Health care units and human resources management trends

OBJECTIVE: To identify factors producing new trends in basic health care unit management and changes in management models. METHODS: This was a prospective study with ten health care unit managers and ten specialists in the fi eld of Health in São Paulo, Southeastern Brazil, in 2010. The Delphi methodology was adopted. There were four stages of data collection, three quantitative and the fourth qualitative. The fi rst three rounds dealt with changing trends in management models, manager profi les and required competencies, and the Mann-Whitney test was used in the analysis. The fourth round took the form of a panel of those involved, using thematic analysis. RESULTS: The main factors which are driving change in basic health care units were identifi ed, as were changes in management models. There was consensus that this process is infl uenced by the diffi culties in managing teams and by politics. The managers were found to be up-to-date with trends in the wider context, with the arrival of social health organizations, but they are not yet anticipating these within the institutions. CONCLUSIONS: Not only the content, but the professional development aspect of training courses in this area should be reviewed. Selection and recruitment, training and assessment of these professionals should be guided by these competencies aligned to the health service mission, vision, values and management models. DESCRIPTORS: Health Personnel, organization & administration. Health Centers. Primary Health Care, manpower. Personnel Management. Decision Making, Organizational. Professional Competence. Competency-Based Education. Rev Saúde Pública 2013;47(1) In 2005, representatives of observatories of human resources in health care from throughout the Americas took part in the seventh Regional Meeting of the Observatory of Human Resources in Health in Toronto, Canada.8 The goal was to reach consensus on appropriate strategies and policies to meet the challenges related to developing human resources in health in the Americas in the second decade of the 20th century. The “Pró-Saúde”a (Pro-Health) project is a Brazilian policy which aims to bring closer together health care professionals’ training and primary health care needs in Brazil. It is a governmental initiative to incentivize changes in the curricula of health care courses with the aim of training professionals qualifi ed to work in the SUS (Brazilian Unifi ed Health System) This was felt to be necessary because of the distance between the academic world and the concrete reality in which health care services are provided is one of the factors which confi rms the ineffectiveness, all over the world, of the health care sector.7 The Municipal Health Department in the city of São Paulo, Southeastern Brazil, is going through some significant changes in the management of human resources. Different legislation applies to health care professionals, depending upon how they were employed.1 Best practice in management can facilitate important improvements in care practices and in the way the service solves problems, strengthening the principles on which primary health care was built in the context of the SUS. It would be impossible to design a profi le of the competencies9 necessary to better prepare local managers without understanding of scenarios and trends in management Competency is the capacity to act effectively in a specifi c situation, supported by, but not limited to, knowledge. Competence is mobilized through day to day experience and is more than just a qualifi cation defi ned by the requisites of a position or post.11,12 This study aimed to identify factors which produce new trends in managing UBS (unidade básica de saúde – basic health care units) and changes in management models.

In 2005, representatives of observatories of human resources in health care from throughout the Americas took part in the seventh Regional Meeting of the Observatory of Human Resources in Health in Toronto, Canada. 8The goal was to reach consensus on appropriate strategies and policies to meet the challenges related to developing human resources in health in the Americas in the second decade of the 20 th century.
The "Pró-Saúde" a (Pro-Health) project is a Brazilian policy which aims to bring closer together health care professionals' training and primary health care needs in Brazil.It is a governmental initiative to incentivize changes in the curricula of health care courses with the aim of training professionals qualifi ed to work in the SUS (Brazilian Unifi ed Health System) This was felt to be necessary because of the distance between the academic world and the concrete reality in which health care services are provided is one of the factors which confi rms the ineffectiveness, all over the world, of the health care sector. 7e Municipal Health Department in the city of São Paulo, Southeastern Brazil, is going through some significant changes in the management of human resources.Different legislation applies to health care professionals, depending upon how they were employed. 1st practice in management can facilitate important improvements in care practices and in the way the service solves problems, strengthening the principles on which primary health care was built in the context of the SUS.It would be impossible to design a profi le of the competencies 9 necessary to better prepare local managers without understanding of scenarios and trends in management Competency is the capacity to act effectively in a specifi c situation, supported by, but not limited to, knowledge.Competence is mobilized through day to day experience and is more than just a qualifi cation defi ned by the requisites of a position or post. 11,12is study aimed to identify factors which produce new trends in managing UBS (unidade básica de saúde -basic health care units) and changes in management models.

