Abstract
The article aimed to understand the view of managers of Primary Health Care Units about the competencies needed to exercise this function. This is qualitative research, conducted in the network of primary health care in Maceió, Alagoas, Brazil, with the participation of eight managers. Semi-structured interviews were performed, and for the treatment of the material, we used the Reflexive Thematic Analysis. The analysis resulted in the themes resulted: area of training, territorialization, work processes, and flows, emotional preparation, leadership, active posture, empathic availability, and professional self-realization. It was considered that the competencies valued by the participants fit the emphasis of the accountability model and incentives for performance. In the field of primary health care, this suggests a retraction toward the implementation of comprehensive health care practices adopted as a political guideline since the consolidation of the Unified Health System, and a reorientation of the route that goes back to the model of care centered on the individual and procedures, limiting care to biomedical care—a phenomenon that has been increasing in recent years in Brazil.
Introduction
The Pan American Health Organization (PAHO, 2017) considers the role of health professionals to be central to achieving the goal of universal access to health. It also includes that to achieve this goal, there is a need for nations to approve health policies that are associated with, affirms that the professional competencies of the members of the health teams must be linked to the strategy adopted for the implementation of primary health care in that adopted in each country. Therefore, it is understood that health professionals, through their actions, produce, and reproduce health systems (Suárez Conejero et al., 2013). Likewise, there is consensus that works management is a determining factor for improving or weakening the quality of health services (Schimith et al., 2017).
In Brazil, the inclusion of the Primary Care Manager function in health teams occurs after the publication of the revised version of the National Primary Care Policy (NPCP) in 2017. However, the wording is quite general regarding the skills and qualifications necessary for this professional to be invested in the position, as the document only provides him with “a qualified professional, preferably with a higher education […] and who has experience in Primary Care” (Portaria n. 2.436, 2017). It is observed that the services of primary care experience a process of expansion and complexification of care policies and models of health teams that demand a professional who exercises responsibility for the management of the organization, integration, and articulation of care (Henrique et al., 2019).
A study promoted by PAHO defined a Regional Framework for Latin America of Essential Competencies in Public Health, indicating a set of knowledge, know-how, and know-how to be expected of all health professionals, regardless of the area of training or position they occupy, which were organized into six domains: health situation analysis; surveillance and control of risks and damages; health promotion and social control; policy, planning, regulation and control; equity of access and quality of care; and global and international health (Suárez Conejero et al., 2013). Another study that proposed a competency matrix for professionals in primary care services in Chile, included as domains of managers: network planning; people, financial, and process management; leadership; support shared decision-making; appropriation of the care model; promoting good treatment with the user; family focus; adult education; resolvability; and teamwork (Dois et al., 2018).
Research that conducted a review of scientific literature on the management in primary care identified as essential competencies of managers: “communication, management teams, planning with priority setting, solving problem-solving, evaluation of performance and leadership” (Pires, Vandresen, Machado, et al., 2019, p. 8). Another study performed with the participation of managers of the Family Health Strategy (FHS) in a municipality in Rio de Janeiro also analyzed the skills needed for the primary care manager and identified three categories: leadership; resource and care management; and mobilization of cognitive and affective resources (Fernandes et al., 2019).
An investigation into the social skills of FHS team managers demonstrated the relevance of these to manage resources such as empathy, assertiveness, expression of feelings, and solving problem-solving, also demonstrating that the participants had greater difficulties in communicating and mediating interpersonal conflicts (Marinho & Borges, 2020). Regarding the preparation of managers for conflict resolution, an investigation found good results with students from a course that offered them theoretical and practical tools to develop dialogic experiences in the daily work in Primary Health Care Units (Gouvêa & Casotti, 2019). Such dialogical tools are important, since the greater involvement and accountability of the team with the objectives and the qualification of primary care services depend, in part, on the manager’s ability to operate co-management and shared management strategies, which democratize decision-making in the Primary Health Care Units (Galavote et al., 2016).
