MANAGERS ' TRAINING AS A STRATEGY FOR STRENGTHENING REGIONALIZATION OF HEALTH

Objective: to report on the experience of permanent education workshops with municipal health managers in the western region of Santa Catarina. These experiences were conducted in the search for strategies to strengthen management and the principle of regionalization. Method: a descriptive study, a type of experience report, using active methodologies for the development of workshops with 48 participants. Results: the main results point out the difficulties faced by managers in the articulation of public and private services, such as inter-municipal agreements, lack of involvement of health professionals in management qualification, chronic underfunding of SUS, and the lack of use of public management instruments. Conclusion: the outstanding advances for regionalization are related to the inter-municipal consortium, the proactive action of collegiate decision-making bodies and the carrying out of permanent education activities that strengthen relations among regional actors. Descriptors: Health Human Resource Training; Regional Health Planning; Health Planning; Public Health Policy; Unified Health System; Health Management. RESUMEN Objetivo: relatar la experiencia de talleres de formación permanente con los gestores municipales de sanidad de la región oeste de Santa Catarina frente a la conformación de las redes de atención sanitaria, en la búsqueda de estrategias para el fortalecimiento de la gestión y del principio de regionalización. Método: estudio descriptivo, tipo relato de experiencia, en el que se emplearon métodos activos para el desarrollo de talleres con 48 participantes. Resultados: los principales resultados señalan que las dificultades de los gestores frente a las relaciones entre servicios públicos y privados, los convenios intermunicipales, la falta de implicación de los profesionales sanitarios en la cualificación de la gestión, infra-financiación crónica del Sistema Único Sanitario y escaso uso de los instrumentos de gestión pública. Conclusión: los avances destacados para regionalización están relacionados con el consorcio intermunicipal, la actuación proactiva de las instancias colegiadas de tomada de decisión y la realización de actividades de formación permanente que fortalecen las relaciones entre los actores regionales. Descritores: Capacitación de Recursos Humanos en Salud; Regionalización; Planificación en Salud; Políticas Públicas de Salud; Sistema Único de Salud; Gestión en Salud. Undegraduate Nursing Students, Universidade Federal da Fronteira Sul/UFFS, Chapecó (SC), Brazil. E-mail: jessicaferreira2603@gmail.com ORCID ID: https://orcid.org/0000-00028284-7883; E-mail: iankacristinaceluppi@gmail.com ORCID ID: https://orcid.org/0000-00022518-6644; Email: lilibaseggio@gmail.com ORCID ID: https://orcid.org/0000-00028331-2311; Doctor in Collective Health, Graduated in Nursing, Universidade Federal da Fronteira Sul/UFFS, Chapecó (SC), Brazil. Email: daniela.savi.geremia@gmail.com ORCID ID: https://orcid.org/0000-00032259-7429; Specialist in Systems and Services Management and Management of Health Care Networks, Technician in Administration in the City Hall of Chapecó (SC), Brazil. Email: gessiani@unochapeco.edu.br ORCID ID: https://orcid.org/0000-00030088-1349; Master in Human Aging, Universidade Comunitária da Região de Chapecó/UNOCHAPECÓ, Chapecó (SC), Brazil. Email: adrianah@unochapeco.edu.br ORCID ID: http://orcid.org/0000-0002-2299-8128 ARTIGO RELATO DE EXPERIÊNCIA Ferreira J, Celuppi IC, Baseggio L et al. Formação de gestores como estratégia para... Português/Inglês Rev enferm UFPE on line., Recife, 12(4):1179-84, abr., 2018 1180 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i4a231285p1179-1184-2018 The Brazilian Sanitary Reform Movement (MRSB), created in the 1970s, had as one of its propositions to guarantee health as the right of every citizen residing in the national territory. This was a popular achievement that resulted in the institutionalization of the Unified Health System (SUS), ensured through the Federal Constitution of 1988. Once SUS was approved, discussions began to create a regulatory law that defined the objectives of this system, its attributions, how financing would be given, decentralization and hierarchization of services, as well as the participation of people, among others. In 1990, the Organic Health Laws were created Law 8.080/90 -, which established the principles and directives of the SUS and Law 8142/90, defining the manner of financing and popular participation. Federal decentralization is one of the guidelines that governs the politicaladministrative-fiscal organization of the system, designating the municipalization of services, which results in greater autonomy and responsibility of municipal management. The aforementioned process represents an advance for the construction of democracy, stimulates participation and social control, and brings the population closer to the systematization of local and regional health, contributing to the effectiveness and improvement of public health services. Furthermore, the integrality of the health care process begins with the reorganization of work processes in the Health Care Networks (RAS), which are organized and executed from various fields of studies and practices. In this way, the municipalities create and organize their health care networks (RAS), which propose the structuring of care in a continuous and integral way from the linking of services. RAS are polyarchic organizations of cooperative and interdependent action, which have the primary health care as a gateway. Its orderly flow allows services to use referral and counter-referral at health care points, thus enabling the exchange of products and information, enhancing the capacity and use of services. However, municipalities are unable to meet all the population's health needs, since they are not self-sufficient financially, and the absence of a financing policy is one of the deficiencies identified in the legislation that governs the system. In this context, regionalization seeks to integrate the federated entities, enabling the provision of services of the three levels of complexity in a regionalized way, which corroborates to the guarantee of accessible, resolutive