Reflections of physicians on work in the Family Health Strategy under the management of Social Organizations

Ballarotti, Bruna; Corneau, Felipe Gonçalves; Junqueira, Virginia; Mendes, Áquilas

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Articles • Interface 23 • 2019 • https://doi.org/10.1590/Interface.180082 copy

Reflections of physicians on work in the Family Health Strategy under the management of Social Organizations

Authorship SCIMAGO INSTITUTIONS RANKINGS

This article presents and analyzes testimonies of physicians who worked in the Family Health Strategy about the work they developed under the management of different Social Organizations (SO) in the city of São Paulo, state of São Paulo, Brazil. The results are discussed in light of the distortions that can emerge from the application of performance indicators (targets) to health services. It was concluded that the simple comparison of services’ performance regarding the achievement of targets is not sufficient to determine which service best fulfills its role in the health network, according to the guidelines of the Brazilian National Health System (SUS) and the Federal Constitution. Although the study does not allow to determine the extent to which the reported distortions affect the work carried out under SO management, it points to the importance of further research on the subject.

Brazilian National Health System; Health management; Privatization

Unit of meaning	Condensed unit of meaning	Category	Dimension
“If we look at the targets every month (...) There isn’t any care quality indicator there. There are numbers that don’t tell much. That number, for example, doesn’t show the work that is done in the team: what I do, what the nurse does, what the community health agents do, what the whole unit does. It doesn’t. I’ve never seen any discussion about changing that perspective.”	Targets do not have any care quality indicator Numbers do not show the work done by the team	Emphasis on quantitative targets	Working process
“But it has always been based on numbers. The focus has never been on quality. [...] I agree that you must have the number of assistances, but you must also have professionals for this”.	Based on numbers. Never on quality You must have numbers You must have professionals for this	Emphasis on quantitative targets	Working process
“So, we must fulfill for [example the] issue of number of consultations, of time per hour, we can’t escape from it. With these courses [clinical meetings], I think it will become more and more limited. [...] because they say the physicians don’t want to come, but I’m sure they do. I’m sure it’s because of this damn production that they don’t want to send the physicians [to clinical meetings]”	We must fulfill the number of consultations They say the physicians don’t want to come to the clinical meetings I’m sure it’s because of the production that they don’t want to send the physicians	Emphasis on quantitative targets	Working process

Unit of meaning	Condensed unit of meaning	Category	Dimension
“To do clinic management at the unit, we use our targets, our parameters: control lists, absence lists, control of time between health demand and consultation, or between health demand and health response. These are things we quantify because we wanted to, locally. This has a much greater impact on the population’s health than controlling if I delivered 400 consultations and 40 home visits.”	To do clinic management at the unit we use our targets We quantify these data because we wanted to Controlling these data has a much greater impact on the population’s health than the amount of consultations and home visits	Emphasis on quantitative targets	Working process

Unit of meaning	Condensed unit of meaning	Category	Dimension
“The administration was performed by the SO. The unit’s manager was appointed by the SO and the whole mode of functioning, the whole working process, the unit’s organization, were determined by the SO. [...] The agenda was determined by the SO. [...] The form of organization of user embracement was also determined by the SO. [...] The times of team meetings were determined by the SO and we were obliged to hold team meetings everyday, we couldn’t hold a longer team meeting during the week. We tried to change it, but the manager’s answer was that we couldn’t do it because the Yellow SO decided it would be in that way [...] And, even so, the majority of the things were barred with this argument: ‘No, this is the rule, this is the contract, the contract between the SO and the municipal government, between the SO and you. This is the company’s rule’”	The whole mode of functioning was determined by the SO. We tried to change some things but it wasn’t possible because the SO decided it would be in a certain way. The majority of the things were barred with this argument: ‘No, this is the rule, this is the contract, the contract between the SO and the municipal government, between the SO and you. This is the company’s rule’.	Work organization	Working process