Primary Health Care Units managers usually face the challenge of low autonomy about health policies and financing, but they have a lot of power over work processes and organization, to define local health priorities and ways of accessing and offering health care attention in the service (Loch, 2019). The role of the manager requires maintaining a permanent dialogue with the other levels of management, team members, users, and the intersectoral network, in addition to meeting the purpose of the service amid these different demands (Gouvêa & Casotti, 2019). In any case, what is observed is that the management of primary care services is undergoing a process of construction, improvement, and changes, which requires the expansion of research on the subject (Fernandes et al., 2019).
This article aimed to understand the view of managers of Primary Health Care Units in the city of Maceió, Alagoas, on the skills needed to exercise this function. We assume competencies “as the knowledge, skills, and attitudes required by the set of human health resources in different areas of practice, to solve health problems efficiently and effectively” (Suárez Conejero et al., 2013, p. 48). The study is justified by the recent officialization of the position of director of Basic Health Units in Brazil, associated with the absence of guidelines in the country’s National Policy of Primary Care, making a study on the subject urgent and unprecedented after this event. We understand that the research results can contribute to the elucidation of the current state of the subject in this scenario, as well as to present evidence on how such competencies impact the model of primary health care in Brazil. This is a qualitative study, the data were produced using semi-structured interviews and the material was treated through Reflexive Thematic Analysis.
Method
The information was produced using semi-structured interviews with research participants (Minayo & Costa, 2018). The interviews were recorded, later transcribed, and treated using Reflexive Thematic Analysis (Braun & Clarke, 2006, 2019).
The research was performed in the primary health care system in the capital Maceió, Alagoas, Brazil. In Brazil, all services at this level of care are called Basic Health Units (BHU). The Municipal Health Secretary of Maceió organizes its political and administrative structure by dividing it into eight Health Districts, where 57 BHU are distributed, all in the direct administration model. Of these Units, 34 (59.65%) work exclusively as a Family Health Strategy, with population coverage of 27.36%. The FHS is defined as the cornerstone of the Unified Health System (Sistema Único de Saúde [SUS]) and demonstrates to be a model that significantly impacts the improvement of the population’s health and the reduction of morbidity and mortality (Castro et al., 2019). It is also recommended by experts, as the most suitable model for the expansion and consolidation of primary care in Brazil (Tasca et al., 2020).
The survey participants were the BHU managers who worked only with FHS teams. As inclusion criteria, professionals were considered to be occupying the position for a period equal to or greater than 3 months. It was also considered to define the population, a survey conducted with the managers of the Health Districts, in the exploratory phase of the research, of which managers considered could be key informants for the research objective. Exclusion criteria were considered managers who had not been appointed in the Official Diary to fill the position. The managers who met the inclusion criteria were invited by the researchers to participate in the study, by telephone, and in-person., At this moment, the principles of representativeness and heterogeneity among the participants and the proportionality among the eight Health Districts were observed.
For the production of information, semi-structured interviews were performed, a technique that assumes the dynamics of interpersonal relationships as a strategy of interlocution with the participants to identify how they think and act on a given theme (Minayo & Costa, 2018). For the interviews, it was used a script with the following guiding questions: (a) how do your previous work/life experiences contribute to the exercise of the role of a manager? and (b) what characteristics do you consider important for a manager to have/know to develop the function? The questions are used as an instrument that allows triggering and keeping the conversation aligned with the objective of the research itself. In addition, we deepened the answers that did not seem to be sufficiently enlightening on the topic in question, not abandoning or even returning to the topic until we were assured that the interviewee had expressed in this regard (Minayo & Costa, 2018; Navarrete et al., 2011).
For the interviews with the participants, the criterion of information saturation was used, defined as the moment of production of the information in which there are no new elements communicated by different participants (Navarrete et al., 2011).guarantee the anonymity of the participants, during the transcription they were identified with names related to the hydrography of Maceió, which included the Manguaba and Mundaú lagoons, the Camaragibe, Meirim, Pratagy, and Sapucaí rivers, and Riacho Doce and Guaxuma streams.
