Technical-assistance arrangements in coping with the COVID-19 pandemic from the managers’ perspective

Abstract Objective: to describe the technical-assistance arrangements developed within the scope of work management in the COVID-19 pandemic care network, from the managers’ perspective. Method: a qualitative research study, of the incorporated single case type, conducted with 23 managers of a Health Care Network. The analysis was applied in two thematic coding cycles, with the aid of the ATLAS.ti software. Results: the arrangements were analyzed in categories related to health care; management; incorporation of technologies; implementation of a field hospital; and retrospective analysis of the experiences as a whole. There was emphasis on the implementation of care flows, virtual health bulletins, Telemonitoring, chatbots, use of applications, and implementation of field hospitals and of basic urgency services within the scope of the Basic Health Units. Hyperjudicialization in the system was identified; as well as weaknesses in information management, intersectoriality and technical-political leadership at the national level; the role of nurses in management positions and for coping with the pandemic. Conclusion: despite the health services’ unpreparedness to face the pandemic, the actors’ resilience promoted dynamism and technical-assistance arrangements in the context of management and humanized care. The study has a potential to contribute to the qualification of the public policy management and development practices.


Introduction
The COVID-19 pandemic has marked social life since 2020, constituting one of the greatest challenges for public health of this century. Insufficient scientific knowledge about the new virus and its high dissemination and lethality produce fear and insecurity regarding the decisions and strategies to face the epidemic. In Brazil, the situation is aggravated due to social and demographic inequality, as well as to distribution and access to the health services, especially those of greater complexity, in addition to the significant concentration of vulnerable population and high prevalence of chronic diseases (1) .
As a result of the pandemic, drastic changes in social life have been taking place since 2020, and one of the major problems of the present and the future -living -is subordinate to facing the pandemic and the social becoming refers to the "becoming pandemic" (2) . As a consequence, the future of the Unified Health System (Sistema Único de Saúde, SUS) emerges not only for its role in combating the pandemic, but as an aggregating element of approximation of different actors around the claim on its strengthening (2) . However, the trap of emergency perspectives and ephemeral solutions must be avoided.
This has challenged health professionals, the scientific community, health managers and rulers who seek to carry out the planning of assertive and rapid assistance, aiming to mitigate contagion and avoid exhaustion of the health systems, in addition to maintaining safe, timely and quality access to the health services (3) . The pandemic exposed chronic weaknesses of the SUS, experienced by managers and workers. In Amazonas, gaps were aggravated by the demographic and territorial particularities, with a capital city that concentrates nearly 53% of the state's population and high-complexity services (4) .
Since the first case, on March 19 th , 2020, Manaus faced two peaks of the disease, becoming the epicenter in the country, in April 2020 and January 2021. In this latter, there was an abrupt increase in the number of cases and deaths that caused made the public and private health services collapse, in addition to the oxygen crisis (5) . On September 24 th , 2020, Manaus reached nearly 204,266 confirmed cases and 9,464 deaths due to COVID-19 (6) .
The impact of the pandemic on the quality of life of individuals and communities has worldwide revealed the importance of developing specific policies and operational guidelines for the crisis context, the need for professionals prepared to promote holistic clinical management of the disease (7) . It requires the application of normative and legal measures to contain COVID-19, aiming at a timely response to the needs of the territory, from the perspective of integrated, accessible and resolute services.
Health systems require adjustments in real time, led by the services (strategic/tactical/operational level), resulting in new technical-assistance arrangements (8) .
These arrangements express the logic of the technical-assistance model adopted by the territory, that is, the way win which health care actions are organized, involving scientific and care aspects, and articulation between physical, technological and human resources available to face the health problems of a community (9) .
The use of the concept of technical-assistance arrangement in this study is due to its property of articulating meanings with a theoretical and empirical basis: a commitment to the appreciation of experiences Specifically regarding the scenario under study, the justification of the research combines the importance of disseminating the experiences of managers with privileged positions and the particularity of the exemplary reality from a national and international point of view, due to the severity of the crisis experienced. In addition to that, the state of the art on this object -of a pandemic still in progress -expresses a large and recent derived scientific production, although still without significant publication on the changes developed with a focus on the management of local services, which still need to be reported.

Method Type of study
This is a qualitative research study, outlined as an incorporated single case study (10) . Adequacy of the research design was due to its delimitation to a complex phenomenon (facing the pandemic), in a specific context (municipality), but which required the incorporation of different analysis units (different types of services and management levels) and sources of evidence (interviews with different informants and documents).
The procedures were reported according to the COREQ (Consolidated Criteria for Reporting Qualitative Research) guide guidelines.

Research scenario
The study was developed in Manaus, capital city of Amazonas, with 2,219,580 inhabitants, representing 52.75% of the state's population, 13.01% of the Northern Region's and 1.04% of Brazil's, being the seventh most populous capital (4) .
To fight against COVID-19, the Health Care Network (HCN) was reorganized, having the following priority entry doors: Basic Health Units (BHUs), Emergency Care Services (ECSs), Emergency Care Units (ECUs) and First Aid (FA) (11)(12) . Clinical hospitalization or in the Intensive Care

Data collection procedures and instruments
The study was conducted in two stages:

Results
In relation to the participants' profile ( Figure 3), there was predominance of women (57%), 61% concentrated in the age group of 40 to 49 years old, 65% with some specialization, 39% nurses and 65% with statutory public contracts. Of these, 39% had from 16 to 20 years of training, 26% were in the institution for a period of 1 to 3 years and 57% have worked in the pandemic for a period of more than 6 months.

