Management-service relationship in the SUS based on Morin’s Theory of Complexity

Relação gestão-serviços no SUS a partir da Teoria da Complexidade de Morin

Relación gestión-servicio del SUS a partir de la Teoría del Pensamiento Complejo de Morin

Abstract

The present study aimed to analyze the conceptions of a health management team about their relationship with professionals in the services offered by a municipal healthcare network. The Focus Groups technique was used for data collection: three groups were conducted with an average of 12 participants each and an approximate duration of two hours. The IRAMUTEQ software was used for data analysis, which allows a lexical analysis of the Descending Hierarchical Classification type. Five distinct classes were found. The theoretical-philosophical framework of Edgar Morin’s Theory of Complexity was used to discuss the results, which proposes the aspiration to non-reductionist knowledge and the recognition of the incompleteness of any type of knowledge. As final considerations, we understand that the phenomenon addressed in this study consists of multiple factors that recursively affect each other. We stress the discussion about the intersection of the territory in the work dynamics of management teams. In addition, we highlight the value of the meeting between different actors as a possibility of genuine openness to difference, toward the collective construction of this health system.

Keywords:
Public Health Policies; Health Management; Health services

Resumo

Objetivou-se analisar as concepções de uma equipe gestora em saúde sobre sua relação com profissionais dos serviços de uma rede municipal. Aplicou-se a técnica de Grupos Focais: foram três grupos, com 12 participantes cada e duração aproximada de duas horas. Para a análise empregou-se o software IRAMUTEQ que permite uma análise lexical do tipo Classificação Hierárquica Descendente, que resultou em cinco classes distintas. Para discussão dos resultados utilizou-se referencial teórico-filosófico da Teoria da Complexidade de Edgar Morin, que traz a aspiração a um saber não reducionista e o reconhecimento da incompletude de qualquer conhecimento. Entende-se que o fenômeno aqui abordado é constituído por múltiplos fatores que se afetam mútua e recursivamente. Destaca-se a discussão dos atravessamentos do território na dinâmica de trabalho da equipe gestoras. Reforça-se o valor do encontro entre diversos atores enquanto possibilidade de abertura genuína à diferença, na direção de uma construção coletiva do sistema de saúde.

Palavras-chave:
Políticas Públicas de Saúde; Gestão de saúde; Serviços de saúde

Resumen

El presente estudio tuvo como objetivo analizar las concepciones de un equipo de gestión de salud sobre su relación con los profesionales de los servicios ofrecidos por una red municipal de salud. Para la recolección de datos se utilizó la técnica de Grupos Focales: se realizaron tres grupos, con una media de 12 participantes cada uno y una duración aproximada de dos horas. Para el análisis de datos se empleó el software IRAMUTEQ que permite realizar análisis léxicos del tipo Clasificación Jerárquica Descendente, resultando en cinco clases distintas. Para la discusión de los resultados se utilizó el referencial teórico-filosófico de la Teoría del Pensamiento Complejo de Edgar Morin, que propone la aspiración a un conocimiento no reduccionista y el reconocimiento de la incompletud de cualquier conocimiento. Como consideraciones finales se entiende que el fenómeno abordado es constituido por múltiples factores que se afectan mutua y recursivamente entre sí. Se destaca la discusión sobre la intersección del territorio en las dinámicas de trabajo de los equipos de gestión. Además, se refuerza el valor del encuentro entre los diversos actores como una posibilidad de verdadera apertura a la diferencia, hacia la construcción colectiva de este sistema de salud.

Palabras clave:
Políticas de Salud Pública; Gestión en Salud; Servicios Sanitarios

Introduction

The Brazilian Unified Health System (SUS), through the guideline of democratic participation, invites workers, managers, and users to think about the model of healthcare services and management of the public health. In this sense, this system is based on a method that enhances the capacity of subjects - individually and collectively - to understand and intervene in reality as well as in social institutions.

However, the involvement of these different social actors in the management of the SUS has been challenging in the daily routine of the services (Dantas et al., 2012). There is still a management based on principles that sacrifice subjectivity in the name of profitability and competitiveness, which on the one hand increases productivity and, on the other, disaggregates teams and separates work from other aspects of life as a whole, even aggravating pathologies resulting from work (Scherer, Pires & Schwartz, 2009). For Paim and Teixeira (2007), the SUS still experiences the influence of centralized, technological, and hierarchical management models, in addition to a persistent “amateurism” in the management of the system at all levels.