The Reflexive Thematic Analysis of Braun and Clarke (2006, 2019) was used to process analysis, an appropriate technique for investigating people’s perceptions of a delimited subject and whose final analysis is the product of deep and immersive work prolonged in the research data, the result of an active and generative reflection movement of the researcher. This technique follows a flow of six phases: familiarization with the material; codification; generation of initial themes; revision of the themes; definition and naming of themes; and writing the final document. Familiarization with the data included the transcription of the interviews and the listening and successive readings of the participant’s speeches. The coding, at first, was performed inductively, that is, guided by the content identified during the reading of the interviews. To generate the initial themes, defined as data domain or patterns of shared meaning, codes were revisited, and networks were established between those who demonstrated some degree of relationship, that is, a concept of the central organization (Braun & Clarke, 2019). The review of the themes followed an interpretive and deductive process, as it sought to establish an intersection between the themes then produced and the competencies in the domains of knowledge, skills, and attitudes (Carbone et al., 2009).
To ensure the accuracy and reliability of the results, two researchers independently and simultaneously conducted the coding and generation phases of the initial themes, using the ATLAS.ti 8.4.24.0 program, with the license key owned by the Autonomous University of Barcelona. The theme review phase was carried out jointly by the three authors. The definition and naming of the themes can be seen in Table 1.
Competencies Organized by Domains, Themes of Analysis, and Definition.
This research was approved under the number 4.248.457, by the Ethics and Research Committee, of the Alagoas State University of Health Sciences (UNCISAL). All participants had given written informed consent after receiving written and oral information.
Results
Seven women and one man, aged between 36 and 65 years participated in the research. Regarding the time of exercise in the role of manager of BHU: three had completed more than 1 and less than 2 years, three had been more than 4 and less than 5 years, and the others had added more than 5 years in the position. Everyone had their employment contracts governed by the commissioned function model—situation in which the positions are filled without the need for a public contest or even without prior communication of the criteria for such hiring. Regarding the level of education: two had completed high school and the others had completed higher education, in the courses: Administration, Biomedicine, Physical Education, Human Resource Management, Pedagogy, and Psychology.
From the Reflexive Thematic Analysis, eight themes were produced, which were associated with the three competencies domains, and can be seen in Table 1.
Knowledge
The knowledge competency “corresponds to information that, when recognized and integrated by the individual in his memory, impacts his judgment or behavior” (Carbone et al., 2009, p. 45). This competence was associated with three themes: training area, territorialization, and work processes and flows.
Training Area
Under this theme, the material that presented the characteristics related to the area or field of training of the primary care manager was organized.
The participant’s reports emphasized that primary care managers must have training in the health field and, if not, seek to qualify in that field. Participants also indicate that a manager unrelated to the specificities of the health sector would find it difficult to conduct work in a BHU.
Territorialization
In this theme, the materials related to the sense of community and territorial belonging that the manager should develop were organized.
The participants related the sense of belonging and the bond that the manager establishes as the community and the territory with a greater sense of responsibility and commitment to the work developed at BHU. However, in this regard, they emphasized previous links, such as having a residence close to the BHU, and did not comment on other strategies that can be put into action to strengthen the links between the manager and the territory.
Processes and workflows
This theme brought together the materials that indicated the need for the primary care manager to know in depth the processes and workflows within a BHU.
Participants emphasized the need for managers to know the competencies of other health team professionals, to delimit the health services’ capacity. They also understand how fundamental it is to be appropriate to the health objectives, indicators, and targets that BHU is responsible for meeting.
Skills
The competence “skill is related to the productive application of knowledge, that is, the person’s ability to establish knowledge stored in their memory and use it in their action” (Carbone et al., 2009, p. 45). The themes associated with this competence were: emotional preparation and leadership.
Emotional preparation
The reports of the participants emphasized the emotional ability to exercise the position of manager.
The participants indicated that the manager occupies a position of mediation between the interests of users, professionals, and other levels of management who are generally not in tune and compete for the prioritization of their demands. In this sense, managers feel called upon and monitored at all times by these agents, while they also understand that they do not have sufficient resources and autonomy to fulfill a large part of these demands. Thus, they value the emotional preparation of managers so as not to become weak in the face of this context of tension and sometimes, of harassment.
Leadership
The leadership aspect was also highly valued for exercising the position of manager.
Participants frequently use the terms boss, to mark a vertical and authoritarian management model, and leader to indicate another management model, no less vertical, but based on persuasive relationships and team building. According to them, when the team’s professionals are treated in a non-authoritarian way, they usually develop their work better. In any case, they emphasized that the difference in power between the manager and the other team members was important.
