Profile of municipal managers of healthcare in Brazil: an overview of three decades

Abstract

Municipal health secretaries are strategic actors in the construction of the Brazilian national health system - SUS, actively participating in the system’s governance. The comparative analysis of the profile of municipal secretaries over three decades (1996, 2006, and 2017) was carried out using the database of three cross-sectional surveys carried out at the national level with structured questionnaires aimed at all municipal health secretaries in the country. The increase in female participation, greater diversity in ethnic and racial terms, greater professional qualification of managers, and the renewal of the generational profile, reiterates the advance of the democratization of these management spaces. Despite the renewal of the profile during SUS’s construction, the challenge remains to make the public machine more representative of Brazilian society as a whole.

Keywords:
unified health system; health management; job description; health manager

Resumo

Os secretários municipais de saúde são atores estratégicos na construção e governança do SUS. Neste estudo, foi realizada uma análise comparativa do perfil dos secretários municipais ao longo de três décadas (1996, 2006 e 2017), com base em dados de três inquéritos transversais realizados em âmbito nacional, por meio de questionários estruturados direcionados para todos os secretários do país. A análise evidenciou aumento da participação feminina, maior diversidade étnica e racial e maior qualificação profissional dos gestores, além da renovação do perfil geracional, mas ainda com predomínio de homens brancos e importantes diferenças regionais. Foi observado avanço da democratização desses espaços de gestão, mas permanece o desafio de tornar a máquina pública mais representativa do conjunto da sociedade brasileira.

Palavras-chave:
sistema único de saúde; gestão em saúde; perfil profissional; gestores de saúde

Resumen:

Les secretarios municipales de salud son actores estratégicos en la construcción del SUS (Sistema Único de Salud) y participan activamente en la gobernanza del sistema. El análisis comparativo del perfil de los secretarios municipales a lo largo de tres décadas (1996, 2006 y 2017) se realizó utilizando la base de datos de tres encuestas transversales realizadas a nivel nacional con cuestionarios estructurados dirigidos a todos los secretarios municipales de salud del país. El aumento de la participación femenina, la mayor diversidad en términos étnicos y raciales, mayor cualificación profesional de los gestores, además de la renovación del perfil generacional, reitera el avance de la democratización de estos espacios de gestión. A pesar de la renovación del perfil durante la construcción del SUS, queda el desafío de hacer que la máquina pública sea más representativa de la sociedad brasileña en su conjunto.

Palabras clave:
sistema sanitario unificado; gestión sanitaria; perfil profesional; gestores sanitarios

1. INTRODUCTION

The Constitution of 1988 represented a milestone in Brazilian political-administrative organization due to its guarantee of greater autonomy to municipalities. In the health sphere, the implementation of the Unified Health System (SUS) defined guidelines and strategies that established an organizational model centered on the structure of municipal health systems, which led to a sharp decentralization which can be understood as a municipalization of health care through the sharing of competencies among the states (Santos, 2013).

M. C. Castro et al. (2019), in analyzing the trajectory of SUS since its implementation, have identified a positive impact played by these changes in the assistance model in terms of health indicators. In addition to advances in epidemiological indicators, the reformulation of intergovernmental relations has provided more space for participation, contributing to a break with the patrimonial managerial practices of the past.

The municipal secretaries of healthcare are strategic actors in the construction of SUS, because in making up the local political elite and all of the bipartite and tripartite spaces for governance in the Brazilian health system, they have become fundamental policy formulators and articulators, and for this reason, they focus substantially on the characteristics and results of health policies (Ouverney, A. L. B. Carvalho, N. M. S. Machado, Moreira, & Ribeiro, 2019).

A series of studies - in large part small, local studies - have traced the profile of these actors and other studies have described their profile on the national level. However, there is a scarcity of longitudinal studies which examine the historical transformations in the profile of municipal healthcare secretaries.

It is this sense that this work will make a comparative analysis based on data collected in 1996/1997, 2006/2007 and 2017. Thus, this article will contribute to the academic debate by bringing a longitudinal perspective, scarce in the literature, and data which, to a certain extent, illustrates the three decades following the construction of SUS, continuing the work initiated by Fleury and Ouverney (2014).

