Reflections on the management of Brazilian Unified Health System for the coordination in facing COVID-19

Abstract

Objective

to reflect on the Unified Health System (SUS) health management, from the perspective of challenges and possibilities to overcome coordination gaps in facing COVID-19.

Method

this is a reflective study, based on the discursive formulation on health management in SUS organized in the following sections: an introduction with the context of the theme, macro challenges in the scope of SUS in the coordination of health care in facing COVID-19, aspects of supporting management coordination actions and final considerations.

Results

there are challenges in the coordination among federal entities, financing, consolidation of health surveillance, regulation, installed capacity, and in the management of people who refer to the importance of establishing strategies to strengthen SUS, mainly in the coordination of healthcare management.

Conclusions and implications for practice

the relevance of the regulatory management authority in SUS for coordination and its organizational potential in providing better care conditions is highlighted, but it is understood that it is necessary to review the territoriality, planning, and work process, as constituent elements of health surveillance.

Keywords:
Pandemics; Health Management; Health Care (Public Health); Public Health Surveillance; Unified Health System

Resumo

Objetivo

Refletir acerca da gestão em saúde do Sistema Único de Saúde (SUS), na perspectiva de desafios e possibilidades para superar lacunas de coordenação no enfrentamento da COVID-19.

Método

Trata-se de estudo reflexivo, fundamentado na formulação discursiva sobre a gestão em saúde no SUS organizado nas seguintes seções: introdução com a contextualização da temática, macrodesafios no âmbito do SUS na coordenação da atenção à saúde no enfrentamento da COVID-19, aspectos para subsidiar ações de coordenação da gestão e considerações finais.

Resultados

Constatam-se desafios na coordenação entre os entes federativos, de financiamento, de consolidação da vigilância em saúde, da regulação, da capacidade instalada e gestão de pessoas que remetem à importância de estabelecer estratégias para o fortalecimento do SUS, principalmente, na coordenação da gestão em saúde.

Conclusões e implicações para a prática

Destaca-se a relevância da autoridade da gestão regulatória no SUS para a coordenação e sua potencialidade de organização em prover melhores condições de atenção, porém, entende-se que é necessário revistar a territorialidade, o planejamento e o processo de trabalho, como elementos constituintes da vigilância em saúde.

Palavras-chave:
Pandemias; Gestão em Saúde; Atenção à Saúde; Vigilância em Saúde Pública; Sistema Único de Saúde

Resumen

Objetivo

reflexionar sobre la gestión de la salud del Sistema Único de Salud (SUS), desde la perspectiva de los retos y posibilidades de superar las lagunas de coordinación en el enfrentamiento a la COVID-19.

Método

Se trata de un estudio reflexivo, basado en la formulación discursiva sobre la gestión de la salud en el SUS organizada en las siguientes secciones: introducción con la contextualización del tema, macro retos en el ámbito del SUS en la coordinación de la atención de la salud para el enfrentamiento a la COVID-19, aspectos para apoyar las acciones de coordinación de la gestión y consideraciones finales.

Resultados

existen desafíos en la coordinación entre las entidades federales, el financiamiento, la consolidación de la vigilancia de la salud, la regulación, la capacidad instalada y la gestión de las personas que se refieren a la importancia de establecer estrategias para fortalecer el SUS principalmente en la coordinación de la gestión en salud.

Conclusiones e implicaciones para la práctica

Se destaca la relevancia de la autoridad de gestión reguladora en el SUS para la coordinación y su potencial organizativo para proporcionar mejores condiciones de atención, aunque se entiende que es necesario revisar la territorialidad, la planificación y el proceso de trabajo, como elementos constitutivos de la vigilancia de la salud.