and quality health, based on agreements between regional actors. In addition, the municipal health manager is considered a key actor in the organization of RAS and in regionalization, and is responsible for the political and administrative articulation between managers. He or she is also responsible for the local coordination of health services. This organization is formed by integration with community entities, public-private partnerships, city councils and city hall, with problem solving and in addition to actions such as SUS planning, control and evaluation. In meetings of the Regional Interagency Commission (CIR) some topics were defined as prioritary and essential demands to accomplish courses of updating and refining on thematics that are inherent to managing. Difficulties in the organization and operation of health care networks and the need to qualify managers for the exercise of autonomy, agreement and decision-making in the structuring of services were the ones pointed out. ● To report on the experience of permanent education workshops with municipal health managers in the western region of Santa Catarina. These experiences were conducted in the search for strategies to strengthen management and the principle of regionalization. A descriptive study, based on reports of experience, developed from workshops for managers, on health care networks carried out in the institutionalized extension project at the Federal University of the Southern Frontier (UFFS). The project began with edict no. 804/2015, entitled "Formation in public management in SUS: emphasis on financing and planning of health services ". It was carried out in partnership between the UFFS with the Association of Municipalities of the West of Santa Catarina (AMOSC), the Regional Development Agencies (ADR) of Chapecó, Palmitos and Quilombo and the Integration and Education and Service Commission (CIES) of the macro-region West. In the State of Santa Catarina, the municipalities are divided into thirty-six ADRs, which carry out administrative functions and structure regional health management. The METHOD OBJECTIVE INTRODUCTION Ferreira J, Celuppi IC, Baseggio L et al. Formação de gestores como estratégia para... Português/Inglês Rev enferm UFPE on line., Recife, 12(4):1179-84, abr., 2018 1181 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i4a231285p1179-1184-2018 project included the municipalities of the ADRs of Chapecó, Quilombo and Palmitos, which are made up of twenty-five municipalities in the west of Santa Catarina: São Carlos, Chapecó, Nova Erechim, Águas de Chapecó, Formosa do Sul, Quilombo, Coronel Freitas , Palmitos, Western Union, Aguas Frias, Guatambu, Wealth, Caxambu do Sul, Irati, Santiago do Sul, Cunha Porã, Pinhalzinho, Cunhataí, Caibi, Jardinópolis, Serra Alta, Cordilheira Alta, Nova Itaberaba, Sul Brasil and Planalto Alegre. The target audience was the municipal health secretaries and coordinators of public health services. The workshops took place during the period from September to November 2015, which were organized by UFFS Nursing and Medicine students, conducted by teachers of these courses and tutors that were selected by CIES. The workshops on Health Care Networks had 10 hours each, totaling 48 participants. The approach used in the meetings aimed to associate theoretical knowledge with professional practice, as well as to stimulate critical-reflexive thinking in managers and the construction of collectivity. In this way, dynamics and conversation circles were made to enable this process. In adult education, learning is driven by overcoming challenges, building new knowledge, considering previous concepts and experiences to solve problems. Thus, different learning-teaching methodolo

The Brazilian Sanitary Reform Movement (MRSB), created in the 1970s, had as one of its propositions to guarantee health as the right of every citizen residing in the national territory.This was a popular achievement that resulted in the institutionalization of the Unified Health System (SUS), ensured through the Federal Constitution of 1988. Federal decentralization is one of the guidelines that governs the politicaladministrative-fiscal organization of the system, designating the municipalization of services, which results in greater autonomy and responsibility of municipal management.The aforementioned process represents an advance for the construction of democracy, stimulates participation and social control, and brings the population closer to the systematization of local and regional health, contributing to the effectiveness and improvement of public health services. In this way, the municipalities create and organize their health care networks (RAS), which propose the structuring of care in a continuous and integral way from the linking of services.RAS are polyarchic organizations of cooperative and interdependent action, which have the primary health care as a gateway.Its orderly flow allows services to use referral and counter-referral at health care points, thus enabling the exchange of products and information, enhancing the capacity and use of services. 7wever, municipalities are unable to meet all the population's health needs, since they are not self-sufficient financially, and the absence of a financing policy is one of the deficiencies identified in the legislation that governs the system. In addition, the municipal health manager is considered a key actor in the organization of RAS and in regionalization, and is responsible for the political and administrative articulation between managers.He or she is also responsible for the local coordination of health services.This organization is formed by integration with community entities, public-private partnerships, city councils and city hall, with problem solving and in addition to actions such as SUS planning, control and evaluation. 8,10 meetings of the Regional Interagency Commission (CIR) some topics were defined as prioritary and essential demands to accomplish courses of updating and refining on thematics that are inherent to managing.Difficulties in the organization and operation of health care networks and the need to qualify managers for the exercise of autonomy, agreement and decision-making in the structuring of services were the ones pointed out.
