ADMINISTRATIVE FUNCTIONS IN THE LOCAL MANAGEMENT OF BASIC HEALTH

Objective: to analyze the accomplishment of the administrative functions in the local management of Basic Health Care. Method: qualitative study, descriptive type, with 21 managers, six managers of health districts and 15 managers of Basic Health Units. For data collection, a semi-structured script was used. The data was analyzed using the Content Analysis technique in the Thematic-Categorical Analysis modality. Results: two analytical categories emerged: a) Assignments of local health managers: lack of definition and coexistence of care and management activities; and b) Realization of administrative functions. Conclusion: the results show a fragile management practice, with the administrative functions performed in an incipient and unsystematic way. There is, also, a certain lack of definition of the duties of the manager, leading them to exercise dual functions (manage and assist). This study leads to a reflection on the work of local health managers in Primary Care and its managerial practices, in search of effectiveness and improvements in health interventions. Descriptors: Primary Health Care; Health Management; Health Services Administration; Health Planning; Organization and Administration; Public Health Administration. RESUMO Objetivo: analisar a realização das funções administrativas na gestão local da Atenção Básica em Saúde. Método: estudo qualitativo, tipo descritivo, com 21 gestores, sendo seis gerentes de distritos sanitários e 15 gerentes de Unidades Básicas de Saúde. Para a coleta de dados, utilizou-se roteiro semiestruturado. Os dados foram analisados a partir da técnica de Análise de Conteúdo, na modalidade Análise Temático-Categorial. Resultados: emergiram duas categorias analíticas: a) Atribuições dos gestores locais de saúde: indefinição e coexistência de atividades assistenciais e gerenciais e b) Realização das funções administrativas. Conclusão: os resultados mostram uma prática gerencial frágil, sendo as funções administrativas realizadas de forma incipiente e assistemática. Há, ainda, certa indefinição das atribuições do cargo de gestor, levando os mesmos a exercerem dupla função (gerenciar e assistir). Este estudo leva a uma reflexão sobre o trabalho de gerentes locais de saúde na Atenção Básica e suas práticas gerenciais, em busca de efetivação e melhorias nas intervenções em saúde. Descritores: Atenção Primária à Saúde; Gestão em saúde; Administração de Serviços de Saúde; Planejamento em Saúde; Organização e Administração; Administração em Saúde Pública. RESUMEN Objetivo: analizar la realización de las funciones administrativas en la gestión local de la Atención Básica en Salud. Método: estudio cualitativo, tipo descriptivo, con 21 gestores, siendo seis gerentes de distritos sanitarios y 15 gerentes de Unidades Básicas de Salud. Para la recolección de datos, se utilizó guión semiestructurado. Los datos fueron analizados a partir de la técnica de Análisis de Contenido, en la modalidad Análisis Temático-Categorial. Resultados: surgieron dos categorías analíticas: a) Atribuciones de los gestores locales de salud: indefinición y coexistencia de actividades asistenciales y gerenciales; y b) realización de las funciones administrativas. Conclusión: los resultados muestran una práctica gerencial frágil, siendo las funciones administrativas realizadas de forma incipiente y asistencial. Hay todavía, cierta indefinición de las atribuciones del cargo de gestor, llevando a los mismos, a ejercer doble función (gestionar y asistir). Este estudio lleva a una reflexión sobre el trabajo de gerentes locales de salud en la Atención Básica y sus prácticas gerenciales, en busca de efectivación y mejoras en las intervenciones en salud. Descriptores: Atención Primaria de Salud, Gestión en Salud; Administración de los Servicios de Salud; Planificación en Salud; Organización y Administración; Administración en Salud Pública. Nurse, PhD, Professor, Federal University of São João Del Rei / UFSJ. Divinópolis (MG), Brazil. E-mail: enftarcisio@ufsj.edu.br; Nurse, PhD, Professor, Federal University of São João Del Rei / UFSJ. Divinópolis (MG), Brazil. E-mail: ricardocavalcante@ufsj.edu.br; Nurse, Master Student of the Post-Graduate Program in Nursing, Federal University of São João Del Rei / UFSJ. Divinópolis (MG), Brazil. E-mail: annagsd@hotmail.com; Nurse, Master Student of the Post-Graduate Program in Nursing, Federal University of São João Del Rei / UFSJ. Divinópolis (MG), Brazil. E-mail: pk-m@hotmail.com ORIGINAL ARTICLE Gontijo TL, Cavalcante RB, Duarte AGS et al. Administrative functions in the local management...

