Management in primary health care: implications on managers workloads

Abstract

OBJECTIVE

To identify which aspects of primary health care management, evidenced in current literature, can influence manager workloads.

METHODOLOGY

Integrative literature review with data collection conducted in April 2016, in five databases, with articles published in English, Spanish and Portuguese between 2006 and 2016.

RESULTS

The results of the 78 studies were organized into two macro categories: increased workloads, especially due to the challenge of managing a new care model and deficits in working conditions; and workloads reduction related to the training of the teams and managers, the autonomy and the support for the managers.

CONCLUSION

In addition to identifying factors that increase and decrease the workloads of managers, this study highlights the promising line of research, given the importance of management for the health sector and effectiveness of Primary Health Care.

Keywords:
Health management; Health services administration; Primary health care; Family health strategy; Occupational health; Working conditions

Resumo

OBJETIVO

Identificar quais aspectos da gestão na atenção primária à saúde, evidenciados na literatura atual, podem influenciar as cargas de trabalho dos gestores.

METODOLOGIA

Revisão integrativa de literatura com coleta dos dados realizada em abril de 2016, em cinco bases de dados, com artigos publicados em inglês, espanhol e português, entre 2006 e 2016.

RESULTADOS

Os resultados dos 78 estudos encontrados foram organizados em duas macro categorias: aumento das cargas de trabalho, especialmente pelo desafio da gestão de novo modelo de atenção e de déficits nas condições de trabalho; e redução das cargas de trabalho relacionada à capacitação das equipes e gestores, à autonomia e ao apoio aos gestores.

CONCLUSÃO

Além de identificar fatores que aumentam e diminuem as cargas de trabalho dos gestores, este estudo ilumina uma linha de investigação promissora, dada a importância da gestão para o setor saúde e para efetivação da Atenção Primária à Saúde.

Palavras-chave:
Gestão em saúde; Administração de serviços de saúde; Atenção primária à saúde; Estratégia Saúde da Família; Saúde do trabalhador; Condições de trabalho

Resumen

OBJETIVO

Identificar qué aspectos de la gestión en la atención primaria de salud, evidenciados en la literatura actual, pueden influenciar las cargas de trabajo de los gestores.

METODOLOGÍA

revisión integradora de la literatura a través de la recolección de datos realizada en cinco bases de datos, con artículos publicados en inglés, español y portugués entre 2006 y 2016.

RESULTADOS

Los resultados de los 78 estudios encontrados se organizaron en dos macro-categorías: aumento de las cargas de trabajo, sobre todo por el desafío de la gestión de un nuevo modelo de atención y del déficit en las condiciones laborales; y reducción de las cargas de trabajo relacionadas a la capacitación de los equipos y gestores, a la autonomía y al apoyo a los gestores.

CONCLUSIÓN

Además de identificar factores que aumentan y disminuyen las cargas de trabajo de los gestores, este estudio lleva consigo una línea de investigación prometedora dada la importancia de la gestión para el sector salud y para la efectividad de la Atención Primaria de la Salud.

Palabras clave:
Gestión en salud; Administración de los servicios de salud; Atención primaria de la salud; Estrategia de salud familiar; Salud laboral; Condiciones de trabajo

INTRODUCTION

Health has consistently occupied a prominent place in the concern of people and nations and it is among the 17 goals for sustainable development, approved by the United Nations in 2015¹. The health objective of ensuring a healthy life and promoting human well-being at all ages is directly related to this study, since it implies ensuring universal access and comprehensive care in all settings of services organization.

The debate on universal access highlights the effectiveness and current relevance of the care model described in Primary Health Care (PHC) in 1978 at the Alma Ata Conference². The debate on universal access has stood out in the World Health Organization and the academic community, and is related to the defense of the right to health and access to quality care. It involves the provision of health systems that take socio-cultural, organizational and economic aspects into account in order to meet the needs of the population, providing adequate infrastructure, human resources and health technologies, with affordable costs³.