Palabras clave:
Pandemias; Gestión em Salud; Atención a la Salud; Vigilancia em Salud Pública; Sistema Único de Salud

INTRODUCTION

In Wuhan, China, the occurrence of SARS-CoV-2 coronavirus Severe Acute Respiratory Syndrome (COVID-19) cases caused the World Health Organization (WHO) on January 27, 2020 to classify the evolution of these cases as Very High Risk to China and Regional and Global High Risk.¹ The rapid contagion and complications resulting from this outbreak led the WHO, on 30 January 2020, to declare this outbreak a Public Health Emergency of International Importance.² As a result of global expansion, epidemiological and health repercussions, on 11 March 2020 the WHO designated COVID-19 as a pandemic.³

It can be estimated that no country will be immune to the effects of the pandemic, either in larger or smaller proportions, perceiving an imbalance in various sectors, with an impact on pillars of society, such as health, economy and education.⁴

In China, health authorities have adjusted strategies as the evidences are consolidated for decision making.⁵ In Europe, health and political authorities have installed protective measures established by the WHO and the European Centre for Disease Prevention and Control (ECDC) to ensure technical support in case detection, reduction of the spread of the virus, as well as public awareness.⁶ In the United States, the rapid expansion of contagion, aggravated by organizational characteristics of the health system, required measures in line with the guidelines of the Centers for Disease Control and Prevention (CDC).⁷ In South Korea, the isolation of 80% of communicators minimized the transmissibility of the virus and the safety of health professionals.⁸ In the Region of the Americas, on April 10, 2020, 34 countries, except Nicaragua, applied restrictions on population movement.⁹

Heads of State in virtually all countries have enacted legal instruments for financial and fiscal protection for specific segments of the population in order to meet needs and maintain essential services.⁹

Health and the economy are closely linked, however, the economic impact of the pandemic reflects on the state apparatus and, clearly, the way the state conducts itself has repercussions on the health system and the economy. Social responsibility, strategic alignment with international reference organizations such as the United Nations (UN), the World Health Organization (WHO), the Pan American Health Organization (PAHO) and national research institutions, is necessary to base emergency public policy decisions on technical criteria and scientific knowledge, without incurring in mistakes.

Considering the expanded health approach, it is necessary to include emergency socioeconomic strategies for minimum resource guarantees to the population in a socially vulnerable situation. The actual or potential socioeconomic impact caused by the application of rigid social distance and other measures adopted are related to the minimization of exposure to infected persons and, consequently, to the possibility of reducing the incidence of cases, in a strategy both to save lives and to alleviate the crisis in health systems, resulting in a gain of time for structuring services and the possible development of other appropriate measures, such as effective treatment specific to COVID-19 and/or development of vaccines.⁹

National health and social care systems require, among other measures, vital data, quantifying the effect of COVID-19 on the health and social care sector, including morbidity and mortality by age, gender, ethnicity and care environment.¹⁰

The pandemic has exposed the need for a rapid review of health systems for a timely response in integrated and universal health and social care services. In spite of questions, limitations or fragilities, the Unified Health System (SUS), based on universality and decentralization, among other principles, has been understood as a relevant differential in the confrontation of COVID-19, given the potentiality of its actions in an approach of integrality.

This reflection is justified by the scale of the impact of COVID-19 on the world, the responsibilities and tasks of management for health systems and services, the opportunity to use the context of the pandemic to address recurrent and emerging problems in SUS. Thus, this article aims to reflect on SUS health management from the perspective of challenges and possibilities to overcome coordination gaps in facing COVID-19.

METHOD

It is a reflective study, based on the discursive formulation on SUS health management, considering current references, analogies and different theoretical and/or practical perspectives.

The reflections woven are guiding axes coming from the scientific literature and the authors' considerations, which, considering the dynamicity and contemporaneity of the subject, considered pertinent to the current pandemic scenario, and may become out of context when it ends or in the near future. However, the reference that subsidizes the management of health systems, although it has the characteristic dynamism of historical-social construction, can be said to be consolidated and, in this sense, advances produced to face the pandemic can have repercussions in overcoming some recurrent problems in SUS and the emergence of new obstacles.

The reflection is presented in the following sections: introduction with the contextualization of the theme, the macro challenges in the scope of the SUS in the coordination of health care in the confrontation of COVID-19, aspects to subsidize management coordination actions and final considerations. Based on the current pandemic situation, with reflections on the basic and recurring challenges of the SUS, perspectives for management in the coordination of the pandemic response were addressed.

RESULTS AND DISCUSSION

Unified Health System macro challenges in coordinating health care in addressing covid-19

In Brazil, the crisis of the coronavirus pandemic exposed difficulties of coordination among the federative entities,¹¹ reinforcing the need to include debates on decision-making relations in the political administrative apparatus through coordination and territoriality.