In this context, the National Humanization Policy (Política Nacional de Humanização - PNH) (Brasil, 2009) emerges with the purposes of breaking with the managerial perspective and introducing methodologies compatible with the democratization of health (Benevides & Passos, 2005; Moreira et al., 2015). Therefore, managers, healthcare professionals, and users are expected to establish relationships that strive for proximity, dialogue, socialization of information and knowledge, and widespread practices in decision-making.

It is worth highlighting the possible contribution of Psychology to the development of these dialogical relationships, by sharing its references concerning bonding, user embracement, and active listening, aiming at incorporating such practices into the performance of all healthcare actors, as well as emphasizing subjectivity, corporeality, and historicity of the individuals that compose this system as essential in the structuring of services and actions in public health (CFP, 2009; Iglesias, 2015).

Merhy and Franco (2013) argue that the work performed in health care precisely takes place through the encounter between subjects. According to the authors, this work is centered on the relational field, as relationships enable listening and the development of bonds key to the production of health.

However, even in the face of the legal apparatus that prioritizes social participation and shared management, among other principles and guidelines that underlie public health, there are still some challenges for implementing what has been formally instituted. Thus, we can state that the set of institutional regulations does not seem to necessarily guarantee the effectiveness of democratic management, nor the social participation aspired since the Brazilian redemocratization movement.

According to Morin (2007, p.24), this can be related to “the scientific and technical culture that, considering its disciplinary and specialized characteristic, separates and compartmentalizes knowledge,” corroborating the hierarchies of knowledge/power. Conversely, the author, through the Complex Thought, embraces contradictions, articulates “the principles of order and disorder, separation and connection, autonomy and dependence that have a dialogue (complementary, concurrent, and antagonistic), in the core of the universe” (Morin, 2003, p.71).

In other words, the Complex Thought simultaneously aims at uniting (contextualizing and globalizing) and accepting the challenge of uncertainty, through the formulation of some complementary and interdependent principles, as guidelines for thinking about complexity. They are as follows: Dialogic Principle, Systemic Principle, Principle of Subject Reintroduction in any kind of Knowledge, Hologrammatic Principle, Recursive Principle, Principle of Self-eco-organization, and Principle of Circular Retroactive Movement (Morin, 2007).

With these principles, Morin (2007) states that this is not a thought that rejects certainty with uncertainty, separation with inseparability; on the contrary, it consists of a constant coming and going between certainties and uncertainties, between the elementary and the global, between the separable and the inseparable in the constitution of richer conceptions of the world, health, and subjects. Thus, this thought seems to be pertinent to analyze the relationships present in the SUS, which is composed of diverse and even contradictory understandings that must be gathered to make comprehensive health care effective. It is, therefore, about escaping from a “mutilating thought,” which produces limiting actions, for adopting a practice that recognizes the incompleteness of knowledge, aggregating the various knowledge and practices in consolidating the principles and guidelines of the SUS.

Hence, the aim of this study is to analyze the conceptions of a health management team about their relationship with professionals in a municipal healthcare network, based on the theoretical-philosophical framework of Edgar Morin’s Theory of Complexity. We understand that such conceptions brought up by management professionals can guide practices, either toward strengthening vertical relationships between users, workers, and managers, or toward a collective construction of this health system, understanding that the management process involves each one of these actors.

Method

Participants

This is a qualitative research, carried out in a municipality in southeastern Brazil, which accounts for: 29 Basic Health Units (Unidades Básicas de Saúde - UBS), four Psychosocial Care Centers (Centros de Atenção Psicossocial - CAPS II, CAPS III, CAPS for Children and Adolescents, and CAPS for Alcohol and Drugs), one Reference Center for Older Adults Care and one for the treatment of Sexually Transmitted Infections, one Healthcare Service for People in Situations of Violence, two Emergency Services, and one Municipal Specialty Center. These services are under the responsibility of the Municipal Health Department, whose organization chart informs that it is divided into the Undersecretary Office of Health Care and the Undersecretary Office of Strategic Support. The management team, the target population of this research, is linked to the Subdepartment of Health Care and is composed of the Coordination of Primary Care, Coordination of Specialized Care, and Coordination of Urgency and Emergency Services.