2. METHODOLOGY

In this study, we present systematized data concerning the profiles of municipal health secretaries in Brazil collected transversally using a national context: the first and second instances of data collection occurred in 1996 (“The Municipalization of Health and Local Power in Brazil”) and 2006 (“The Municipalization of Health: Innovation in Management and Local Democracy in Brazil”), coordinated respectively by the Getulio Vargas Foundation and the National School of Public Health; and the third instance took place in 2017 (“National Survey of Municipal Managers of the Unified Health System”), which was coordinated by the National School of Public Health and the Federal University of Paraíba. The National Board of Municipal Health Secretaries was involved in the operationalization of these studies.

The three studies based their data collection on structured questionnaires. The first two were filled out in printed form and the last was online with the instrument being shared with the participants using the SurveyMonkey^® platform. All of the municipal health secretaries in Brazil were invited to take part in these three studies with the participation rates being 28.6% in 1996 (1,422 respondents/4,973 municipalities); 19.5% in 2006 (1,083 respondents/5,563 municipalities) and 41.5% in 2017 (2,313 respondents/5,570 municipalities).

The variables utilized to trace the profile of these municipal secretaries were sex, age, race/ethnicity, level of education, and area of professional training. They were categorized and analyzed in terms of frequency and relative frequency, with results appearing in table form. The databases and the categories for each variable were managed by the main authors to standardize the three studies’ analyses. This standardization was not possible for “graduate/specialization” under “level of education”, because this information was not available for the 1996 survey.

The three studies were approved by the Research Ethics Committee and the participants received the Clarified Free Will Consent Form. This article has been organized based on approval from the Research Ethics Committee of the Medical Sciences Center of the Federal University of Paraíba (CCM/UFPB), embodied by Report nº 4,147,229. The research data used in this article was ceded by the respective coordinators.

3. RESULTS

Table 1
Profile of Municipal Health Secretaries in Brazil 1996/2006/2017 (%)