English/Portuguese J Nurs UFPE on line., Recife, 11(12):4980-88, Dec., 2017  4981  Since the implementation of the Unified Health System (UHS), a major change has begun in the role of the State in relation to the organization of public health services.The management and organization, that were previously centralized at the federal level, were gradually transferred, to States and municipalities, through decentralization.2] This led to a a considerable increase in municipal health services, mainly in Primary Care, which in turn, generated the need to incorporate new managers. 3 the daily work of these managers, the administrative functions coordinate and synchronize, the other functions related to their activities and are developed in a cyclical and dynamic sequence.Thus, the administrative functions are defined as: Goal planning, execution, monitoring/follow-up of actions and continuous evaluation of interventions or any of its components. 4The accomplishment of administrative functions in managerial practice assists decision making and enables improvements in within a political, economic, social and professional context, and should be part of the management practice in health. 5e World Health Organization (WHO) points out that deficiencies in managerial capacity, especially at the local level, are widely cited as a problem in the performance of health services and that, although the necessary conditions for improving this capacity are known, little is known about how countries try to overcome them. 6e administrative functions in Primary Care are currently developed in a traditional, bureaucratic and non-systematic way.In addition, continuous evaluation of interventions is carried out in an incipient way without programming. 3,7ack of professionalization, training and institutionalization of the position to perform this function. 3,6e analysis of the administrative functions of local managers, understood here as managers of Primary Care services, has great relevance, since health management is a complex and little studied function. 3This can be due to the fact that, historically, management is only executing actions planned at the federal level, not accumulating management experiences at the local/municipal level.
In view of the above and considering the context of decentralization, we asked: How do the managers who work in the scope of the basic care, in the municipal sphere, have performed the administrative functions?Its originality consists in demonstrating the daily work of local health managers, carrying out the administrative functions, coping with the actions and difficulties encountered in the management of Primary Care services.
• To analyze the accomplishment of the administrative functions in the municipal management of Basic Care.
A qualitative study 8 , a descriptive type, carried out with the Managers of the Basic Care of a medium-sized municipality in the central-western region of Minas Gerais/MG, Brazil.The use of the case study is justified because it is a methodological framework capable of capturing contemporary events and preserving the holistic and significant characteristics of real-life events. 9The municipality is among the main ones in the State and it is an Expanded Health Region, which covers 54 municipalities.It has a population of approximately 217 thousand inhabitants and is divided into ten health districts, called sanitary sectors.
There are seven sanitary district managers who assume managerial responsibility for the Primary Care services based in each district.There are, also, 34 Basic Health Units (BHU), distributed in these ten health districts: 20 allocated with Family Health Strategy (FHS) teams and 14 with traditional teams (traditional UBS).There are 17 managers who assume the managerial responsibility of these 34 UBS.Thus, the municipality counts on 24 local health managers, being seven managers of sanitary districts and 17 of BHUs.Data was collected, through interviews, using a semi-structured script that addressed aspects related to data identification, training, professional and management experience, daily work and, administrative functions.The interviews were pre-scheduled and took place in a reserved room defined by the interviewee himself.Three local health managers were not interviewed, since one was on vacation, another did not meet the criterion of inclusion, of having been in the position for at least six months, and another because of being on leave to health.Thus, the total number of participants in this study was 21 local health managers.
The data collected were analyzed through the Content Analysis, in the Thematic-Category modality. 10First, a "floating reading" was performed, which allowed the first contact with the text to be analyzed and a more precise alignment of the study objectives.In addition, the formulations of the hypotheses and the elaboration of indicators that supported the final interpretation were combined.In this proanalysis, the text was cut, generating registration units that were coded and analyzed following the rules of completeness, representativeness, homogeneity and pertinence.The next stage was the transformation, in which the abstraction of content representations was performed, and finally, in the phase of the treatment of the results obtained, of the inferences and interpretations, the categorization was performed by convergence of the context units.
For maintenance and anonymity of participants, sanitary district managers were identified as G1, G2, G3 [...] and BHU managers by RG1, RG2, RG3, respectively.From the analysis of the interviews, emerged two analytical categories, namely: a) Assignments of local health managers: lack of definition and coexistence of care and management activities; and b) Carrying out the administrative functions.