Care model involves the availability of appropriate services, equipment and tools, techniques, technologies and workforce, as well as appropriate work organization to provide individual or collective assistance⁴. The implementation of care models requires financial resources and adequate management. In Brazil, the National Policy on Primary Care, approved in 2006, updated in 2011 and modified in 2017^5-6) is guided by the precepts of PHC explained in the Family Health Strategy (FHS). This was incorporated into the National Policy on Primary Care and proposes to restructure the healthcare model, guided by the principles of the Unified Health System. The FHS can be understood as a non-material technological innovation of health work organization, which aims at solving problems and meeting the health needs of individuals and collectivities, articulating physical, technological and human resources⁷. In 2017 several significant changes were approved in the National Policy on Primary Care⁶. These changes occurred in the context of a broad process of rights reduction, with negative impact on social policies, adopted by the Brazilian government in 2016, after the removal of a democratically elected president. Despite these changes in the National Policy on Primary Care, it still constitutes the main public policy for the population to access health services.

The PHC care model materializes with interfaces among the political, ideological, organizational, economic and cultural dimensions. In this scenario, the manager of local, regional and municipal levels faces political-ideological, socio-economic and administrative-financial conflicts searching to provide health care in the broadest sense and with more complex responsibilities than that established by the biomedicine model^8-9.

However, in the Brazilian case and in documents of the multilateral organizations of the field of health¹⁰, despite the complexity involved in this work, the attributions/competencies of managers are not explicit. In addition, the literature dealing with the implications of this work on managers' workloads is reduced¹¹.

Workloads, in this study, are considered as elements present in the work process that interact dynamically with each other and with the worker's body, and can trigger the workers' wear and sickness¹². Identifying aspects of management that can contribute to increase or reduce managers' workloads can guide policy action to seek measures to reduce workloads, contributing to achieve the universal right to health¹³.

In this context, the present study aims to identify which aspects of management in primary health care, evidenced in the current literature, can influence the workloads of managers.

METHOD

The present study consists on an integrative literature review and followed the steps suggested by Ganong¹⁴, with the aim of understanding a pre-determined phenomenon using procedures recognized in the academic community for this type of study^15-16.

In order to guarantee the scientific rigor required for studies of this nature, methodological development followed the steps stipulated previously in protocol, which was validated by a researcher external to this study. The protocol was guided by the following research question: What aspects of management in Primary Health Care, evidenced in the current literature, can influence the workloads of the managers? Next, the inclusion and exclusion criteria were defined, the stages of identification and selection, the evaluation and inclusion of the selected studies, and finally, the condensation of the subjects that meet the objective of this study.

The data collection was performed by two independent reviewers, from April 26 to 30, 2016 in the databases PubMed, Latin American and Caribbean Literature in Health Sciences (LILACS), Scientific Electronic Library Online (SciELO), Scopus and Cumulative Index to Nursing and Allied Health Literature (CINAHL).

The search keys used were based on the Health Sciences Descriptors (DECS) and the Medical Subject Headings (MESH), using Boolean operators AND and OR, which follow:

• -Gestão em Saúde/ Health Management/ Gestión en Salud;

• -Administração em Saúde/ Health Administration/ Administración en Salud;

• -Administração de Serviços de Saúde/ Health Services Administration/ Administración de los Servicios de Salud;

• -Atenção Primária à Saúde / Primary Health Care/Atención Primaria de la Salud;

• -Estratégia Saúde da Família/Family Health Strategy/Estrategia de Salud Familiar.

The inclusion criteria were complete articles that contained in the title and/or abstract the terms stipulated in the search keys, published and subject to access via VPN (Virtual Private Network), by the Federal University of Santa Catarina. Articles published in the English, Spanish and Portuguese languages between 2006 and 2016 also served as criteria for inclusion. The period studied is justified by the search for recent publications and in the Brazilian case by the adoption of Basic Health Care as a national policy guided by the precepts of PHC⁵, which remains valid, despite the changes occurred in 2017⁶.

