. Presence of care gaps in medium-complexity; Establishment of Public Health Consortia, led by the governor - government priority; . Implementation of Polyclinic / CEO, via CPS, to provide specialized care in all health regions (except the capital): more timely and humanized access to SC;
. Contractual instruments for distribution of SC supply among municipalities;
. Low dependence of the private sector in SC;
. Guaranteed transportation, via CPS, for access to polyclinics / CEO: reducing inequalities between headquarters and inland of the region and absenteeism;
. The satisfaction of the population with the polyclinics and CEO and perception of health managers regarding the impossibility of providing SC by the municipalities - conditioning factors of project maintenance;
. Conflicts between municipalities and polyclinics / CEO to provide specialized procedures/visits made available to municipal regulations and exclusive to internal references - "autonomization" of CPS;
. Political interference in CPS and threats of discontinuity. |
"In Sobral, he (Cid Gomes) (...) saw the municipalities around Sobral, going to Sobral without any sharing of responsibility other than to direct the user to the higher complexity level. (...) This statement was powerful in him and said: "Look, in the municipality, the discussion was about the expanded SUS; today, the SUS lives another moment, which is regionalization" (E1)
"There were many difficulties; the population complained a lot. And regionalization has met that need. But regionalization with the polyclinic was a huge leap in quality for the population" (E5)
"In this region, people seek the public health network only. Health is addressed and fought in the public health network, and not in private care (E15)"
"Our concern is that today, within the polyclinic, they work with 50% of the vacancies for internal return. If the contract is 300 visits to pediatricians, the municipalities apportion 150, and the polyclinic has 150 to manage internally" (E6)
"Mayors affirm, and I am saying this because I already heard here and where I worked (...) the funds would not go to the polyclinic but stay within the municipality" (E2)
"So if you tell the people of municipality X that they won't be served anymore because the mayor no longer wants to finance the polyclinics, I believe people would remove him from office. People feel good about access to polyclinics. This is something that is already part of our network. It is the highest-rated health service throughout the state of Ceará" (E1) |
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Governanceand planning of the network
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. Acting Regional Interagency Commission - with expanded participation of providers and managers - decision-making space for regionalization conducted by the SESA/CRES;
. Representation of COSEMS at the CIR - one of the SMS of the region;
. Consortial assemblies - chaired by the mayor of the CPS - "mayorization" of the CPS;
. Adoption of PGASS to replace the PPI - in the early stage, induced by the state;
. Possible political impacts concerning the replacement of the PPI;
. Active participation in CRES in conducting the PGASS implementation process in the health region;
. Recognition of the need for territory-based and health needs-based planning;
. Tensions between the need for increased service offer x lack of new resources;
. Priority of discussions on PGASS at the CIR in 2017 - the locus of regional planning. |
"Seeing the determinants and constraints of each territory, a stage that is skipped by managers when assuming their position, who are swamped by demands. The PGASS would serve to emphasize this moment, such an important stage that is knowing what that population needs" (E11)
"It's a war, a war. Because PGASS will reformulate much consolidated political structure. The PPIs from all over Brazil were made back there and have been a "copy-and-paste" thing for ten years now" (E1)
"(With PGASS) we became more aware of the allocation of resources, so we can have more autonomy to say: 'look, I want this service here, I pay and I get it" (E3)
"(...) nothing was allocated (resources) without first being submitted to the CIR and receiving the approval of each manager of the region's municipalities" (E11) |
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Qualification of human resources
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. Extensive training of leading and managerial staff: SMS, SESA/CRES technicians, Polyclinic direction / CEO - undertaken mainly by the State School of Public Health;
. Historical political engagement of the local health movement;
. APS qualification processes - QualificaAPS - spearheaded and developed by SESA/CRES;
. Difficulties in hiring polyclinic specialist doctors for workload - hiring by number of procedures - consequences for the quality of actions and involvement in continuing education activities and interprofessional relationship;
. Higher retention of professionals in the polyclinic compared to primary care in the municipalities. |
"Focus is on primary care. So the state is very concerned about primary care, it is constantly offering possibilities, training... Now they are implementing the QualificAPSUS, which is a project for restructuring primary care, to make a new risk stratification and a new territorialization" (E3)
"It's amazing how we have a hard time with doctors. Impressive. We put this up for discussion and are practically hostage ... You won't find any doctor today (in the polyclinic) if you say "You will work 20 hours" (E10) |
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Assistance coordination mechanisms
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. Linking users to polyclinics for longitudinal follow-up;
. Lack of shared electronic medical records;
. Low polyclinic/CEO, hospitals, and primary care integration. |
"If we look at it, they should not even be here; they should return to the PSF ... So when patients get here (polyclinic), it's impressive, they don't want to go back!" (E10)
"A patient who had an endoscopy at the polyclinic, the gastroenterologist did it, prescribed the medication; he is at home, and there is no reason to return to the PSF. Thus, a counter-reference by the polyclinic was essential"(E13)
"(...) When the patient is discharged from hospital, the counter-reference does not come, although the flows arerecorded. The specialized care doctor doesn't do it. We have less than 30% of patients with counter-referral. The system does not support counter-referrals. Patient follow-up is patchy" (E10). |
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Network regulation and information systems
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. Computerized outpatient and hospital regulation system, developed by the state (UNISUS-WEB);
. Accountability of users for the scheduling of procedure and exchange of clinical information;
. Access to polyclinics through primary care referrals - minimization of policy crossings to ensure SC;
. Need for the qualification of regulatory processes from the PHC and in the regulatory centers;
. Polyclinic/CEO did not refer to other network services (absence of "external regulation");
. Need to adapt regulatory flows based on the necessities of the territory and the PHC and the adoption of clinical protocols for more appropriate and rational use of resources;
. High absenteeism rates in specialist visits/CEO. |
"Because it generates a counterflow for the patient. When he needs services outside the polyclinic, we send the patient back to the municipality, and there he seeks his regulation to do the service outside, whether at the municipal hospital, or another hospital outside. We (polyclinic) do not make external regulation" (E10)
I will give an example: there (the polyclinic) we can find ECG equipment. It does echocardiography, but then my PSF could not ask for it. I have to send it there to the cardiologist so that he may request. Then I say 'Wow, if I have a doctor who says he can interpret this type of exam, which would improve the resolution, the link is with the PSF, why will I refer to the specialist to order the exam?" (E2) |
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Network funding adequacy
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. State counterpart guarantee for polyclinics / CEO financing;
. Direct withholding of ICMS for CPS funding - funding continuity;
. Polyclinic funding - state + municipality (no federal funding). |
"In some places, the state participates with 60-70%. If it costs 100, I will divide the cost proportional to the population of the municipalities, discounting the ICMS of each of them, provided it is no more than 10% of the ICMS. It has a safety lock. Some municipalities collect so little ICMS that when you gather four-five municipalities, 10% of each, it does not arrive at 60%; this is when the State completes. And why is that only 10%? Because there's another rule. If you withdraw more than 10% from the municipality, you break the municipality that has so little revenue"(E1). |