The surveyed management team is composed of 45 professionals, mostly women.A total of 36 professionals from this management participated in this survey, 30 women and six men. Regarding age, the age group between 39 and 50 years was predominant (Mean = 44.5; SD = 3.85), with higher education, with 25 participants holding a specialization degree. As for their majors, Nursing and Social Work degrees outstood with 10 professionals each. As for the participants’ working arrangements, 32 work under the statutory regime.

Instruments

The Focus Group (FG) was used as a data collection technique, considering that this instrument tends to collaborate so that participants, together, create new conceptions about the study question, which favored the understanding of perceptions, beliefs, and attitudes about the addressed theme (Trad, 2009; Souza, 2020). Each FG is normally conducted by two researchers, one with the role of moderator and the other as an observer of group dynamics. A script for stimulating the discussions is also used.

Procedures

Data collection took place through the development of three FG, with 12 participants each, lasting approximately two hours. Each FG started with the disposition of pictures randomly cut from magazines, followed by requesting the participants to choose the image they considered to represent the relationship between management and service. Based on this choice, each participant presented their picture to the group and commented on the association made between the image and the management-service relationship. This strategy was a trigger for the following discussion, guided by a script, and which was centered on the relationship between healthcare management and services and the paths and impasses toward the production of integration for co-management. FG sessions were recorded with a recorder and a cell phone, under the authorization of participants in digital audio files; then, they were transcribed following the protocol of the informed consent form on the part of the target population of the survey (Resolution No. 466/12 of the National Health Council). It is noteworthy that this study was approved by the Research Ethics Committee under number 2,410,025.

Data analysis

A lexical analysis of the Descending Hierarchical Classification (CHD) type was followed, using the IRAMUTEQ software (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires) as a data exploration tool, which “allows different forms of statistical analysis on textual corpora and on tables of individuals by words” (Camargo & Justo, 2013, p. 513).

Thus, with the aid of IRAMUTEQ, the CHD method was used, which correlates text segments and their vocabularies forming a hierarchical scheme of vocabulary classes. Classes are subdivided from the closest to the furthest in terms of vocabulary, considering the descending logic of CHD. Thus, it was possible to visualize the hierarchical scheme of the five generated classes (Figure 1) as well as the concatenation between them. Within each class, words are arranged in chi-square order (χ2), which consists in associating the word with the class. Finally, it is worth noting that the software also allows retrieving, from the original corpus, text segments associated with each class, and thus, the apprehension of the context of statistically significant words for the qualitative analysis (Camargo & Justo, 2013).

Figure 1
Dendrogram of Descending Hierarchical Classification

Results

The textual corpus submitted to the CHD obtained an exploitation of 95.32%. After data processing, the corpus was divided into 941 text segments, with 3,683 vocabulary entries and 33,122 distinct forms. The material was partitioned into five distinct classes. At first, there was a division into two sub-corpora. In this first partition, class 5 was created, titled “Metaphors on the Relationship between Management Professionals and Service Professionals,” in such way this class is separated from all others. From a second partition, class 4 was obtained, titled “Powers and Challenges of Mechanisms for Meetings between Management and Services.” The third partition resulted in class 3, titled “Management conjectures and expectations regarding Service Professionals.” Finally, there was a fourth partition, resulting in classes 1 and 2, respectively titled: “Identity and work routine” and “Territory: complexity, possibilities and challenges.” The following figure demonstrates the corpus and sub-corpora partitions for creating the five classes.

Class 5 represents 13.38% of the analyzed material, titled “Metaphors on the Relationship between Management Professionals and Service Professionals.” This class expresses the content created from the initial dynamics of exposing the pictures to the participants to discuss the understandings about the management-services relationship. Hence, the word “picture” (χ2=318.95) accounts for the highest chi-square value, followed by the words “choosing” (χ2=124.35), “representing” (χ2=91.16) and “relationship” (χ2=61.18).

Among the metaphors created by the participants about the management-service relationship, the metaphor of “looking” is highlighted (χ2=43.8), to which different meanings are assigned. They emphasize the importance of paying attention to the “look” of the management in relation to the services and vice versa, with the purpose of creating a more confident “look” between both groups. Another participant explains the choice of the picture because of the need to “look” inside the management itself, so that they can also understand and analyze the movements of this management to make this relationship effective. Still regarding this “look,” participants refer to a “lighthearted look” to maintain a “good relationship.”