To compose the sample were excluded: duplicate studies, theses and dissertations, books, all literature reviews, editorials, newsletters, documents of governmental entities and results of scientific events, as well as articles out of the theme and those not available in full.

Figure 1
Strategy of search and selection of review studies

The corpus of the research included 78 articles which were inserted in software Atlas.ti (Qualitative Research and Solutions), version 7.6.1®. Each article, when inserted in the software, is automatically assigned an order number and identified as primary document (P1, P2... successively).

The analytical process followed the steps of the exhaustive reading of each article in order to identify the whole content of each text, after the selection of significant fragments (quotations, in the terminology of Atlas.ti) and the assignment of codes. The analysis of the data found in the texts, and their organization in a graphical format (network, software language) made it possible to synthesize the findings and to elaborate analytical categories.

The ethical aspects were observed in this review article, citing the authors and indicating the source in the paraphrases.

Results

The findings of this review were organized into two macro categories: management in PHC and increase of workloads; PHC management and reduction of workloads.

Management in PHC and Increase of workloads

Considering the work process of the managers in PHC found in the articles published on management in the PHC, it was possible to identify several aspects that could contribute to increase their workloads, especially what was highlighted as challenges and difficulties found in the work of management in this field of attention. The set of these challenges and difficulties, with their indication of their greater or lesser presence in the studied literature, is presented in Figure 2.

Figure 2
Challenges and difficulties encountered in management in PHC that can increase the workloads of managers

Among the main challenges or difficulties mentioned by the authors who studied PHC management stands out the difficulties involved in a new care model, which is complex, aims to meet people's health needs, goes beyond the model of individual and curative care, and involves multi-professional teams oriented to perform an interdisciplinary work ^(17-35. As illustrated in the following sections:

The health team should take a multidisciplinary approach and organize the work in a horizontal way, which allows the participation of all those involved in the decision-making process. Another attribute of this strategy is to instigate the exercise of social control of the population for which it is responsible¹⁸.

It is necessary to redesign the macro-processes of work, especially as regards the understanding that the management competences should be broadened. [...] and capable to “unleash among the workers a process of reflection and revision of their practices leading to adherence and commitment to a process of production of health care and not to fulfill fragmented tasks centered on the development of isolated procedures”³⁵.

Several aspects of management mentioned in the texts as challenges or difficulties, visible in group 1 of Figure 2, are related to the characteristics of the PHC model itself, highlighting aspects of this new model that constitutes a challenge for management. Among them were the difficulties of effectiveness of the comprehensive care, including the deficits in the functioning of the care network^{18-19,26,31,35-46} and the challenges of deploying and working intersectorality^{18-19,23,25,28,31,47-53}. It was identified difficulties related to the effectiveness of the Healthcare Councils in relation to the articulation with the population for sharing and approval management instruments of the Unified Health System, in the Brazilian case^19,54. It was also found lack of knowledge by the managers related to the territory under their liability^18,51,55 and about the aspects that involve the management of PHC^17,21,28,40.

The second challenge/difficulty that appeared most in the texts and that can contribute to increase the workloads of the managers is the turnover of professionals working in PHC^{19-20,22,28,30-32,35-36,42,45-46,56,59}, in particular medical professionals, which difficult the establishment of bond with colleagues, managers and users, illustrated below.

Issues such as the precariousness of the bond and the lack of incentives do not stimulate workers to remain in their jobs, leading them to seek better opportunities. Various studies [...] have demonstrated the high turnover of health professionals in Brazil, which generates higher costs of replacement of personnel, dissatisfaction in the work environment and difficulties to provide care to the user due to interruptions in the services²⁰.

The great difficulty we have in relation to human resources is due to turnover, due to the profile too, you know? This makes working progress difficult ³⁵ .

The turnover of professionals is associated with other aspects related to the typical management as the workforce management^{17,19-20,27,31,36,45-46,51,59,60-63}, their qualification to work in the PHC, the working conditions^{19,36,40-42,49}, the functioning and effectiveness of the teams that work in PHC, all presented in group 4 of Figure 2. In this group, also integrating managers' work, we identified aspects related to planning, work organization, quality management, among others.