 Assignments of local health managers: lack of definition and coexistence of care and management activities
The attributions of local health managers are not clearly defined and delimited in the organizational structure of the municipality under study: "Today, our activities are the most diverse.We are trying to systematize some of the functions and duties of management, because all positions are new in the organization chart.(G1)".
They show priorities for the service under their responsibility, such as:

Another manager points out as a priority:
For me, priority is the epidemiological question, is the evaluation of the epidemiology of the health sector.(G4) The interviewed managers also report, performing both managerial and care activities, in their daily work.Assistance activities involve "[...] some home visits, curative evaluation, some interventions that we already do with the problem already installed.(RG4)".
In the understanding of the managers, the main administrative activities carried out are: In addition, difficulties were identified by managers in the development of activities in their daily work.
The difficulty is infrastructure itself and material that is missing, right, lack of computer, sometimes, lack enough space for people to work, and some professionals who sometimes have a shortage of a certain workforce.(RG16)

 Realization of administrative functions
In this category, were analyzed how administrative functions (planning, execution, monitoring / monitoring and evaluation) are developed in the daily work of local health managers.Identifying what is planning and setting goals, to achieve desired results, were not carried out by the majority of respondents and this administrative function is centralized in higher instance, not involving the participation of local managers, being as established goals pre-established by the municipal management.
There is no plan until then, this function is administrative and centralized in a higher instance, there are no taxis.(RG6) [...]Although the interviewees recognize the planning / programming as an administrative function, they justify their absence in great demand of problems that emerge in their daily work.So, they report: I was not able to manage, which is a part of trying to schedule a thing in the long run, because a person is trying to put out fire, a problem with a person settled, has not been achieved yet.I'm more in the fire extinguisher.(RG3) Linked to the fact that they do not plan their actions, the participants are unaware of the sanitary reality and how the health need in their area of coverage.

[...] as you do not know your population, you are not known for the health problems of your population, it is difficult for you to establish strategies. (RG5)
The managers understand as monitoring and control actions, an inspection of the work performed by the professional team, which is performed through meetings, conversations, monitoring of the municipal information system and observation of work.
Through the meetings, for example, the Community Health Agents, at the end of the month, sit down with the nurses and close the production of the month, I look at this production I talk to the nurse I have a conversation with the agents in particular, for example: "O, miss, is this how it is there in your area?(RG13) It can be highlighted that the verification of the commitment with the productions guides the administrative function of monitoring / control:

Yes, I follow the day by day, by the production, by the productivity of each one, the daily life itself, the daily life [...](RG6)
It was also, identified that, the evaluation, as an administrative function, is performed in an unsystematic way, without having preestablished parameters and criteria.The evaluation performed by local health managers comes from meetings, conversations and based on the opinion of the manager himself:

By myself. Now a criterion of evaluation, index to measure does not have [...] In meetings as I told you right, in the team meetings we sit down and evaluate if it worked. (RG9)
Although the interviewees recognize the existence of health information systems, local management does not use it as a support in the development of administrative functions, such as planning, monitoring/follow up and the evaluation: We use (information systems) to feed, we feed these systems, but it does not use to get the information it offers us.(RG3) English/Portuguese J Nurs UFPE on line., Recife, 11(12):4980-88, Dec., 2017 4984 It was identified that the profile of the local health managers involved is similar to that found in other studies that analyzed managerial practice in Primary Care, with the majority, of females being between 25 and 45 years of age, working as effective public servants. 3,11 emphasize that the highest percentage of managers are Nursing graduates, being one of the professions that have most inserted themselves in health management.  In azil, activities of the managerial dimension are highlighted in the work of nurses.  Skis and abilities they come from the academic training process, and this should be reviewed, not only in terms of content, but, also, in the ways and strategies of development of these professionals. 15The performance of a manager is based on his knowledge that is the result of knowledge, accumulated during his personal and professional trajectory. 13 the analysis of the daily work of the local health managers, the incipient is perceived and unsystematic performance of the administrative functions.The activities carried out by them involve, as a matter of priority, assistance and bureaucratic actions 14 and, also, the appreciation of the welfare of the members of the professional team aiming at production.This can be demonstrated by the lack of definition of the responsibilities of the position, the involvement of the managers in the assistance activities and the priorities indicated by them.With this concomitance, these managers become detached from their administrative functions.This can lead to conflicts and failure to effectively comply with what is really the responsibility of the local health manager. 16garding administrative functions such as goal planning, execution, monitoring / followup actions and plans, and continuous evaluation of interventions or any of its components, they are not prioritized and remain pending.Local management is based on the transfer of goals defined by the municipal health department and on the verification of the production of the work.
The management of Primary Care should be an important instrument for the implementation of health policies.To do this, managers must efficiently carry out, the analysis of the work process, including the diagnosis, planning and monitoring of their development and problem solving, in order to achieve the goals defined in the planning process. 17r the effective development of management, at least three technical, human and conceptual skills are required. 4The first one concerns the use of specific knowledge and the ability to use methods and techniques necessary for the performance of the tasks performed in the environment.job.Human ability relates to the capacity for interpersonal relationships, involving communication, the motivation, the leadership, and conflict resolution.Finally, the conceptual skill refers to the manager's ability to handle administrative functions such as planning, executing, monitoring, and evaluating the activities assigned to him. 4e interviewed managers perform their activities prioritizing the development of technical skills, such as the execution of assistance actions and bureaucratic activities of the administration, followed by human, corresponding to the valorization of the welfare of the members of the professional team aiming at production.Aspects of the conceptual dimension are not prioritized, such as planning, execution, monitoring / monitoring and evaluation, impairing the performance of managerial work.Therefore, there is no local planning of goals in the short, medium and long term, so little development of effective monitoring / monitoring actions and evaluation of expected results.
The fulfillment of goals already planned and imposed by the central level causes a certain subordination to the decisions that come from it, a fact that generates resistance in the professional teams.However, decisions at the central level are no longer prioritized and fulfilled.This model, that prioritizes the permanence of the bureaucratized relationship and of imposition determined by the level of greater comprehensiveness contravenes, the principle of decentralization of health, that aims at the reduction of the central influence and promotion of the autonomy with respect to the planning and organization. 3 the Basic Attention, the realization of the situational diagnosis is essential step of the planning.Defined as a method of identifying and analyzing a reality and its needs, it is necessary that the manager and his team really know the reality of their territory, so that they can develop the actions in order to contemplate UHS principles. 12,18 the city under study, managers are unaware of the needs and specificities of the area under their management, reinforcing the idea that service planning is fragile.This causes this administrative function to be performed reactively, where problems are