Another metaphor brought up by the participants associates the management-services relationship with a “table” (χ2=37.38), which indicates the difficulty in maintaining spaces for dialogue and systematic approximation between these instances: management and service. Despite exposing this difficulty in engaging in effective dialogue, the participants also highlighted the potential of meetings between management and service to develop bonds:

I found this picture interesting, because on this table there is water, a jar of juice being served, this allows for the creation of bonds, which we must have with the service professionals. I notice differences when I join a team with which I have a bond and a team with which I do not have it yet.

Class 4 represents 14.90% of the analyzed material, titled “Powers and Challenges of Mechanisms for Meetings between Management and Services,” in such a way that the words with the highest chi-square values are: “meeting” (χ2=79.33) and “collegiate” (χ2=69.25). Participants highlight team meetings and management collegiate meetings as important mechanisms for gathering management and services. According to the participants, through these spaces, the management can act “in the sense of appreciating, encouraging, and supporting the services,” as well as facing the challenge of having “to beg for the team to pay attention to tuberculosis data, [...] to pay attention to smokers, to people with mental disorders.”

Participants also point out the existence of certain “tensions” in these meetings between management and services. Thus, they highlight the need to be strategic in the use of these spaces for strengthening the management-services relationship, knowing the time to intervene through speech and silence. Moreover, participants mention the need to implement strategies to strengthen relationships within the management itself through regular meetings between technical areas, “in such a way these meetings can mean something else, to perceive them as a coping strategy, investing in the relationship between management teams. How are we going to provide territorial or institutional support if we do not practice it ourselves?”

In addition, the discussion on the need to continue these strategies so that they are not discredited, as well as paying attention to this space of management collegiate to actually guarantee the democratization of decisions and information, emerged in this class. In the participant’s words: “The collegiate body has to be very careful, it is nice, it is an interesting space, but sometimes it is always attended by the same person, that person who did not even have meetings with her own team in such a way to share what had been discussed there. Hence, there was only one person with all the information, this is also dangerous.”

Class 3 represents 26.3% of the analyzed content, titled “Management Conjectures and Expectations regarding Service Professionals.” The words with the highest chi-square values are: “expecting” (χ2=41.22), “thinking” (χ2=34.19), “lack” (χ2=25.89), “organization” (χ2=25.36), and “health policy” (χ2=23.75). Participants state that, sometimes, there is “lack,” in the management-services relationship, in making what the management “expects” from these services more explicit, which would be to comply with the principles and guidelines of the “health policy.” In this debate, other participants add that there is a “struggle between the managements” of the same department, which probably makes it difficult to understand the “unique priority of the health sector.”

Still concerning expectations, the participants point out that they expect greater organization of the services, in the sense of knowing the health policies, as well as the epidemiological data of the territory, for health care planning. The management professionals, participants in this research, are also hold accountable for having the expectation of improvements in the SUS organization they serve. “This quality that we expect from the care provided by health services also needs our contribution. I honestly hope that people see and understand the complexity of working in the field of Health Care.” The participants also mention an expectation of recognition on the part of the services: “What I expect from them is the recognition that we are two sides of the same coin, we cannot be separated. And this integration is very difficult.”

Class 2 represents 12.60% of the analyzed material, titled “Territory: complexity, possibilities and challenges,” in such a way that the word “territory” (χ2=66.84) appears with the highest chi-square value, followed by the words “health” (χ2=57.95), “violence” (χ2=48.06), “listening” (χ2=36.04), “articulation” (χ2=34.51), “action” (χ2= 31.38) and “care” (χ2=30.79). It is worth noting that territory is understood by the participants “as a place to live, as an existential place for people, as a geographical space [...]”. Participants considered the breadth of the concept of territory, highlighting its dynamism, complexity, and organicity.

When addressing this theme, the participants discuss how this territory also permeates their work processes, highlighting the development of territorial articulation as one of the functions of the management. In the participant’s words: “We deal with territories that have more traffic, more violence, homophobia, older people. And then we ended up having to deal with issues that are not linked to the governability of a single technical area, of a Health Unit, but rather as a whole. All technical areas will have to be responsible for taking care of that territory.”