And, thirdly, aspects described in groups 2 and 3 of Figure 2 were highlighted.

Group 2 describes aspects related to the workforce of the manager including: the deficits in the training for management^{18,20,27,36,40,42,47,64-69}, discrepancy between speech and practice⁷⁰ political influence^{17,19,36,38,40,44,61,63,66-67}; little autonomy^{17,25,29,36,40,50,56,59,63,66,68}; Overload^22,36,55,66; duplicity of activities - management and care, especially in the case of nurses; insecurity in employment^{17,22,26,40,45,48,57} and difficulties related to power relations.

The quotations below illustrate the training deficit among the managers:

[...] managers with little training in Public Health and previous experience in management⁴⁰.

Most of the leaders of the selected municipalities have been acquiring, in practice, the necessary experience for management work. They also suggest a lack of professional improvement, since most of the interviewees had not taken courses to support the realization of management tasks³¹.

This lack of training for management and management in PHC significantly affects the effectiveness of the proposed care model, in which the manager has the coordinating role in order to offer a user-centered attention. It is also important to consider that users have even more complex care needs.

Group 3 describes aspects related to labor instruments, understood in a broad sense including: deficits in the physical area, equipment, materials and information systems^{18,24,27,38,41-42,44-46-50,54,57,61-62,64-66}, problems in the geographical location of local health units^65,71, with emphasis on the deficits in financing and also on efficiency in the application of resources^{18-19,24,27-28,30,35-36,40,50,65,71-73}.

It was also identified aspects related to who is directed the work in healthcare, that is, the users of the services as possible generators of increase of the workloads of the managers^{17,19,24,27,35,40,50,65-66,70}, these aspects are part of group 5 of Figure 2.

Management in PHC and Reduction of workloads

This review also showed aspects that facilitate the PHC management which can contribute to reduce the workloads of managers, presented in Figure 3.

Figure 3
Aspects of management in PHC that can contribute to reduce the workload of managers.

The results indicate that the training/continuing education of the workforce of the PHC teams is one of the main factors that contributes to reducing the workload of managers^{19-25,27,32,34,47-48,51,56,61,74-76}, aspect described in group 1 of Figure 3.

The importance of education/training for management and management experience has also been identified ^17,27,56,76, elements described in group 3 of Figure 3. The national and international literature is convergent in relation to the importance of the training/education of the managers, which can contribute to the reduction of their workloads. One study mentions that managers/managers who hold positions of high, middle management or other, need to be inserted in the process of permanent education³⁶. Another study indicates that in Serbia the perceived competence deficit in health management can be significantly reduced through training⁷⁵. Others ^77-80 show that the training of managers can reduce workloads by facilitating processes in the management of health units.

Groups 5 and 6 articulate typical aspects of management work, how to do it and the institutional conditions available.

Among them, the question of the autonomy of these managers, group 5, was highlighted as one of the factors contributing to reduce workloads^{25-27,42,56,60-61,76}. The responsible autonomy in the practice of the managers, for a decision making in the management of the territory, is of fundamental importance. To managers means the prioritization of the actions to be developed by the team during the care of individuals, families and community⁷⁵. The minimum autonomy necessary for the adequate performance of their functions indicates the manager's need to act in favor of transformations and to have political will to seek them⁴², in addition to exercising the leadership⁸¹, investing in planning⁸² and in the territorialization⁸³, and make use of the available information systems^84-86 and improve communication⁸⁷.

Institutional support is another of the factors, described in group 6, as a facilitator for the management and that can contribute to reduce the workloads of managers. Institutional support to be offered based on the needs that the service or group presents. The role of the supporter is to be prudent, to be attentive to the needs of the group, to listen to the anxieties, fragilities and strengths, to intercede in times of conflict, in an attempt to provide an atmosphere of trust and solidarity²¹. International studies^36,71,88-89 corroborate with the Brazilian ones, when they highlight changes in the work process and that these changes occurred due to support^{21,25,37,66,90-91}, signaling a more participatory management, where all are held accountable and have collective deliberative spaces. Support is presented as a precursor to change in management³⁷. In the group 5 is, also, that the realization of planning and assessment are also contributing to the reduction of workloads of managers in PHC^{13,56,61,64,92}. The evaluation of services and the creation of the Family Health Strategy, the latter in Brazil, appeared as factors contributing to the reorganization of PHC and to the reduction of managers' workloads in PHC^20,92-94.