The SUS recognizes founding weaknesses arising from underfunding,¹² from the process of decentralization,¹³ from the depreciation of infrastructure at different levels of attention, especially at the tertiary level.¹⁴ In addition to these issues, there are adversities related to human resources,¹⁵ including deficit, difficulty in setting up, different forms of hiring, job insecurity, and low investment in continuing education. Thus, both structural and human capital limitations justify the urgent need for this system to be adjusted to respond to the recurring management demands that have worsened with the pandemic.

The heterogeneity of contexts in the process of political, administrative and financial decentralization, in addition to the very issue of technological incorporation driven by the decentralized management relationship, aligned with attempts to regionalize health care, has shown fragmentation of the system. The logic of regionalization as a resource to favor access, completeness, organization of locoregional systems and economy of scale, although it is stimulated as a strategic policy, has not yet reached its full potential.

A historical aspect, of complex approach, concerns the regional inequality in the distribution of health equipment in Brazil,¹⁶ remnants of the public-private mix, of market interests, and of the scrapping of the public health sector itself. For example, the insufficient and distinct coverage of beds in Intensive Care Unit (ICU). Data show that 64% of health regions, adding private and public beds, are below the recommended parameter,¹⁷ that is, ten ICU beds for every 100,000 inhabitants.¹⁸ Simulations for the pandemic scenario pointed out that 30% of health regions in the country are vulnerable to overcrowding, in addition to scarcity of ICU beds, ventilators and respirators.¹⁹

The ICU bed strongly requested in the pandemic scenario, an assistance resource exposed as an example, presents unequal distribution and low installed capacity, when approached in health regions. It is noteworthy that the expansion of the number of ICU beds requires time for its creation due to the high financial investment for installation, the peculiarity of access to equipment and material resources required, the need for specialized and trained personnel, among other requirements.

This observation highlights the need to regulate assistance at the federal level, the re-discussion of health regions within the scope of health management, and the relevance of the manager, at different levels, to appropriate the data that allow the dynamic diagnosis of the network and available assistance resources. For example, the National Registry of Health Establishment (CNES), in force and consolidated. However, the pandemic exposes that, for many managers, this is a tool that is little updated and used as a management support tool, revealing that available management resources could be better used, although they have been trivialized and currently, in view of the urgency to make decisions about the assistance infrastructure and operation of services, several managers have demonstrated inconsistency in the diagnosis of installed capacity, which in turn results in decision-making fragility.

In different contexts of states and municipalities, unequal conditions of access to the Internet, technological park, and training of personnel to use Health Information Systems (HIS) are recurrent situations.²⁰ To face the pandemic, weaknesses in structural and operational issues, which require data generated by the HIS for decision-making, assistance, and management are other obstacles to be overcome.

The regulation of access and assistance, a powerful management tool to make care available in timely time and space, presents limitations in the coordination of the federated entities, especially for the attention of medium and high complexity, chronic complaint of managers.²¹ In the scenario of a pandemic, the circulation of users, by free demand or referrals, in search of the possibility of access, may imply the worsening of the health situation and increased risk of dissemination of the disease.

The arrival of a pandemic has intensified the processes of fragility in attention to acute and chronic conditions. It is noteworthy that the attention approach was no longer sufficient and adequately organized to meet the demand in SUS, a situation resulting from limitations of health care models, fragmented and reactive operation of the health system, and insufficient qualification of Primary Health Care (PHC) to fulfill its functions and attributes in the health system.²²

Funding, a controversial aspect that includes everything from insufficient resources to proper application, interfaces with all the other challenges and implications for all federal levels. The management of the Ministry of Health (MS), Secretariats of Health of states and municipalities already presented recurrent budgetary difficulties,²³ despite the situation that the pandemic requires a proactive posture of managers in negotiations of the executive, legislative and judicial powers, including intersectoral approach in the use of financial resources, in order to ensure budget for the purchase of inputs without losing responsibility for the provision of human capital and its training.