DISCUSSION
English/Portuguese J Nurs UFPE on line., Recife, 11(12):4980-88, Dec., 2017 4985 known and attacked only when already installed.This positioning may not be sufficient for solving problems as well as, it may induce errors.In contrast to reactive planning, in proactive planning, the broad reality is known and interventions are anticipated. 19In this way, the administrative function is carried out with excellence and reaches the assumptions for its development and final objective.
The administrative monitoring / monitoring function is defined as a systematic and continuous process of routine monitoring of information and observation of planned interventions, allowing rapid assessment and consequent intervention in order to meet the expectations established in the planning.20Failures may occur when monitoring / followup is not performed systematically or when managers are not supported with reliable information.
In relation to the evaluation, it was also found not to be a common practice in the scenario under study.Health interventions, usually, tend to be complex, thus, requiring, routinely assessed. 21Therefore, using the evaluation mechanism is important, as it allows the realization of new plans and goals that aim to improve the care provided to the user population of the units of health.
In Brazil, as well as in the municipality analyzed, health evaluation occurs through incipient processes. 22It is poorly ordered and incorporated into everyday practices, and is almost always prescriptive and bureaucratic. 20he evaluation is carried out in an unscheduled way , informal, without systematic registration, without parameters and criteria, through meetings, conversations and individual observations.Another aspect that demonstrates that local management can be considered incipient is the non-use of information systems as a subsidy in the exercise of administrative functions, since we observe its use only to launch the daily production and feeding of the system.This also reinforces the concern that managers have with the production of the professionals under their coordination.The systems are an important instrument in the planning of activities and services, offer data regarding the health conditions of the local population, favor the service approach to the needs of the assisted community and assist in the process of managerial decision making based on situational reality, making possible the transformation.However, the analysis and knowledge of the health conditions, problems and needs of the population based on the information system and through epidemiological data, are poorly performed by managers. 13,23 this sense, health information systems are underutilized and play a bureaucratic role of feeding the central levels with information that is not used in local planning.In fact, health information systems need to be incorporated as tools to support management, enhancing the collection, organization, analysis and sharing of information.It was emphasized that local decision depends on an organized flow of information and this can be aided by an efficient information system. 23fficulties in the development of administrative functions in their daily work were also pointed out by the interviewees.The low support of the central level, in what corresponds to human, physical and material resources, is common.The lack or scarcity of resources can restrict the proper functioning of the health system, due to the user's dissatisfaction, overload and stress of the health team, with a drop in income. 24Other studies also show difficulties such as inadequate physical structure, incomplete composition of teams, lack of capacity, lack of financial resources, equipment and equipment, and difficulty in referencing users.  Thercise of functions corresponding to a health system and / or its components occurs in the context of tensions and conflicts within a context and requires, managers, to deal with the complexity of existing dimensions in health and require, satisfactory working conditions of the municipal system.  In r to carry out an effective management practice in daily work, aiming at qualified service to users, requires balanced and competent professionals, who can overcome the limitations of the service, promote the consolidation of UHS principles and the consequent transformation of health practices, creating conditions for directing the work process, developing services, applying resources and solving user problems. 28anagers also, need, to promote integration and good interpersonal relationships, minimizing existing conflicts and valuing, the performance of professionals, aiming at, the quality of care provided. 29 is worth mentioning that a managerial policy, to institutionalize the development of administrative functions, must be assumed 27 and that, in each health organization the performance of managers who perform these functions successfully and are prepared to meet the demands of the citizen with efficiency, effectiveness and efficiency. 12,28ealth management must be able to, English/Portuguese J Nurs UFPE on line., Recife, 11(12):4980-88, Dec., 2017 4986 politically and technically, organize the work process, with the aim of improving the health status of the population and making health an important locus of citizenship construction. 30good manager can be defined by his ability to plan, support implementation, and evaluate actions taken in health services.The development of qualified managers goes beyond investments in their training.It is necessary to clearly, define, its responsibilities and attributions, availability of manuals and support systems.The maintenance of an efficient management framework also, depends, on good financial remuneration, degree of autonomy and availability of permanent education.
This study sought to contribute to the work of local health managers in the management of Primary Care services, in addition to rethinking their managerial practices, in search of effectiveness and improvements in health interventions.
The results showed the fragile managerial practice, and the administrative functions performed in an incipient and unsystematic way.There was a lack of definition of the duties of the manager, leading to them, to perform a dual function (manage and assist).Therefore, there is a need for better structuring of the organizational model of management in the municipality under study, with positions and attributions delimited, continuous improvement, aiming at the qualification of the local health management and, consequently, improvement in the assistance provided to the population.