Still another group of elements, group 2 in Figure 3, were found aspects relate to the characteristics of the new PHC care model^35,37,49,65. These elements, when present and performed properly, contribute to reduce managers' workloads.

DISCUSSION

The study showed the existence of significant literature on management in PHC, and it is possible to identify several aspects, including difficulties and facilities present in the work of PHC managers, which may contribute to the increase and also to the reduction of their workloads. Management in the healthcare sector has been recognized as fundamental and one of the most significant macro-problems for the implementation of public health policies^95-96.

The studies, corpus of this research, made it possible to identify characteristics of the work of the manager, but none specifically addressed what consists this work. Also, no article was found dealing with the workloads of the managers who work in the PHC.

It was highlighted in the publications studied the mention of challenges and difficulties that can generate an increase in the workloads of the managers, predominating the identification of the great difficulty of implementing a new care model that extends the scope of the biomedicine model.

In Brazil, the PHC incorporated in the National Basic Care Policy, constitutes a technological innovation, non-material and of work organization in healthcare ⁽⁹⁷ which broadens the scope of actions typical of the biomedical model⁹⁸. This innovation imply new demands and/or challenges for managers due to more responsibility at the local level requiring the involvement of several actors, including teams trained to carry out this work, community participation and public investment. It should be noted that, in the case of Brazil, since the implementation of the Family Health Program, the proposal has already been to reorganize services and reorient care practices. It presented a new dynamic for the structuring of health services, with a central focus on the work process in healthcare, in an interdisciplinary perspective, aiming at a change in the way of treating health^7-8,97.

This innovation implies new demands and/or challenges, since it requires the manager to be more accountable at the local level and the participation of other actors. This process triggers suffering with the conflict of current models of care, which may imply an increase in the workload of the managers, who have the responsibility of coordinating the process. The manager is required high responsibility and coordinate multiple factors over which he has poor governance.

Despite the international signage, since the late 1970s², about the relevance of the PHC model for the effectiveness of the right to health, the curative medicine based on the paradigm of biomedicine it still hegemonic ^8,98. Just as it is significant the lack of clarity of managers and/or management team about the management model that privileges the PHC as a coordinator of the care, aiming at reaching the comprehensiveness.

On the other hand, when the prescribed in the PHC care model is implemented, it contributes to reduce the workloads of managers. As is the case for the implementation of territorialization actions, intersectoral practices, as well as practices that strengthen the user embracement, and also the bond and good relations with the users.

Another important element that seems to be strongly related to workloads is education, training for management and work in PHC model. Deficits in this scope emerged as obstacles to the performance of the manager in the PHC, highlighting the lack of capacity of the managers to carry out this work and the lack of capacity of the teams to act in this model. It was also mentioned the difficulty generated by the accumulation of management and care activities, which is also mentioned in a study that deals with the work of nurse managers in PHC⁹⁹.

Continuing education was identified as essential for the good performance of the teams and with positive effects in reducing the workloads of managers. The literature points out the importance of lifelong education as a strategy for reorganization and operation of services, and even the work processes, aimed at overcoming alienation caused by work overload¹⁰⁰.

In Brazil there is a public policy for the permanent education of health workers, but this presents great difficulty in operationalization, either due to insufficient financial resources, lack of political will or personnel, or even the capacity of higher levels to create interinstitutional or sectoral arrangements for its implementation¹⁰¹. The lack of motivation of the managers to create strategies that articulate the needs of improvement of the practice of these professionals with the permanent education in healthcare can be an aspect that also makes difficult the operationalization of this policy. The articulation between education and healthcare is related not only to the actions of the health services, but also to the management and education institutions¹⁰¹.