One of the challenges of financing includes technical feasibility and monetary authority to make resources available for planning and regulating the provision of health professionals and support services, training of personnel, acquisition of inputs of different natures, materials for diagnosis, therapy, Personal Protective Equipment (PPE), adequacy of physical structure and operation of ICU beds, availability of reaguard beds in general hospitals and/or create campaign hospitals, increase prevention measures, in short, a set of means necessary to confront COVID-19.

Quantitative-qualitative gaps of professionals represent a historical challenge, from aspects of training²⁴ aggravated by the measures of job insecurity,²⁵ interruption of policies inducing qualification and professional attachment.²⁶ This scenario becomes more complex the more internalized the municipality is, but it is also a problem present in large centers, whose services require highly specialized professional staff. The management of people is a challenge that is growing at the present time, which corresponds to the confrontation of this pandemic, with the aggravating workload, with professionals exposed to unhealthy conditions, which put them in a situation of getting ill, which results in a decrease in the number of personnel.

In summary, the challenges presented are not new, but the pandemic exposes and amplifies the seriousness of recurring management problems in health care coordination, which challenge the operation of a universalist health system, in a country of continental dimensions with heterogeneous socioeconomic and health characteristics, regional diversities and peculiarities among the federated entities that have autonomy and hierarchy relations in the federative function. However, it is necessary to emphasize that the Brazilian differential for the confrontation of COVID-19 can be exactly the relevant and strategic elements that compose the framework of SUS.

Aspects to subsidize management coordination actions

The reflections presented can collaborate with managers and health professionals in the singularity of their contexts, adding efforts of different actors and resources to coordinate actions to confront COVID-19, which will also bring contributions to the improvement of the health system. Although the challenges are not new, the urgency of the pandemic requires quick responses, considering viable and feasible propositions in each situation. There is no pretension and/or feasibility in indicating guidelines to be operated in a uniform manner in different scenarios; it is possible to reflect on possible paths.

To build contextualized alternatives, considering the SUS organizational mechanism and the breadth of several departmental actions, the relevance of organizing articulated, intersectoral committees to confront COVID-19 that strengthen the actions in the federated entities is highlighted. The technical group formed for management/defrontation should issue normatizations and technical notes based on the criteria aligned in the committees and cabinets, having dialogue and scientific evidence as a guiding thread for decision making, considering an agenda that brings together schedules for different phases of the epidemic, including analysis of flows and simulations of possible scenarios, a primary exercise for preparatory actions and plans to respond to demands.

In this sense, the collegiate management, by establishing spaces for constant debate on planning and monitoring, helps to overcome difficulties in organizing access to care, ordering emergency services, and overcoming administrative rigidity, since these committees need to have strategic and rapid action in decision-making.

In order to make viable the actions of managers and their teams, there is a rich bibliographic collection available, in different types of publications, including digital media, that disseminate knowledge and research results whose incorporation into practice favors the adoption and/or adaptation of strategies that provide institutional innovations to confront COVID-19. Among so many resources, for example, to enable management support advisory services, to establish an interface between strategic planning and collegiate management,²⁷ to favor the approach with universities and technology parks to stimulate and incorporate research products that can respond to local needs;²⁸ to use scientific material disseminated to create operational procedures and devices to disseminate knowledge via institutional email and/or applications for the exchange of audio and video messages over the Internet for cell phones.

A set of federal actions has been implemented in an attempt to strengthen the confrontation with COVID 19, transferred through the Block for the Costing of Actions and Public Services of Health²⁹ and for the creation of a specific budget in the federal entities.³⁰ However, underfunding, a problem that has been present since the implementation of SUS, which has worsened over time and, more recently, the policy of deep austerity with the Consticutional Amendment 95/2016,³¹ provides progress in the deconstruction of SUS with the suffocation of funding. There is an opportunity to resume the perennial dialogue of health underfunding as one of the alternatives to face the challenges and consolidate the financing agenda in the SUS agenda.

The pandemic has triggered emergency funding measures, coming from other government sectors, a necessary measure, but one that requires clarity of the limitation of these resources in the face of the uncertainty of the duration of the pandemic. The technical area of Health Economics of the Ministry of Health could be an important channel for the dissemination of economic information analysis of public resources to favor decision making by managers.