In this sense, the figure of the territorial articulator was created in this management, whose function, according to the participants, is to know more about each of the territories to improve the health system, through management, services, and community partnership:

A practical example of this movement of the articulator, of being close to the territory, was a situation in a place with a very high rate of teenage pregnancy […] we did a survey on the epidemiological situation in the area, we discussed it with the network, […] We found a practical solution, we retrieved the team’s history and found that some time ago they allowed the access of teenagers who sought family planning services, who, due to any transition there, were prevented from it. […] And how about trying to reopen it now, to think about a group, a dialogue, a participation with them? They were able to review this role and see that it was an experience that has been working.

The participants point out that when they manage to be in the territory, there is an improvement in the management-service relationship: “they feel appreciated, it makes a huge difference for us to be there.” Nevertheless, some participants reported they still feel insecure, especially when the issue concerning the territory is not directly related to the technical area in which they work. Participants also recognize that they are not always able to appropriate this territory. For some of them, this articulation is still flawed: “we do not articulate territory with social movement, with schools.”

The expressive repetition of the words “violence,” “health,” “care,” and “action” refer to the territory as a place of care, but also as a space for violation of rights due to manifestations of social issues. In this context, the participants report the challenge of thinking about the comprehensiveness of health care taking into account only health, thus highlighting the intersectoral articulations as paramount to deal with these situations in the territory. Thus, another participant highlights the fact that management is not in the territory as an authority that will provide an answer to the problems, but rather with the intention of discussing the health policy implemented to each reality.

Class 1 comprises 32.78% of the analyzed content, titled: “Management: identity and work routine.” The words with the highest chi-square values are: “there” (χ2=32.82), “when” (χ2=29.51), and “speaking” (χ2=29.23). The first two are adverbs, one indicating place and the other indicating time, apparently used to situate and/or contextualize the management. This class comprises from the specific role of management to the participants’ perception of occupying different roles - “manager” (χ2=21.08) and “service professional” (χ2=18.47).

In this sense, participants refer to the heterogeneity of the management team and, therefore, the difficulty in recognizing themselves with a “common identity,” as indicated in the excerpt: “Management is this place; in fact, we are many ‘managements,’ we can even talk about a whole, but there are many ‘managements’ here within this group […]”.

Participants emphasize that this management team assumed, at the municipal level, a centrality regarding the resolution of conflicts and/or problems related to Health Care and other issues that “do not necessarily belong there. Hence, if it succeeds, it is because of the Department, if it does not, it is because of our management.” Based on this consideration, they claim that the “capture” of management due to changes enhances the fragmentation of demands to the service professionals: “So, it cannot work. I go there to talk about women’s health, she is going to talk about mental health, she is going to talk about the Street Clinic [Consultório na Rua project], and then service professionals want to know what time they are going to do what they have to do.” Another participant adds that this fragmentation will also negatively influence the functioning of management itself.

The participants still mention that it is not a “comfortable position, that of the management [...] you have to conduct this negotiation there, and come back and do it here. Because we are in the middle of this, this is the worst place to be in life.” In addition, these participants report to feel little recognized, so much so that the financial compensation for occupying this position is lower compared with the wage of service professionals.

Discussion

The content of all classes presented in the results indicates the complexity of the health system, its multidimensionality and connections, ambiguities, uncertainties, order and disorder. This evokes the Complex Thought, as introduced by Morin, to understand the relationships present in the SUS, which are the object of this study. Next, we present the discussion of the results associated with the principles of Complex Thought.

The Dialogic Principle allows us to problematize relationships beyond a perspective that excludes contradiction; on the contrary, this principle assumes the acceptance of opposites, that is, it maintains duality as a central aspect, associating “two terms that are both complementary and antagonistic at the same time” (Morin, 2015: p.39). Management and services, in addition to other social instances and actors, compose the unit formed by the SUS. This does not mean that these two places (management and services) have, or should have, equivalent understandings and logic. The issue consists in benefiting from the coexistence of this diversity, which has antagonisms, which are also part of this system.