Unit of meaning	Condensed unit of meaning	Category	Dimension
“To solve their problem, patients have to go 4 or 5 times to the unit, because they will get in people’s production 4 or 5 times. In this way, you exceed the target. With the same problem, not doing things and leaving them to the next day. For example: you come today because your prescription will expire. Today, I heard you saying that your prescription will expire. I keep your prescription and ask you to come back in a few days. I write in the production that I heard you. Then, on the next day, in the team meeting, I make your prescription and you get in the production again, because I made your prescription. On the third day, when you come to pick up your prescription, you get in the production again. People do this on purpose and it is stimulated by the unit’s manager.”	To solve their problem, patients have to go 4 or 5 times to the unit, because they will get in people’s production 4 or 5 times. It is like this that the target is exceeded: with the same problem, not solving it on that day, leaving it to the next day. People do this on purpose and it is stimulated by the unit’s manager.	Emphasis on quantitative targets	Working process

Unit of meaning	Condensed unit of meaning	Category	Dimension
“At the Blue SO, the target was considered very important, both of home visits and consultations. (...) It was always easy to exceed the consultation target. But not the home visit target. What did we do? You have four weeks. You did it in the first week, when you listed your priorities; in the other three weeks, if you had to return to some patient’s home you returned there, otherwise you simulated a demand - you delivered a normal exam, you made registrations with a community health agent - to exceed the home visit target.”	The target was considered very important, both of home visits and consultations. What did we do to exceed the home visit target? In the first week, you listed your priorities. If you had to return to some patient’s home you returned there, otherwise you simulated a demand: you delivered a normal exam, you made registrations with a community health agent	Emphasis on quantitative targets	Working process

Unit of meaning	Condensed unit of meaning	Category	Dimension
“Now they call it management contract. The management contract between the SO and the municipal government has changed. So, I know that now everything is based on numbers. [...] It was said in a threatening tone. To the physicians nobody said anything, and we don’t have a physician there at the moment, so we can’t exceed the target anyway. [...] The meeting in which the supervisor was. Someone says this comes from the municipal government, the municipal government says it comes from the Yellow SO. The Yellow SO must deliver what the municipal government requires; otherwise, its contract is terminated. It must demand it of the manager and the manager must demand it of us, so that everybody keeps their jobs; it was like a threat. But I couldn’t care less”	The management contract between the SO and the municipal government has changed, now everything is based on numbers. It was said in a threatening tone. The SO must deliver what the municipal government requires; otherwise, its contract is terminated. It must demand it of the manager and the manager must demand it of us, so that everybody keeps their jobs; it was like a threat. But I couldn’t care less	Management characteristic	Working process
“So, sometimes, when we hear the supervisor of the Yellow SO saying like ‘so, you must think that if we don’t meet the target... why does one person meets it and the other doesn’t? Why could it be? Well, we can replace this professional.’ To me, this is moral harassment, coercion and something else. I tell the girls, the community health agents of my team, ‘do you know all the targets? You work well, don’t worry about that. You’ve always met the target, you don’t need to be nervous, you’ll get sick and then the situation will get worse. But I think that saying that is bad. So many professionals being absent from work, so many good people. “(...) “So, the professionals get sick (...) stress makes everything worse.”	When we hear the supervisor of the Yellow SO saying like ‘so, you must think that if we don’t meet the target... why does one person meets it and the other doesn’t? Why could it be? Well, we can replace this professional.’ To me, this is moral harassment, coercion. I tell the community health agents of my team, ‘You’ve always met the target, you don’t need to be nervous, you’ll get sick and then the situation will get worse’. So, the professionals get sick. Stress makes everything worse.	Management characteristic	Working process
“The discourse is the following: we’ll meet the targets, if people start complaining about the targets, that everything must be justified all the time, that quantity doesn’t measure quality... The manager used to say ‘if you don’t prove it’s necessary, that you’re meeting the targets, if you say: downward, perhaps the government thinks this unit is not necessary... Let’s close this unit, let’s invest in another one, let’s reduce the teams, and so on.’ There was a lot of terrorism.”	The discourse is: we’ll meet the targets, if people start complaining about the targets, the manager used to say ‘if you don’t prove it’s necessary, perhaps the government thinks this unit is not necessary... Let’s close this unit, reduce the teams’. There was a lot of terrorism.	Management characteristic	Working process

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[1] Translator: Carolina Siqueira Muniz Ventura