• To report on the experience of permanent education workshops with municipal health managers in the western region of Santa Catarina.These experiences were conducted in the search for strategies to strengthen management and the principle of regionalization.
A descriptive study, based on reports of experience, developed from workshops for managers, on health care networks carried out in the institutionalized extension project at the Federal University of the Southern Frontier (UFFS).The project began with edict no.804/2015, entitled "Formation in public management in SUS: emphasis on financing and planning of health services ".It was carried out in partnership between the UFFS with the Association of Municipalities of the West of Santa Catarina (AMOSC), the Regional Development Agencies (ADR) of Chapecó, Palmitos and Quilombo and the Integration and Education and Service Commission (CIES) of the macro-region West.
In the State of Santa Catarina, the municipalities are divided into thirty-six ADRs, which carry out administrative functions and structure regional health management.The The target audience was the municipal health secretaries and coordinators of public health services.The workshops took place during the period from September to November 2015, which were organized by UFFS Nursing and Medicine students, conducted by teachers of these courses and tutors that were selected by CIES.The workshops on Health Care Networks had 10 hours each, totaling 48 participants.

METHOD
The approach used in the meetings aimed to associate theoretical knowledge with professional practice, as well as to stimulate critical-reflexive thinking in managers and the construction of collectivity.In this way, dynamics and conversation circles were made to enable this process.
In adult education, learning is driven by overcoming challenges, building new knowledge, considering previous concepts and experiences to solve problems. 11us, different learning-teaching methodologies were used during the workshops in order to qualify learning.Initially it was developed an exercise that dealt with the influence of teamwork and assertive communication for the effectiveness of RAS, called "Node Dynamics".In this one, the participants formed an initial circle, in order to recognize who was to their right and to their left.After three minutes of dispersion the participants extended their hands to the members to their right and left, according to the original circle, forming a large knot, which needed to be solved together.Following from analogies with the accomplishment of the activity, there emerged reflections and questions based on the obstacles perceived by the managers in the institutionalization of the regionalized networks, in addition to strategies that minimize the management and assistance impasses.
In this context, tutors explained the use of regional management tools, such as Integrated Pactual Programming (PPI), the Regionalization Master Plan (PDR) and the Investment Master Plan (PDI), which are tools that facilitate planning and pacts in the health regions.The main concepts and ideas that underpin the RAS model, the ordering of the flow of services in the health region, the priority care networks and the basic care as the preferred entry point of the system were discussed.

As
an activity, managers divided themselves into groups and developed posters with the main advances and challenges encountered in their professional practice, in view of the implementation of SUS, regarding health financing in the region, public-private relations, decentralization, interpersonal relationship, management and organization of SUS, assistance to users, human resources and social control.Based on the information obtained, it was possible to identify common barriers and, at the same time, to highlight the potential of each municipality as fundamental factors for the resolution of regional barriers.Finally, feedback was made with the participants through an evaluation form.
From the discussions carried out during the activities with the managers, there were reports about the difficulties to structure the regionalization through inter-municipal agreements in the western region of Santa Catarina.The lack of knowledge about the structure of health services and equipment available in neighboring municipalities configures this situation.It was also highlighted the influence of joint decisionmaking spaces, such as: the Regional Interagency Committee (CIR), the Bipartite Interagency Committee (CIB) and the Tripartite Interagency Committee (CIT), which provide and subsidize negotiation among managers and favor regionalization.