For Morin (2007, p.15) the word system precisely refers to the “organized set of different parts, which produce qualities that would not exist if the parts were isolated from each other.” In this sense, as addressed by the participants, the need for continuity and regularity of these meetings between management and service (the meetings and collegiate bodies presented in this study, for example) is emphasized to ensure the democratization of decisions and to share different points of view, which for Cecílio (2005) are conditioned by the place each actor occupies in the SUS and by their intentions.

It is worth noting that such meetings, which according to the Systemic Principle, must link knowledge of the parts to the knowledge of the whole (Morin, 2007), do not take place without “tensions” and “disorder,” they involve “to beg for the team to pay attention to tuberculosis data, […] to pay attention to smokers, to people with mental disorders,” which does not necessarily mean that the service disregards these situations, as indicated by the study participants, but it can assume different understandings or focus on other situations understood by the services as priorities in that time-space. This is mainly due to the understanding that “all knowledge is a reconstruction or translation performed by a brain, within a culture, and a specific time” (Morin, 2000, p.211-212) - Principle of Subject Reintroduction in any kind of Knowledge. Thus, we can state that there is not necessarily a “single priority in the health sector.”

As pointed out by Cecílio (2005), the “organization” that professionals of the analyzed management perceive is not the same as that perceived by the service professionals; these differences are part of the tensions that constitute any organization and are related to conflicts present in the managers’ agendas. According to the Complex Thought, these conflicts should be accepted as a possibility, including the reconstruction of daily relationships in favor of continued and comprehensive health care. Considering the perspective that management and service can mutually create a more confident “look,” as brought up by the participant, toward the integration of these several actors in the construction of SUS.

However, this largely depends on the way institutions deal with conflicts: by enabling new configurations of healthcare organizations, by the encounter of heterogeneous, inseparably associated concepts and practices, as mentioned by Morin (2007); or by recognizing those well-defined places of power: management determines and services comply (Cecílio, 2005, Paim & Teixeira, 2007, Penedo, Goncalo & Queluz, 2019).

In this discussion, Cecílio (2005) proposes an analysis of conflicts present in healthcare organizations, which meets the need reported by the participants for a “look” inside the institutions. It is about putting different points of view on the “table,” based on the place each actor occupies and their interests, the ways of acting in the face of contradictions (whether offensive, neglectful, or allying with other actors), the resources that they control to deal with problem-situations, for a possible affirmation of spaces for the negotiation of a new contractuality that can make the rules of the game clearer.

Hence, it is understood that it is possible to establish that bond presented by the participants as favorable to the work of the management with the services. In addition, according to the participants, it is noteworthy the difference of working with a team with which they have more bonds and a team with which they do not have it yet. Thus, the importance of establishing a bond between workers is highlighted, also understood as a relationship of affection, respect, and trust, favorable to deepening the process of co-responsibility for health (Barbosa & Bosi, 2017; Brazil, 2011, Santos & Miranda, 2016).

The possibility of developing a bond between workers also converges with the discussions brought up by Campos (2013) on the potential to promote co-management as a pedagogical and therapeutic instrument. The pedagogical dimension refers to the learning character of these encounters regarded in the permanent exchanges between these actors, whereas the therapeutic dimension is effective by providing opportunities for new meanings of relationships, care practices, worldviews.

According to the Complex Thought, it is about the ethics of solidarity, which postulates the understanding between men with regard to gathering “events, actions, interactions, retroactions, determinations, chances, which constitute our phenomenal world” (Morin, 2015, p.13; Morin, 2003). Thus, it makes sense to highlight the importance of spaces for the encounter between service and management professionals, such as meetings and management collegiate bodies, so that everyone has access to information relevant to work - for instance, political movements that permeate the SUS, “the power struggles between the managements,” the operationalization within the department, and also the organization of services and team meetings on the part of workers of these places. What management does is related to the work process of the services; at the same time, the performance of the service professionals affects the work of the management, which, in turn, will echo in the functioning of the health system.

With the Hologrammatic Principle, Morin (2007, p.27) proposes that “the part is not only in the whole, but the whole is inscribed in the part,” which supposes a mutual influence between parts (management and services) and the whole (SUS) and enables to analyze the losses with the fragmentation between “management professionals” and the “service professionals” and within the management itself through its division into technical areas. It concerns a specialization that detaches the object from its context, fragments problems, separates what is united, makes the multidimensional as unidimensional (Morin, 2003). Therefore, it is not about rejecting the possibility of seeking an “identity” on the part of this management; the Complex Thought aims at this distinction, but not with the intention of separating it, but rather of connecting it (to distinguish and connect it).