It was also highlighted, as challenge that leads to the increase in managers' workloads, the deficit on working conditions. Among them are the deficits in the composition of the workforce in PHC and the precariousness of the labor relations, with absence of a salary and career policy, which has implied in high turnover of the workers, mainly of the doctors. A study carried out by Carvalho and collaborators¹⁰²⁾ on the need and dynamics of the workforce in PHC in Brazil, points out that the number of registered nurses and doctors in Health Centers/Basic Health Units grew at rates of 42% and 17% , while dental surgeons grew only 8% in Brazil. Thus, despite the increase in the number of registered doctors, their turnover is one of the aspects that hinders the functioning of services and the constitution of teams that can act in the perspective of interdisciplinarity and comprehensiveness.

In terms of working conditions, the shortage of material and financial resources were also significant as potential generators of increased workloads of the manager, due to the difficulties they cause in the quality and resolution of assistance to users. In this perspective, management in primary care must overcome the limits of fragmented care and fragmented management, to a level that considers fundamental aspects such as working conditions, policy of people management, incorporation of technologies, multi-professional work, permanent education and participatory planning¹⁰³. It is necessary managers able to implement policies and new models of care and with capacity and competence to manage the serious problems that are presented in this process¹⁰⁴.

They also contribute to the reduction of managers' workloads, aspects such as autonomy at work, the possibility of carrying out planning and evaluation of work results, as well as having institutional support to conduct the management in order to enable the qualification of PHC and the effectiveness of their attributes and cooperative collective work, more resolutive and satisfactory in healthcare. Regarding autonomy, a study published in 2017 on the coordination of Health Care Networks in Rio de Janeiro, Brazil, and in the region of Lisbon, Portugal, in primary health care, shows differences between the two cities. There is greater autonomy in Rio de Janeiro and smaller in the Lisbon Region, whose decision-making processes and action plans are under the care of the Portuguese National System. Autonomy in decision-making processes is related to political or institutional decisions, interfering with the action of managers¹⁰⁵

Planning and evaluation are highlighted in the studies as contributors to the organization of work in PHC and as essential for proper management, however the choice of planning method interferes with results. And, in addition to the method, the definition of problems or situational diagnoses constitute the starting point for planning¹⁰³. It is also worth noting that the goals imposed by the macro policy of the health system do not always facilitate the work process of the managers and, consequently, of the teams in PHC¹⁰⁶.

CONCLUSION

We did not find in the literature studied on management in PHC a description of what characterizes the manager's doing in this important scope of health services organization. However, a significant number of publications on management in PHC were found, showing that it is fundamental for the implementation of public policies.

Also, in this review, no article was found dealing with the workloads of the managers who work in the PHC. However, it was possible to identify, in the publications studied, the mention of challenges and difficulties that can increase the workload of managers. And these were predominant, highlighting the great difficulty of implementing a new care model that extends the scope of the biomedicine model, the people management and the deficits in working conditions.

It was also possible to identify aspects of the management work that can contribute to reduce their workloads. Among them were those related to the availability of workforce, including teams and managers trained to work with the PHC. And also the institutional support received for the operationalization of care and aspects related to the management of the actions with planning, autonomy and evaluation.

To boost health care that respects the attributes of PHC, investment in continuing education is needed pari passu with strategies/policies that minimize the aspects that disadvantage the investment/financing in material and human resources.

These data suggest that aspects of the labor of managers on PHC have implications for workloads and that this is a promising field of research that can contribute to actions towards achieving PHC and universal health access. However, there is a need for studies with a greater level of evidence, especially those that can be obtained in field research.

It is also included as a limitation of the study the defined time parameter for the search strategy and the accomplishment of the review in social historical period of significant changes for PHC, especially in Brazil.

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Publication Dates

• Publication in this collection
  03 Oct 2019
• Date of issue
  2019

History

• Received
  26 July 2018
• Accepted
  12 Mar 2019