Federal Decree no.7,508/11 rescued RAS as an instrument for inter-federative articulation and organization of services in the health region by creating the Public Action Organizational Contract (COAP).The latter establishes an agreement to integrate and systematize the health services in the network, defining responsibilities, goals with evaluation criteria, supervision and the amount of financial resources to be made available. Ahead of this instrument, the managers of the west of Santa Catarina emerged with discussions regarding the benefits of COAP for the conformation of the networks in the region, considering the delineation of

RESULTS E DISCUSSION
Português/Inglês Rev enferm UFPE on line., Recife, 12(4):1179-84, abr., 2018 1182 commitments between the three federated entities and legal accountability of the agreements signed through it.However, there are obstacles in the institution of this contract, such as the difficulty of adaptation to this tool, minimization of local planning, insufficient financing and independent of planning, and little repercussion in the user service.Therefore, the effectiveness of the use of COAP is still questionable and there are no evaluations of the impacts of its use.Thus, the State of Santa Catarina had not adhered to the decree until the happening of the workshops. 14om this, the financial management of municipalities was highlighted as a determining factor for the operation of SANs.As managers say, the segmentation of resources into predestined blocks constituted an obstacle to planning autonomy.Therefore, this form of financial designation was dissonant to that proposed by municipalization, because while limiting basic actions and establishing sanitary priorities by blocks, it restricts the definition of health needs through municipal particularities and social control.It is worth mentioning that the financing blocks were in force until the beginning of 2017, after approval by the National Council of Municipal Health Secretaries (CONASEMS) in the same year, are now defined as cost and investment items, meeting the old demands of municipal managers of health.: 2147 The chronic underfunding of SUS constitutes another obstacle listed for the structuring and operation of services in the municipalities of the western region since the decrease of the budgetary participation of the Union from the decentralization.It made the municipal sphere the largest responsible for the financial contribution proportional to its collection in the health sector.Additionally, this situation of insufficient resources submit the municipalities to buy services of the private system and to use the health consortiums for the inter-municipal agreement.As an example used in the region, the Inter-municipal Health Consortium of the West of Santa Catarina (CIS AMOSC). 16nicipal managers point out contradictions between the public-private logic, making it difficult to implement and operate RAS.In a study of management in the midwest of the country, the authors corroborate this idea by affirming the great influence that the private sector has on municipal management, due to the difficulty of the public network to meet the demands, a relationship is created of dependence between managers and private entities to guarantee the offer of services.Moreover, although this role of supplementary health is very important for ensuring care, the provision of these services is not based on the needs of the population, but rather on the profitability of procedures.This often creates difficulty in hiring specific services, such as the main example of consultations with certain medical specialties.In addition, the establishment of a bond ends up being hampered by this process, since the contracts established are temporary, leading to a great turnover in the offer of these services. 17ivate health services were portrayed as obstacles to the organization of primary care as the system's main gateway, since the models of health care used in public and supplementary health are distinct and private care is structured from the biomedical model.Another obstacle to the organization of RAS flow is the lack of guidance to the population about the functioning of the system, which results in the direct search for secondary and tertiary care services.This situation contrasts the idea of primary care as welcoming the user and linking their health needs with all levels of complexity, shaping the foundation of health care and the ordering of networks. 18e managers also spoke about the lack of commitment and the engagement of health professionals with SUS and the integral care in the RAS, a fact that influences the low resolution of the primary care services.This may be related to the form of hiring the worker, since the public bond provides stability, which can directly affect the satisfaction and quality of health work 6 .This deadlock corroborates to the exacerbation of expenses and expansion of the demand for specialized services, resulting in larger service queues.
Another characteristic difficulty of the region are the long distances between the RAS points, since most of the municipalities are small, with a population average of 13 After all, what is seen throughout this extension project is the importance of deliberative councils for the decision-making process; the use of management instruments to strengthen agreements, the linkages between the municipalities of the western region of Santa Catarina and the definition of the health care model adopted for the establishment of RAS, privileging SUS principles and guidelines.This article reports on the experience of training workshops for the SUS, aimed at managers and health professionals in the western region of Santa Catarina, in which it was possible to identify difficulties and potentialities in the structure and organization of RAS.The main difficulties are related to the lack of engagement of the professionals with the public health system, which results in low resolution of primary care and in the disarticulation of the attention points of the networks.Such situations threaten the guarantee of access to health.
Despite the lack of financial resources to meet health expenditures, municipal managers have good expectations regarding changes in portaria no.204 of 2006.This provides for greater flexibility in the fund-tofund transfer criteria, establishing two modalities of transfer: costing and investment, ending with the six financing blocks.However, the fulfillment of this old demand of the managers needs to be carefully analyzed in the planning process of the SUS, and, in guaranteeing the prioritization of primary health care as the preferred entry point of the SARs.
As a strategy to strengthen the regionalization, managers reinforce the proactivity of collegiate deliberative decisionmaking institutions, such as CIR, CIB and CIT.It is also worth mentioning the advances in the capacity of care provided by health insurance agreements and consortia in the region.
In the meantime, the network of workshops for critical training rescued the debate on the subject and offered subsidies to expand the capacity of managers in the intervention of the regional reality of the municipalities of the west of Santa Catarina.These conclusions come from the progress of the workshops, as well as the evaluations made by participants at the end of the training module.The participants emphasized the need for continuity of courses with the same purpose of training and updating new managers, especially when there are changes of political mandates, since, besides setting up a strategy of approximation between municipalities, it creates an opportunity to strengthen relations in public health management.