METHODS
This was a prospective study with ten managers of health care units and ten specialists in the area from ten UBS in the city of São Paulo, Southeastern Brazil, in 2010.The study included one of the technical

INTRODUCTION
a Ministério da Saúde.Ministério da Educação.Programa Nacional de Reorientação da Formação Profi ssional em Saúde -Pró-Saúde: objetivos, implementação e desenvolvimento potencial.Brasília (DF); 2007 [cited 2007 Nov 7].Available from: http://www.prosaude.org/rel/pro_saude1.pdfsupervisors of the Central-East neighborhood, Butantã, with approximately 377,567 inhabitants.The study was composed of ten UBS: fi ve traditional, three mixed (traditional model plus family health center or outpatients care, one family health center and one referral center for specialties.The units had employees who had passed a competitive exam, and employees who were subcontracted; in the mixed units there were also employees contracted according to private sector labor laws (CLT), and public servants who were part of the Family Health Program and completed their work day for extra income via a partner institution.The participants were recognized for their theoretical and practical knowledge in the area studied (researchers or experienced leaders in managing health care services).
The Delphi 5 method was used as it is a prospective research technique.Prospective methods 10 should be used when the data on a specifi c subject in a specifi c area are scarce.Such methods are suitable for two types of situations: forecasting when a new process or product will be widely adopted and what new developments or discoveries will occur in a specifi c area.
The Delphi 5 methodology provides the construction of collective knowledge among a group of specialists and minimizes the disadvantages normally associated with group interaction by isolating its members.Moreover, it combines normative or guided exploration with the inclination of the individual to extrapolate their personal experience into the future.This methodology consists of an interactive questionnaire, which circulates among a group of experts or specialists over and over again, seeking a convergence of opinions and views about the future.This strategy aims to develop social agents participating in the process, which justifi es its adoption.
The feedback takes the form of a panel.The moderator asks the experts to justify their perceptions and opinions during the plenary session and stimulates discussion among the panelists.
The objective is not to make absolutely exact forecasts but rather to indicate trends and perspectives related to the topic being studied.
Two groups of participants took part in: UBS managers and experts in the health care fi eld, so as to compare the results of their views.
After analysis of the groups' views using the Mann-Whitney 4 test, in the third round, the managers received data obtained from their own group, analyzed the b Wharton School of Business.Delphi Decision Aid .Philadelphia; 2005 [cited 2007 Nov 11].Available from: http://armstrong.wharton.upenn.edu/delphi2responses and were given the opportunity to review their responses from the fi rst and second rounds if they thought it necessary.In the fourth round, the feedback was in the form of a panel.The specialists and managers could ask questions and explain their views and opinions in the discussion stimulated in this session.
The Delphi program from the Wharton School of Business b was used, as it provides the mean, median and confi dence interval for each question automatically.The questionnaire could be completed over the internet or the copy sent out.
The instrument for collecting data was structured to characterize the respondent and identify their perception of the nature and intensity of change.It included general questions about trends in managing health care units and human resources.The questionnaire included a question about the profi le expected of a professional who manages a health care unit and a table describing the competencies desired in this professional. 1e Mann-Whitney 4 test is a non-parametric test, used to compare the means of two unmatched groups.The test was used to assess divergent questions, both between the group of managers and the group of experts and within the group of managers themselves in their specifi c rounds.
The fourth round was fi lmed and the sound recorded, with the previous permission of the participants.The aim was to analyze the variables which infl uenced the managers' and experts' opinions.The meeting was an opportunity for continuous professional development and the round was organized in three parts: A synthesis of the research was presented, highlighting the objectives, methods used and results of the fi rst three rounds.
In the second part, fi ve of the experts were invited to talk about the topics with regards to a: leadership competencies, developing teams, working with action plans and results and managing teams taking into consideration the different work contracts (CLT, outsourced, commissioned and temporary contracts).Another topic presented by an expert was the management of health care services in partnership with social health care organizations.
In the third stage there was a debate between the experts on the question which had obtained the best results, giving the managers and other participants the opportunity to express their positions or clear up any doubts about the meanings and importance of the topics.
The qualitative material was analyzed using thematic analysis technique. 6There was an initial read through of the transcribed material and the "Corpus" was created, paying attention to completeness, representativeness, homogeneity and relevance.The units of meaning contained in the participants' discursive content were identifi ed.The chronicle was produced by synthesizing the discourse, highlighting and identifying values, behaviors, confl icts and contradictions that permeated the approaches of topics.
The analytical categories derived from the theoretical framework related to managing human resources in health were used as constructs that guided the analysis of empirical data derived from the group in the four rounds.
The study satisfi ed Resolution CNS196/96 requirements and participants signed consent forms.The study was approved by the Ethical Research Committee of the State Health Department in February 2008 (CAAE:0197.0.162.000-07).