It is about knowing, in this process of distinction, the “identity” not only of the management, but also of the services, in the case of this study; to apprehend its resources, understandings, difficulties and potentialities, especially considering the discussion that comprises the Complex Thought, according to which one cannot know the whole without knowing the parts; however, one cannot lose sight of the relationship between these parts and their context, as one cannot know the parts without knowing the whole (Morin, 2015). None of these parts alone have the qualities to make this system effective; therefore, the importance of these parts in a process of joint construction of this system is affirmed (Morin, 2007), as we can observe in the words of the participant in class 3, when seeking to achieve “the recognition that we are two sides of the same coin, we cannot be separated.”

It is noteworthy that the way we propose to analyze these management, services, and system, in accordance with the Complex Thought, goes beyond reductionism, which restricts the parts, and holism, which only considers the whole (Morin, 2015); the parts and the whole are equally essential, without attributing values of importance to one or the other. It consists of an understanding that the whole can enrich the knowledge of the parts, which, in turn, will enrich the knowledge of the whole in the same movement (Morin, 2015).

At this point, the Recursive Principle is linked to the Hologrammatic Principle to broaden the understanding of such relationships under discussion. According to this principle, “products and effects produce and cause what produces them” (Morin, 2007, p.28), which means that this health system is also produced by the interactions between these management and services professionals, but this system, once produced, retroacts on management and services and produces them. Hence, being able to question the management, health services, and “health policies” that the participants expect service professionals to implement, considering that these policies constitute the SUS, management and services are products and producers of these management-service relationships.

The participants recognize the importance of management and services being together through those meeting spaces. Nevertheless, they realize that one of the challenges is to make them organic, to promote the establishment of close and trusting relationships between professionals and managers, key attributes to effectively resume the sharing of management as opposed to vertical relationships (Brasil, 2009).

It is understood that this challenge of being together and that insecurity mentioned by the participants - in facing issues brought up by the territory that are not directly related to their technical areas - are related to the influence of our education based on what Morin (2015) calls “simplifying paradigm,” which attempts to dissipate the complexity of phenomena, to eliminate the disorder that is part of life, “to separate what is connected (disjunction) or unify what is diverse (reduction)” (Morin, 2015, p.31).

However, it must be considered that the participants’ recognition of the importance of being connected to the services is already favorable to the analyses and interventions that support the overcoming of challenges. As well as the understanding that is necessary to (re)create instruments, mechanisms, and/or strategies to facilitate the democratic opening of management.

In this study, the territory is also highlighted as an important element in the composition of this system, which, according to the participants, permeates their work processes. The participants’ perspective of the territory is in line with the conception of some authors (Furtado et al., 2016; Lima & Yasui, 2014; Santos, 2002) of collective health that address dynamism, vivacity, and the numerous relationships that compose the territory, marking its essentiality in the lives of people and the social body, in a reciprocal influence. For Santos (2002), the territory consists of the inseparable set of physical, natural, artificial aspects, social practices, combinations of technique and politics.

At this point, as brought up by the participant, the “[...] complexity of working in the field of Health Care” is presented. The Principle of Self-eco-organization brings to the discussion the capacity of institutions to organize themselves, in this case, management, services, and the SUS, in a process called by Morin (2015) as self-organization, but which precisely depends on of the relationship that these instances establish with the territory.

Thus, the management team in question considers as one of its functions, precisely, the territorial articulation, in the figure of the territorial articulator, whose function, according to the participants, is to know more about each of the territories for strengthening the SUS, through the management, services, and community partnership. This proposal is close to that of the articulators of the Primary Health Care (Doricci et al., 2016; Ordonez, & Arantes, 2019), which aims to strengthen services at the municipal level, through humanization, communication, listening, and collective discussion of local needs (Doricci et al., 2016).

The participants also recognize the importance of articulation with other sectors to address, for example, the issue of violence present in the territories. It is an intention to extrapolate the healthcare field specifically to integrate the other daily relationships that people experience in their territories (Carmo & Guizardi, 2017). Nevertheless, they encounter a type of thinking based on a logic of linear causality, contrary to what is postulated by the Complex Thought in its Principle of Circular Retroactive Movement, of a non-linear relationship that moves between cause and effect and, thus, aggregates other sectors and social actors.