	Brazil			Northern			Northeastern			Midwestern			Southeastern			Southern
	1996	2006	2017	1996	2006	2017	1996	2006	2017	1996	2006	2017	1996	2006	2017	1996	2006	2017
Sex
Female	39.7	50.1	58	42.3	58.6	44.2	49.7	54.9	61.2	41.6	46.2	57.7	31.1	45.6	57.5	45.1	47.2	57.7
Male	60	49.2	42	57.7	41.4	55.8	51.3	43.6	38.8	57.5	53.8	42.3	69.5	54.3	42.4	54.4	51.6	42.3
Age
Up to 30	12.1	11.4	10	12.8	10	9.6	17.2	12.2	13.2	10.6	7.7	9.7	9.4	12.6	6.8	13	10.5	6.5
30 to 40	34.8	28.3	37.1	47.4	28.7	35	37	29.7	39	40.8	25.5	39.5	30.6	26	36.4	35.6	30.5	32.5
40 to 50	33.6	36.6	30.2	32.1	48.2	32.5	33.2	34.1	27.5	32.7	41.3	29.8	35.2	33	33.7	32.3	39.3	31.2
50 to 60	13.4	17.7	19.1	6.4	8.2	20.8	9.7	16.6	16.4	8	22.3	19	15.8	22.1	18.2	14.9	14.9	26.5
Over 60	3.9	3.7	3.6	1.3	0.9	2	2.1	4.4	3.8	4.4	3.2	1.9	6	5	4.8	2.3	2.1	3.2
Skin Color
White	84.2	69.3	59	47.4	33.8	38	68.1	51.8	46.2	76	68.4	57.8	89.7	83.4	69.4	94.6	89.5	89.7
Brown	11.5	26.4	35.3	42.3	64.9	54.3	29	41.6	478	15	25.2	37	5.9	13.8	23.4	2.8	7.2	7.8
Black	1.1	2.6	3.4	2.6	0	5.6	0.8	4	3.4	2.7	3.4	3.3	1.2	2.2	4.8	0.5	1.8	0.5
Asian	1.7	0.3	1.7	2.6	1.3	1	0	0	1.3	2.7	0.6	1.9	2.3	0.4	2.3	1.4	0.3	2
Indigenous	0.6	0.1	0.6	3.8	0	1	0.8	0	1.2	0.9	1.1	0	0.2	0	0	0.2	0	0
Level of Education
Incomplete Elementary	1.3	0.7	0.3	0	0	0.5	0.4	0.5	0.2	1.8	0	0.4	1.2	1.6	0.4	1.9	0.3	0.5
Incomplete High School	4.3	1.7	1.7	6.4	0	3	2.5	1.5	1.4	2.7	2.6	1.5	3	2.1	1	7	1.9	3.2
Incomplete College	20.9	29	17.2	50	49.9	23.4	16	23.4	14.6	31	35.8	18.3	14.9	23.3	16.3	23.5	34.8	20.8
Bachelor’s Degree	68.8	29.8	33.1	39.7	30.5	33.5	76.1	32.8	34.5	62.8	26.9	32.1	73.4	31.6	32.5	65.6	23.4	31
Specialization	-	34	42	-	19.6	36.5	-	36.4	42.8	-	31.4	43	-	36	43.7	-	34.1	40
Master’s Degree	2.7	2.9	5	1.3	0	2.5	2.9	3.5	5.4	0	0.9	4.5	4.8	2.9	5.6	0.9	4	4
PhD	1.5	0.6	0.7	2.6	0	0.5	1.7	0.2	1	0.8	1.1	0.4	2.5	1.1	0.6	0.2	0.4	0.5
Area of Training
Health other than medicine	33.2	33.7	62.4	43.6	42.3	60.3	43.6	39.6	68.2	37.2	32.2	59.4	28.8	30	58.7	30.7	27.2	54.3
Medicine	31.2	11.2	3.3	21.8	5.8	3.2	31.5	13.2	2.6	31	6.8	2.6	41.4	14.8	4.9	19.3	6.7	3.2
Others	35.6	55.1	34.3	34.6	51.9	36.5	24.9	47.2	29.2	31.8	61	38	29.8	55.2	36.4	50	66.1	42.5

• Source: Elaborated by the authors.

In terms of sex, we may observe a continual growth in the participation of women in the management of SUS over these three decades (Table 1). In Brazil, there was an inversion of the proportion of men and women commanding municipal (SUS) health secretariats between 1996 and 2017, with the representation of women going from 39.7% to 58% among managers during this period. Regionally, meanwhile, the Northern Region stands out due to its reversal in the female representation observed from 2006 to 2017 after the stronger expansion in the number of female health secretaries in the country from 1996 to 2006, and the Southeastern Region had the largest proportional increase in female health secretaries among the regions from 1996 to 2017 (+26.4%).

In terms of the distribution by age group on a national level, we may observe the predominance of managers between the ages of 30 and 50 (Table 1). Nationally as well as regionally, the 30 to 40 age group was predominant in 1996 (except in the Southeast), the 40 to 50 age group was predominant in 2006, and the 30 to 40 age group was predominant again in 2017. At the same time, there was an increase in the 50 to 60 age group nationally as well as regionally with a greater emphasis on the Northern Region which went from 6.4% in 1996 to 20.8% in 2017. Therefore, there was a double movement of renewal and maturation on the part of managers during the length of analyzed period.

Examining race/ethnicity, it is clear that self-declared white managers continued to dominate over this period, even though there was a reduction in their proportion from 84.2% in 1996 to 59% in 2017. At the same time, those who declared themselves brown increased from 11.5%, in 1996 to 35.5% in 2017, with very low participation on the part of blacks, Asians, and indigenous managers. Regionally, we note the increment in the percentage of white managers in the Northern Region between 2006 and 2017, the only region where this was true, even though the proportion of brown respondents in this region was the highest in the country in 1996, and this group became predominant in relation to the white group in 2006 and maintained this position in 2017. On the other hand, there was a large predominance of white managers in the Southern Region and the other races/ethnicities together did not sum more than 10%.

