network where certain specialized services are offered, generated through a singular production function. They differ by their respective technological densities)⁽⁸8 Mendes EV. As redes de atenção à saúde. Organização Panamericana da Saúde, 2a ed. Brasília: 2011.⁾.	Secondary Care	Every patient who is referred for breast or mammography ultrasonography has the offer of a specialized mastology service and, with an altered result, is automatically referred to the mastologist and within this service the puncture is already done and is already being sent to the care line and will follow-up the comprehensive care. (M1) Mammography and breast ultrasonography are not performed here. We always need to be forwarded and the result is a huge waiting line... (M3).
	Tertiary Care	The limit would be in the tertiary sector, especially the communication with this sector. I prioritize the marking and stay in the regulator every two days. It's as if I want to get my problem up front and the tertiary sector has difficulty. I can get the job because I'm insistent. (M4) What is certain is that when the patient is discharged from the hospital, he/she returns to the specialty outpatient clinic as a way to re-educate herself and then to the territory to follow up at the Basic Health Unit. (M2)

Thematic Category	Subcategories	Speeches of individuals
Support Systems "São lugares institucionais das redes onde se prestam serviços comuns a todos os pontos de Atenção à Saúde, quer seja no apoio diagnóstico e terapêutico, quer na assistência farmacêutica e sistemas de informação de saúde para obtenção de dados úteis à regulação, programação e ajuste na assistência à saúde da população" (They are institutional places of the networks where services are provided common to all points of Health Care, whether in the diagnostic and therapeutic support, or in the pharmaceutical assistance and health information systems to obtain useful data for regulation, programming and adjustment in the health care of the population)⁽⁸8 Mendes EV. As redes de atenção à saúde. Organização Panamericana da Saúde, 2a ed. Brasília: 2011.⁾.	Diagnostic and therapeutic support	We have a very large population and few equipment ... I do not know if [the solution] would increase the number of mammographs. Statistics show that the numbers of mammographers are more than adequate and are in adequate numbers, but would be a better redistribution of services. (M5) [...] I think we have two nodes: the maintenance of mammography equipment, because they break down and generate a waiting line, [...] and we still have absenteeism. (M1) [...] and absenteeism is high [...], almost 30% absenteeism and is complicated because the patient does not get out of line and harms the other patient who needs to get in line. (M3)
	Information System	[...] we do not have much related to that SISMAMA Program, I do not know what happened and I think I never implemented it here. (M4) Who does the mammograms for our region is [...] an outsourced company and what I have contact with them have never fed anything about SISMAMA and I do not receive any data. (M6) The SISMAMA system itself is not being used in everyday life for management and it is a discussion that we must make. Who feeds the bank are the services of reference and would be a good tool, but we are not performing this practice. (M5)

Thematic Category	Subcategories	Speeches of individuals
Logistic Systems "São soluções tecnológicas, fortemente ancoradas na tecnologia da informação, que garantem uma organização racional dos fluxos e contrafluxos da informação, produtos e pessoas na Rede de Atenção à Saúde, e deve contribuir para a efetiva coordenação entre os pontos da RAS" (These are technological solutions, strongly anchored in information technology, which ensure a rational organization of the flows and counterflows of information, products and people in the Network of Health Care, and should contribute to the effective coordination between the points of RAS)⁽⁸8 Mendes EV. As redes de atenção à saúde. Organização Panamericana da Saúde, 2a ed. Brasília: 2011.⁾.	People flow	[...] In our region we have no difficulty regarding referrals and our rear with regard to breast cancer is quite efficient and it works. Our cancer care network works. (M2) [...] anyone who is regulating tries to check a place near their residence, but the area is too large and can be scheduled too far. (M7)
	Information flow	[...] the information does not reach all women and the vast majority looks when it sees a palpable nodule or retraction and with that is already in a more advanced stage [...]. (M6) There is a lack of awareness of the population to do the preventive exams, we know that the media is important and it may be necessary to disclose in the popular program, in a soap opera, the problem of breast cancer. (M2) The user or population is disbelieving that the danger lives next door and that they should do the preventive exams annually. [...] it would help if the media intervened with commercials and novel approach. (M7)

Thematic Category	Subcategories	Speeches of individuals
Network Governance System "A governança das Redes de Atenção à Saúde é o arranjo organizativo que permite a gestão de todos os componentes, de forma a gerar um excedente cooperativo entre os atores sociais em situação, aumentar a interdependência entre eles e obter resultados para a população adscrita" (The governance of health care networks is the organizational arrangement that allows the management of all the components, so as to generate a cooperative surplus among the social actors in the situation, increase the interdependence between them and obtain results for the attached population)⁽⁸8 Mendes EV. As redes de atenção à saúde. Organização Panamericana da Saúde, 2a ed. Brasília: 2011.⁾.	Formulation and strategic decision to organize and coordinate the interaction between the network components	The Municipality is very large and ca not have a vision of a whole and we must work in partnerships... (M2) We have a special problem [...], because I have a set of Basic Health Units, being more than 50% municipalized, that is, no management contract. (M5) In our region we have no difficulty regarding referrals and our rear with regard to breast cancer is quite efficient and it works. Our cancer care network works. (M2)

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[1] Corresponding Author: Rosely Erlach Goldman E-mail: rosely.goldman@unifesp.br