Attitudes
Attitude competence is related to “a person feeling or predisposition, which influences their conduct about others, work or situations.” (Carbone et al., 2009, p. 45). The following themes were associated with this competence: active posture, empathic availability, and professional self-realization.
Active Posture
The managers valued the need for the professional invested in the function to have an active and determined posture in face of the daily demands of the BHU.
The participants, when dealing with this topic, referred that the daily health service includes managing access and assistance to a large and diverse demand of users, as well as guaranteeing a series of inputs so that attention can be performed. However, it is not uncommon to have to deal with the lack of professional provision to assume the responsibilities of those who are away, on leave, on vacation, etc. Likewise, they also face delays in requests for the supply of essential inputs to achieve assistance. In this sense, they say that there is a need for active posture and determination of the primary care manager to avoid and solve these needs.
Empathic availability
The managers also consider the empathic availability of this professional with the others to be important, especially with the users who seek assistance at the BHU.
In this sense, the participants indicate that it is important to recognize the needs and reality of the users who seek the BHU. However, part of this recognition demonstrates maintaining an existentialist perspective with the community when they suggest that it should be treated with “lovingness.” Otherwise, instruments that promoted users to be participants and protagonists in health processes were not addressed in the participant’s reports. In other words, it can be a limitation that the theme of empathy imposes on relationships: a kind of loving consensus.
Professional self-realization
The managers also highlighted professional self-realization as an important factor for the development of the function, as well as for the position itself.
The participants indicated that, in the situation, they live in, the employment relationship and the salary they receive for the function are not determinants for their continuity in the position. They also demonstrate that although the role of primary care manager is a commanding position, they have little autonomy to undertake changes. Thus, the report seeks to find other means of pleasure and professional satisfaction to remain in management.
Discussion
Regarding the knowledge category, the participants addressed the topic “training area,” indicating that it is important that the primary care manager has completed a higher education course in the health area or that, otherwise, has acquired specific knowledge of the health sector. It is necessary to consider that the NPCP, informs that the manager must be “a qualified professional, preferably with a higher education” (Portaria n. 2.436, 2017), but is completely absent in defining or characterizing what is about as a qualified professional. Henrique et al. (2019) argue that due to the absence of a specific policy for training and preparing managers, what is observed is that the construction of skills for the management of BHU depends on the interest and individual search of the professionals invested in the position. Pires, Vandresen, Forte, et al. (2019) indicate that the lack of adequate training for the primary care manager reduces the effectiveness of the service in meeting health needs, and suggests greater investment in continuing education as a tool for training these professionals. Gouvêa and Casotti (2019) identified in a study that even managers graduating from health courses, it is possible to find weaknesses in their training to exercise the position since in general, they experience curriculum are hegemonically oriented to the biomedical model, which makes it difficult for them to develop skills for interprofessional, participatory, and collaborative work in basic care. The transformation of health education that is oriented toward interprofessional and intersectoral practice remains a challenge (Suárez Conejero et al., 2013).
Participants also addressed the topic “territorialization,” indicating that it is important for the manager to maintain a close link with the assisted community and to know their contexts for producing life. The concept of territory in primary care has a polysemy in its definition, which for Merhy et al. (2019) translate into a dispute between a perspective that understands territory as a strategy to map a certain place and another that understands it as the way that certain subjects organize and produce their living. For Bernardes (2017), however, this dispute does not imply the exclusion of one of the terms, but together they operate a tension between strategies of administration, regulation, and actions in health and the strategic field itself, which, in turns, defines the health actions and regulations that will be offered. In this sense, territorialization is a process of capturing and reducing the irregularities of living in a given community, which are now signified by homogeneous domains of the health-disease process, even if provisional and partial, which tend to guide the governability of living and access to health services for those who reside there. In the same way, as the participants of this research stated, Hillesheim and Couto (2017) indicate that in primary care the term territoriality assumes the notion of a link between the health team and the community. The authors also include that the NPCP provides two qualifiers for territory: the design of a defined territory and the image of territory in dynamic movement, which perpetuates the tension of using this concept and leads us to take the territory as a living organism, in the process (Hillesheim & Couto, 2017). In this sense, to advance in strong primary care, it is necessary to recognize that the health-disease processes occur between people, and the relationship between professionals and users must be improved, so together they guide the services attention to local health necessity (Tasca et al., 2020).