In terms of the level of education, there was an increase in the proportion of managers with at least a college education which went from 68.8% in 1996 to 80.8% (47.7% with graduate degrees) in 2017, while there was a reduction in the number of managers with incomplete college educations or less (26.5% in 1996 and 19.2% in 2017). From a regional point of view, the Northern Region stands out once again with there having been 56.4% with incomplete college education or less in 1996 and 26.9% in 2017 (a fall of 29.5%), with this region remaining the one with the highest proportion of managers with a college education or less, followed by the Southern Region with 24.5%.

The most pronounced change in the profile of these secretaries in the three studies was in the area of training. While the proportion of managers with training in the health area remained relatively stable between 1996 (64.4%) and 2017 (65.7%), even though there was an important reduction in this proportion in 2006 (44.9%), the percentage of managers who are doctors plummeted from 31.2% in 1996 to 3.3% in 2017, a phenomenon which took place in a homogeneous manner throughout the country, even though the proportion of doctors in 1996 was already lower in the Southern and Northern Regions than the rest of the country. The other extreme was represented by the Southern Region in which managers with health training only became the majority in the 2017 survey.

The 2017 survey data provides important findings in terms of sex and professional training in relation to the managerial salary group. As we can see in Graphic 1, the proportion of women has increased to the extent that the salary for the position has diminished, and women represent a very small proportion in the municipalities that pay more than 15 times the minimum wage (two of the 12 which are in this group).

Graphic 1
Salary Group by Sex (2017)

4. DISCUSSION

This work demonstrates the relevant changes in the occupants of the position of municipal health secretary, with women, self-declared white individuals, and those in the 30 to 50 age group with a college degree and health training predominating in recent years.

In terms of the presented changes in this profile, we can see a marked increase in the presence of women in this field, and the feminization of health management has already been described by other studies such as Arcari, Barros, Rosa, Marchi, and Martins (2020), A. L. B. Carvalho, Ouverney, M. G. O. Carvalho, and N. M. S. Machado (2020), J. L. Castro, J. L. Castro, and Vilar (2006), Fleury and Ouverney (2014, 2018), Garózi (2014), Luna (2008), and Ouverney et al. (2019).

The entrance of women in institutional decision-making spaces has been a slow and difficult process. Historically, women have been associated with domestic functions which are largely a legacy of structural institutional mechanisms (p. ex., family, church, school, the state) which have perpetuated masculine dominance (Bourdieu, 2011; Miltersteiner, Oliveira, Hryniewicz, Sant’anna, & Moura, 2020). However, with the passage of time, women have conquered more space in the job market, and the results of this study demonstrate the predominant entrance of women in the municipal management of SUS.

In this sense, A. L. M. Carvalho et al. (2020) have already observed a predominance of female managers with training in the area of nursing and previous experience in Primary Health Care in the running of SUS, which in part may explain the historic role of this professional category in the administrative functions of various types within the context of SUS. However, this feminization of management has not occurred on all levels of public administration. For example, there is a strong masculine predominance in those serving as mayors (Instituto Brasileiro de Geografia e Estatística [IBGE], 2017).

Miltersteiner et al. (2020), in analyzing feminine leadership in public administration, observe that gender prejudice is still a barrier for women, with one of its effects being a demand for greater education on the part of women as compared to men who occupy the same functions. Kon (2002) analyzes the effects of the division of labor by gender, which reveals a tendency to favor the male sex while offering worse salaries and working conditions for women, which are caused by a reproduction of the social aspects which influence the type of work performed by women. Added to this is the fact that the National Household Survey has shown that Brazilian women earn 20.5% less than men on average while performing similar functions.

Another problematic aspect identified in the analyzed surveys is the representation of the black, indigenous and Asian populations as health secretaries in the municipalities of Brazil. Even though there has been a gradual increase in the proportion of managers who declare themselves black or brown, which indicates that an inclusive process may be having a positive impact in terms of representation in state decision making spaces, the challenge of making the Brazilian public machine truly representative of society persists.