In this sense, the debate reaches the dimension of social participation in the appropriation of territories. As a result, it is worth resuming that the National Humanization Policy (Brasil, 2009) provides for the inclusion of social actors, such as managers, workers and users, in the construction of mechanisms or arrangements capable of analyzing and proposing changes from care services to management. Merhy (2013) suggests, in this debate, a “publicizing reform,” in which the SUS is built through the daily exercise of expanding citizenship and the appropriation of public spaces. This demonstrates the continuous and unfinished nature of the construction and/or implementation of health co-management.

It is understood that the exercise of Complex Thought in the field of health care can be a possibility to face the challenges presented by the participants concerning articulation with the territories, including social movements, schools and other sectors and from the perspective of an authority that will provide the answer to the problems of the services. Complex Thought acts by mobilizing the whole, by bringing simplicity and complexity together, by gathering the characteristic opposites of reality, by contractuality, contextualization, while recognizing the singular, the individual and the concrete (Morin, 2007).

In this logic of thought, it is possible to understand that when health professionals - whether from the management and/or services - deny the possibility of meeting, the result is possibly an increase in the rate of teenage pregnancy, for example, as brought up by the participants. According to Santos et al. (2012), this population, as well as any user of the system, needs to be heard, respected, and valued in their ideas, experiences and feelings to adhere to the actions and services offered by health care. “Adolescents do not want things to be handed to them on a silver platter and, perhaps, they have not found this space in the health service yet” (Santos et al., 2012, p.1281). Thus, Complex Thought requires constant dialogue and negotiation with reality, without intending to control it, precisely because it accepts the challenge of uncertainty and understands the diversity of realities and the need to rethink and modify healthcare practices (Morin, 2003).

Final considerations

This study sought to analyze the conceptions of a health management team about their relationship with professionals in a municipal healthcare network, based on the theoretical-philosophical framework of Edgar Morin’s Theory of Complexity. The exercise of Complex Thought emerges in this study as a possibility of contributing to the consolidation of articulations necessary for the SUS, as this way of thinking about the world and its relationships embraces contradictions, considers differences and then connects them, recognizes the importance of everyone in the composition of this health system by stating that “the whole is at the same time more and less than the sum of its parts” (Morin, 2015, p.45).

Thus, the value of the encounter between the different health actors is stressed, converging with the conclusions of other studies in the area. Nevertheless, it is noteworthy that the meeting is not limited to gathering people, which means to state that meetings and management collegiate bodies themselves do not guarantee the necessary integration; it is necessary to enable, in this meeting, a genuine openness to the difference, to the constant analysis of the work processes of management and services, to the conflict and to the construction of an ethical and solidary perspective between these health actors.

Therefore, this research also stresses the importance of the bond between professionals, which possibly favors the recognition required by management and service professionals in relation to the work performed by them, in addition to enabling more transparency of information and expectations each professional has in relation to the other’s work.

Furthermore, according to the results, there is a network of interactions that can determine the quality of the management-service relationship and its effects on the population’s work processes and health production. The relevance of this study is also due to the fact that, by participating in the research, professionals of this management team were able to verbalize and reflect on these daily relationships and their repercussions throughout the work process, both for the management team itself and for the professionals who work in the services. The present study directly contributes to the production of scientific knowledge in the field of health care.

Thus, the phenomenon addressed in this study is constituted by multiple and diverse factors that recursively affect each other. This characterizes the health system as being produced also by interactions between these management and service professionals; but this system, once produced, retroacts on management and services, thus producing them; and hence a relationship is established: product and producer continuously interacting. The discussion on the intersection of territory in the work dynamics of the management teams stands out, in addition to the importance of this context for the services. This indicates the need for organization also on the part of management teams based on the complexity of the territories.

Finally, addressing these relationships only from the point of view of management professionals is considered a limitation of this study. For this reason, the need for further research is indicated to apprehend the understandings of service professionals and users about the relationships in the SUS, aiming at confirming the democratic principles of this health system.

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Publication Dates

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

History

• Received
  04 Nov 2020
• Reviewed
  13 Mar 2021
• Accepted
  24 June 2021