In order to streamline and make these measures feasible, it is recommended to establish intersectoral communication that also involves the legislative power, the judiciary and society in each federal entity, especially the National Congress and the Judiciary Power.³²

Regionalisation has the power to favour health responses in territories.³³ In order to face the pandemic, it is necessary to identify more vulnerable regions in order to optimize the use of services and scale up the installed assistance capacity.¹⁹ When considering the previous inequality of Brazilian health regions, the internalization of the pandemic will require regional planning and reorganization of the health system by means of assistance regulation.³⁴

The articulating role of regulation contributes to mapping the operational capacity for rapid response³⁵ for intra- and interstate transfers, including a line of care, with referral services, for suspect users who test positive or require emergency attention for COVID-19. The elaboration of assistance flows for access aims not only to promote care, but also to prevent or minimize health services from becoming sites of disease dissemination. It should be emphasized that these assistance flows will not be watertight, but as monitoring indicates progress, stabilization or regression of the number of cases, of the occupation of beds and services, there is a need for revision and readjustment of these flows, with the respective institutional and social communication, in order to give agility to management in its capacity to meet demands.

In this sense, in order to ensure the actions of health services regarding the availability of production, storage and distribution of equipment, materials and inputs, it is necessary to intensify the articulations in the three federated entities, with agile agreement between the inter-managerial committees, Bipartite and Tripartite Inter-Managerial Commissions (CIB and CIT), honoring the space of the collegiate instances of the National Council of Health Secretaries (CONASS), the National Council of Municipal Health Secretaries (CONASEMS), the Council of Municipal Health Secretaries (COSEMS), the National Health Council (CNS) and its social control instances.

In order to face the complexity of the Brazilian sanitary framework, the potential of Health Surveillance in the articulation between 'cause control', 'risk control' and 'damage control' of the means of work, activities and technical and social relations is confirmed,³⁶ but it is identified that the advancement and strengthening of the Health Surveillance approach is diverse among federated entities and health regions.

The National Health Surveillance Agency (ANVISA) has a relevant role to assist health management³⁷ in acts to prevent and reduce health risks related to the production and use of products and services, both with regard to the regulation of equipment, medications, IPE (EPI), as well as the guidelines that underpin the local action of health surveillance in the establishment of health protocols.

Since COVID-19 is a recent disease, remote access information and updating is important,³⁸ but for management, regulation of inputs, circulation of people, prevention guidelines are constantly updated,³⁹ with information shared in a dynamic way, including those related to material quality monitoring.

Rapid actions to respond to the demands need to be adopted by the Health Surveillance sectors, to activate Event Monitoring Committees, as well as to classify the level of emergency (zero, I, II, III),⁴⁰ in addition to articulating with the Emergency Health Operation Centers (EHOCs) in monitoring epidemiological data to guide, direct strategies and support management decision making.^41,42 The timely potential of a Health Surveillance Strategy Information Center to support management stands out.

Still in the regulatory field, although in this article, emphasis is given to SUS management, the National Agency for Supplementary Health (ANS), a reference body for the supplementary health sector, has a relevant role in coordinating actions to confront COVID-19, in response to needs in the face of the health crisis, recommending that public and private resources be regulated solely by SUS management.⁴³

The priority of health management should be active case detection and surveillance in socially vulnerable populations,⁴⁴ from the perspective of access to strategies and testing to screen contacts and implement isolation in these areas.⁴⁵ Containment of the source of contamination is the best strategy to protect vulnerable communities.⁴⁴ In rural Vietnam, screening and telehealth⁴⁶ have been used; in China, local production face masks have been used in their rural communities.⁴⁷

A guideline adopted in Brazil to strengthen a faster and more timely response to demand has been telehealth,⁴⁸ with guidance in this pandemic of expanding telemedicine strategies.⁴⁹ The expansion of this service, coordinated by technical reference centers in the service, can substantially minimize problems arising from the behaviors adopted by the services, including in interlocution with regulatory centers.

The SIS and communication capacity are key to strengthen strategic actions in Health Surveillance. Therefore, the MS, the system manager, must make the information available through a routine of disclosure of epidemiological conditions. Communication includes strengthening links between managers and communities both for the dissemination of relevant information and to collect data to support decision making.