Data treatment and analysis
The interviews were transcribed with the aid of the Google Docs tool, respecting authenticity and literality.
The transcribed texts were made available for knowledge and review by the interviewees, but there was no demand for review. Qualitative data saturation was confirmed by the recurrence of the contents and scope of magnitude of the codes, allowing consistent interpretations. the corpus by theoretical associations (13) , anchored in the concept of technical-assistance arrangements.
To increase reliability, coding was in charge of a researcher, reviewed by a second one and submitted to consensus by 3 collaborating researchers, in specific meetings for this purpose.
Triangulation between data from the interviews and documents occurred to the extent that, in the categorization process, any references to norms or guiding policy formulations that impacted on the processes of coping with the pandemic were identified, in order to better understand the bases used by the actors in the management process.

Ethical aspects
The study met the standards of the National Health

Implementation of a field hospital
In the process of creation and operation of field

Discussion
The to a reduction in morbidity and mortality (14) . They state strategies for the provision of care to the vulnerable population in the PHC context, reasserting the relevance of this care level in assuming the leading role in the health systems, especially in the face of public health emergencies, with emphasis on monitoring cases with territorial responsibility (15) . A number of studies developed in South Africa address the importance of PHC in coping with COVID-19, reinforcing the urgent need for investments, especially with a focus on the workers, as it directly impacts on the most resolute and timely response to the contextualized health needs, in addition to providing strengthening of the health system, with major impacts on coping with pandemics (15)(16) .
Also within the PHC scope, another action evidenced by the reports is the implementation of the basic urgency services in BHUs that occurred in April 2020, at the peak of the first crisis in the municipality, motivated by the deliberations from the instituted collegiate bodies. This measure was considered an advance for PHC, expanding the problem-solving capacity of care, alleviating the overload of the Urgency and Emergency Network (UEN), and constituting a strategic and valuable resource to face the pandemic (17) . A study carried out in Norway evidenced that people with COVID-19 demand more primary care between the first and the eighth week, resulting in recovery and in reduction of the overload of other care levels (18) .
The managers' attempt to assemble groups, committees and the like was noticed, in addition to the search for local, national and international partnerships, considered fundamental for strengthening and agility in decision-making, focusing on a shared management of the crisis based on the epidemiological scenario, aiming at the elaboration of guidelines for coping with the pandemic. It is a consensus that, in times of crisis, the path of dialog with experts from different areas and the participation of civil society becomes essential to promote positive impacts and avoid undesired effects of the decisions taken on health care and social protection (19) .
The collective effort in the elaboration of SOPs, technical notes and other normative documents is notorious, intending the health services for the surveillance and timely treatment of the cases. Although the country has a robust health system, with significant capillarity, strategic planning to respond to public health emergencies is still challenging and incipient, which was not different in the municipality of Manaus, becoming the symbol of the catastrophe, due to the total collapse of the health system, with crowded hospitals and deaths at the homes due to lack of access to the services, in addition to saturated cemeteries and burials in collective graves (20) .
In the face of chaos, the reports signal the adoption  (15,20) .
Bold and courageous leadership is identified as a priority condition to implement innovative approaches to communication, aiming at mitigating the virus and at health care anchored to the diverse scientific evidence (27) , with the adoption of a proactive stance by managers being extremely relevant (28) , using different ways of communicating the policies adopted to society, anchored in utilitarian, republican/democratic ethical principles (29) . Brazil has taken no responsibility for accurate  Although the study presents a potential contribution to health management in the face of public health emergencies, it is noteworthy that the reports were limited to the experiences related to the first peak of the disease that occurred in Manaus, with an urgent need for studies focused on the experiences that occurred in other scenarios and pandemic moments.

Conclusion
The study showed that coping with the COVID-19 pandemic required dynamism and restructuring of the services to respond to the population's needs, evidencing new technical-assistance arrangements both in terms of management and health care, with the rapid implementation of flow of differentiated care for people with signs of flu syndromes, virtual health newsletters and online care (telemonitoring, chatbots and apps) standing out.

The implementation of basic urgency services in
BHUs during the pandemic was evidenced, configuring an advance from the managers' perspective, as these services were not offered in Manaus. The effort to implement field hospitals and the relevance to the peak moments of the disease in the municipality was notorious.
Among the interviewees, the large number of nurses occupying management positions stood out, evidencing the leading role and significant contribution of the category to facing the pandemic in Manaus.
The SUS fragility was reinforced in several fields, such as information management and incipient and weak intersectoriality. The reports made it clear that the system was not prepared to face this pandemic, which was aggravated by the MS stance and behavior, from a technical and political perspective, contributing to the celerity of the collapse in Manaus.
The study presents a potential contribution to the qualification and strengthening of the public management practices in a critical scenario and the development of policies aimed at health emergencies. It is indispensable to develop other studies aimed at apprehending the experiences built during pandemics, covering not only the technical aspects, but all the subjectivity of work, even the mutual relationships between the technologies implemented and the actors' experiences.