The increase in the average education of municipal managers during the analyzed period suggests the greater technical capacity of SUS in conducting local policies, to the extent that the healthcare field involves a great complexity of knowledge and tasks which require properly qualified actors. We should not state that more education is always related to better policy and technical decisions in our health systems. However, it seems reasonable to point to more qualified managers as being able to deal with the greater complexity of the Brazilian health system, and we have seen a gradual improvement in its management.

The presence of doctors running SUS has become rarer, especially where there are lower salaries for the position of secretary, while there has been a strong increase in the presence of nurses and those with experience in areas not linked directly to health, like administration. In part, we can deduce that the lower representation of doctors indicates deeper changes in Brazilian society and a break from the traditional elite structures in favor of a greater democratization of the public sphere (Fleury & Ouverney, 2014; Petrarca, 2017), as well as a change in the profile and the political and economic organization of the medical category over the past few decades (M. H. Machado, 1997). On the other hand, we should also bear in mind that part of the explanation for this change of profile in the professional training of health secretaries represents a twofold change characterized by lower incomes for positions in municipal management, as well as the increasingly technical nature of public administration to the extent that technicians with experience in administration are being sought for the formulation and implementation of health policies.

In terms of the greater presence of managers in the 31 to 40 age group, this converges with the studies of Garózi (2014), Luna (2008) and Pinafo, Carvalho, Nunes, Domingos, and Bonfim (2016). The current generation of managers grew up when SUS was created, which reflects the importance of paying specific attention to the qualification of these political actors, as Peres et al. (2021) point out in indicating gaps in the development of competencies which are considered essential for improving the managerial capacity of these actors.

Analyzing the profile of health secretaries longitudinally matters at a time when this country is going through a political transformation with social and healthcare rights under constant threat.

This study has a few limitations in part due to the transversal design adopted in each of the analyzed studies. Participation, as expected in studies of this nature, was low, even though it grew with time. This combined with the study sampling processes and the use of printed questionnaires in the first two steps and online questionnaires in the third, makes it possible that selection biases have occurred which limit the generalization and representativeness of the results related here. The authors of this study have sought to balance the variables to make them comparable in the best way possible, but problems may have occurred in this process.

5. FINAL CONSIDERATIONS

The aspects analyzed in this study confirm a broad increase in female participation; the continuity of the expanding presence of various populational groups; greater professional qualifications; a considerable reduction in the percentage of managers who are doctors; the renewal of the generational profile of municipal health secretaries; and reiterate the advance of democratization in these managerial spaces. However, the expansion of possible managerial positions for those who traditionally have not held them is still not sufficient for the full democratization of the Brazilian state.

The national analysis of the profile of municipal health secretaries has been part of the Brazilian research agenda for thirty years. This scientific exercise which began in the 1990s should continue as Fleury (2014, p. 22) affirmed by saying that “a new decade will be a fabulous opportunity to find out what has changed in recent decades.” Following this logic, this article contributes another step in this historic construction.

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• [Translated version] Note: All quotes in English translated by this article’s translator.

• One of the reviewers did not authorize the disclosure of their identity.
• Peer review report: The peer review report is available at this URL

Edited by

Editor-in-chief: Alketa Peci (Fundação Getulio Vargas, Rio de Janeiro / RJ - Brazil) https://orcid.org/0000-0002-0488-1744

Associate editor: Gabriela Spanghero Lotta (Fundação Getulio Vargas, São Paulo / SP - Brazil) https://orcid.org/0000-0003-2801-1628

Maria Ceci Misoczky (Universidade Federal do Rio Grande do Sul, Porto Alegre / RS - Brazil) https://orcid.org/0000-0003-2020-5882

Publication Dates

• Publication in this collection
  11 Nov 2022
• Date of issue
  Sep-Oct 2022

History

• Received
  23 Apr 2022
• Accepted
  16 Aug 2022