The management of health professionals needs to provide safe conditions both for the qualified care of users and professionals, ranging from training for care, provision of IPE, training and supervision in the adoption of biosecurity norms already recommended for the updating of the conduct of scientific societies before COVID-19.³² One cannot fail to install, in the conduct of management, improvisation in care practice that can expose professionals to process of getting ill, besides facilitating the dissemination of COVID-19.

The MS in Brazil focuses on strengthening team capacity building actions in the Brazilian regions, hiring health professionals to address COVID-19.³² However, strategies to overcome quantiqualitative staffing gaps include multiple approaches to training, capacity building, employability, working conditions, among others, widely known and, why not say, until recently, low priority. Considering the dynamics of work and professional training, identifying and recruiting a contingent of health professionals to rebuild teams is not something simple in a country with a heterogeneous distribution of professionals.

The pandemic shows that without health workers it is not possible to think and make it happen in relation to health. Therefore, it is necessary to revisit the field of training and induction of continuing education, which, in this context of the pandemic, has revealed strengths and gaps, of professional qualification and attachment and which needs, after minimizing events, to establish dialogues between the academy and the service, and vice versa, emphasizing the required skills with the specificity of interventions needed in each context.

In this reflection, we should recognize, although it has not been explored, the relevant role of initiatives by social institutions⁵⁰ to create employment and income possibilities, for example, the making of facial masks, which are essential for prevention strategies, in addition to the many educational strategies that have been broadcast, in different media, adding efforts in health care.

In Brazil, the coordination of actions to confront COVID-19 has relied on universities, especially those public universities, which have produced scientific knowledge qualified as an agile, innovative and pertinent response to the challenges of the pandemic. The importance of funding to conduct the academy activities for both research production^51,52 and the training of human resources should be highlighted.⁵³

The situation of the pandemic may stimulate, in the different federative entities, in the field of management, approximation and linking of actions between university and services, since the qualification of managers is still seen as limiting. The pandemic may encourage the incorporation of technologies and innovations, a way for the university to exercise its social role in health, both in terms of people's living conditions and the productive sector of the economy.

The real post-Pandemic challenge is above the question of accepting the sum of all the adversities already presented, regarding SUS. It is understood that the emerging challenge refers to the fact of recognizing SUS as the largest and main Brazilian public policy, which plays a differentiated role in addressing COVID-19. However, the historical fragilities of this System, the current threats and aggravated findings in the context of the pandemic, the mission is presented to society to revisit the initial proposals of the Sanitary Reform, reinforce the advances obtained and show the project of realignment, in the perspective of reaching advances for the consolidation of SUS as a universal, public and free system, that considers the regionalization and coordination as powers in this (re)building.

FINAL CONSIDERATIONS AND IMPLICATIONS FOR PRACTICE

COVID-19 is an unprecedented challenge for health systems worldwide and, in the Brazilian public health system, considering the peculiarities of federal entities, it is necessary to recognize advances, setbacks and limitations in management, as well as the existence of chronic aspects that challenge health coordination in a period that already adds up to more than 30 years of SUS.

Coordination, as a basic requirement of management, favors the capacity of communication for the management of assistance and organizational actions, with decision making focused on care, processes that guide the network of care and allow the connection between the levels of the health system. To this end, the coordination function of the management instances should be occupied by professionals with technical responsibility and strong leadership in crisis management experience. In the absence of this profile, a manager who has the capacity to articulate with the sectors involved and reinforce the autonomy of actions in public health management should be considered or prioritized.

It is recommended that health management, in effecting coordination, review the territoriality, planning and working process as constituent elements of public health surveillance, conceptually constructed, which passes not only the guarantee of access to health care or the organization of supply, but also the space for change in the model of care.

As a contribution of this reflection, the relevance of the regulatory management authority in the SUS for the coordination of care, brought up by the pandemic, and its potentiality as an organization to provide better conditions of care with a view to complying with the doctrinal principles that govern this health system, focused on people who are users, health professionals, and managers is highlighted.

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Edited by

Associate Editor

Antonio José Almeida Filho

Publication Dates

• Publication in this collection
  14 Sept 2020
• Date of issue
  2020

History

• Received
  21 May 2020
• Accepted
  07 Aug 2020