RESULTS
The fi rst and second questions, which were concerned with the macro-scenario, asked whether health care units should promote change in their policies over the next ten years.The mean response was 6.5, on a scale of 0 to 10.
The mean score obtained on the degree of interference of these changes in managing people was 7.7.
Using different work contracts and forms of dealing with the professionals obtained the highest rating of diffi culty of all the trends concerning policies of human resource management: mean of 8.0.
The degree of diffi culty in implementing tools for professional development or strategies for managing people had a mean of 6.4.The proposals included: providing continuous professional development for professionals at all levels, including providing postgraduate courses; intensive use of computerized means of self-learning (distance learning); continuous monitoring of the group/institution atmosphere; management delegating authority and responsibility; regular performance appraisals, presenting the professionals with feedback to involve them and value them.
Training in health care sciences and specialization in managing health care services were the questions which scored the highest with respect to the profi le of selecting managers: with means of 7.2 and 8.3 respectively.
The questions with the greatest degree of importance regarding effi cient and effective management were: ethical and social responsibility (mean 9.5), managing change and confl ict (9.2); effi cient communication (9.1) and systemic vision (9.0).
Widening partnerships with private institutions and foundation etc. and making them more effective gained the highest degree of interference (mean 7.2) with regards to trends in human resource management policies.
The questions which received the highest scores from the experts as regards the profi le of manager training were: training in Health Sciences (mean of 7.7) and Specialization in Health Care service Management (mean of 8.6), in accordance with the managers' choices in the fi rst round.
In the profi le of competencies for management, ethical and social responsibilities were the issues which the experts scored the highest (mean of 9.0), coinciding with the managers' choices.Political competence (knowing what to say and how and when to say it) got the highest mean of 8.85, developing teams, 8.8 and negotiation, 8.7.
Rounds one and three, in which the managers participated, showed similar results for all the questions, i.e., there was no statistical difference.Rounds one (of the managers) and round two (of the experts) were divergent, signifi cance observed for questions six and 26.
Question six asked the participants to assess aspects related to trends in managing people, the degree of diffi culty in implementing trends in the Municipal Health Department, taking into account different work contracts and relationships between professionals.
The degree of diffi culty had a mean of 8.0 according to the managers and 5.5 according to the experts (p = 0.02).In question 26, which asked participants to assess the degree of importance the manager of the health care unit has in developing competencies and managing change and confl icts, the managers gave it a mean score of 9.3 and the experts 8.4 (p = 0.03), indicating signifi cant differences of opinion between managers and experts.
In the view of the experts, the division of Social Health Organization in the regions could be better organized and thus negotiate the transfer of health care units to other partners.As regards the different employment contracts and different relationships between the professionals in this administration format, the experts defended partnerships with Social Health Organizations as the only way to make the SUS viable.According to them, the State should develop instruments to support managers and facilitate the supplemental salary, diminishing confl icts related to managing human resources.
The results obtained in the fi rst three rounds on identifying the profi le of competencies which the health care professional who occupies or is going to occupy this post should have, was ratifi ed in the fourth round and added to the leadership competencies and management of plans, actions and results for managers and experts.
In the experts' opinion, the managers' training should not be the most important question but rather what they "deliver", i.e., competence in resolving problems and leading teams in order to meet goals.For the majority of the managers, and more than 50% of the experts, managers' training profi le should be: a degree in the health care area and specialization in health services.
There was a consensus among the subjects that this manager should show ethical and social responsibility, have systematic and comprehensive long term vision and be an effective communicator.They should know how to negotiate, manage change and confl ict, develop and unite teams, have political competencies, be good negotiators, know how to lead and work with plans, actions and results.

DISCUSSION
Health care units are not anticipating the changes in the external environment in developing their management policies and general and human resource management.The training and ongoing education of the health care professionals who hold and will hold, these positions is not in alignment with trends.The results show that current managers are not prepared to exercise this function when taking into account the changes accompanying the advent of public-private partnerships. 1e demands of previous decades of which premise was based exclusively on technical knowledge are different to today's need of competencies training.In addition to knowledge, it is necessary to develop new abilities which will be permeated by practical changes in attitude towards work.The new health care manager should align theory to the real needs of practice.The manager is understood as a whole individual who takes on a position of leadership within the health care system. 1 The concept of competencies takes into account the individual's taking initiative and responsibility, practical intelligence of the situations, supported on acquired knowledge and transforms them.It includes the ability to mobilize networks of agents around the same situations, co-responsibility and sharing what is at stake in each situation. 9anges in the external environment of health organizations may continue to affect their dynamics at an accelerated rate, 1 and therefore policies, including those of human resource management should direct training and continuous professional development of health care professionals in order to manage services integrated with the SUS.
It is necessary to formulate proposals in which human resource development in health care is aligned to the new demands of the coming decade.Managers' recruitment, selection, development and assessment should be guided by competencies.These competencies should, in turn, be aligned with the mission, vision and values and the management model adopted and should be revised whenever changes occur in the macro and micro scenario. 1rrent needs are different, reality has changed and today it is not enough to be appointed and to want to be a manager; it is necessary to have training and competencies specific to the function.Preparing people indiscriminately, whether to be managers or administrators, does not bring the desired result, as competencies can only be developed where the already exist, and development programs only work to support their fortifi cation. 3t only the content, but the professional development aspect and strategies of academic training for these professionals should be reviewed, aligned to the current context and the specifi cs of different generations.An educational process needs to be constructed which combines professional development in the perspective of enabling the individual to do their job effi ciently, as well as effective self-realization. 2