Still in the knowledge category, the topic “processes and workflows” were addressed, indicating the importance of the manager being appropriate to the capacity and objectives of the health service itself. Corroborates with these results, Fernandes et al. (2019) which also identified as a necessary competence for BHU managers, the knowledge of the health network, the flows of care, and health indicators so from that point, the service can be organized and prepared for health care. However, the absence of technical criteria for accessing the position allows many managers to be deprived of this knowledge. The study of Henrique et al. (2019) identified that the managers of the BHU surveyed demonstrated that they were not prepared for the function, both because of the fragility and distance with the practice of services identified in the courses that train professionals in the health area, as well as the lack of training and continuing education offered in service for managers, it generally affects learning-by-doing for these professionals when they take office. Even so, a literature review study indicates that the essential skills of primary care managers are the organization of the teamwork and the planning of the services action priorities (Pires, Vandresen, Machado, et al., 2019). PAHO (2017) guides the use of continuing education as a tool to develop professionals in areas that present these gaps in technical, programmatic, or management.
In the skills category, the theme “emotional preparation” was valued, as the participants indicate that the position of manager is the depository of the tension of several and different agents with whom they need to deal with to achieve the health services’ objectives. These data are corroborated with the research of Marinho and Borges (2020) who, when investigating the social skills of FHS managers, identified the skills for problem-solving and conflict management as self-perceived forces by these professionals, even though most of the participants considered these deficiencies to be overcome. Also, the study by Fernandes et al. (2019) identified competencies related to the mobilization of cognitive and affective resources the ability to adapt to different situations, conduct confrontations, adjust to different contexts, and have creative and innovative initiatives. The study by Loch (2019) identified that BHU managers, to conduct their work, considered it essential to use listening, empathy, seeking to meet the expectations of other team members, having flexibility, and knowing how to deal with the imperfection of certain actions.
Another theme related to the skills category was “leadership,” indicating the replacement of authoritarian management models in health, with persuasive and team-building models. Similar to Fernandes et al.’s (2019) study, which identified leadership as the manager’s ability to influence and drive other team members to achieve service goals. However, it is also necessary to consider that in health work, all subjects partly exercise their government and the government of the other (Merhy et al., 2019), so the leadership must use participatory and collaborative strategies that mobilize negotiating the forces in dispute and building common projects. The study by Gouvêa and Casotti (2019) identified that the use of the Circular Process tool—where a person assists in transforming an opposition relationship into a cooperative one—in the training of primary care managers favored the development of skills for measurement and facilitation of the work process, as well as promoting they experience participatory and dialogical actions in the BHU. The evaluation of a leadership and management training course for primary care service managers in rural settings in Zambia found that students who completed it, improved their ability to lead teams, strengthened their skills and confidence in the use of information technology and communication, and promoted improvements in service quality and access, suggesting that skills for leadership and management can be increased with specific training for this purpose (Foster et al., 2018). Tasca et al. (2020) recommend that it is necessary to strengthen and train leaders in the scope of primary care management, so they can, before society, defend the FHS model as an organizing component of SUS.
In the attitude domain, they valued the theme “active posture,” as they usually face demands at the level of personnel and inputs for which they do not have adequate support and provision to resolve. Pires, Vandresen, Forte, et al. (2019) identify in the scientific literature that the lack of material inputs and financial autonomy of primary care managers are responsible for the increase in the workloads of these professionals. Loch (2019) says that the image produced about the managers doing, that he plans and systematically controls the work, is pure folklore, and primary care managers are characterized by being agents of change in an adverse, tense context, and limited autonomy. It also demonstrated that the managers who best reached the health objectives and remained in the job longer were those who managed to establish broad networks of interpersonal relationships, formal and informal, through which they obtained information, influenced decisions, and identified opportunities (Loch 2019). The manager’s competence to manage resources and material inputs is also highlighted in the study by Fernandes et al. (2019), which was associated with the network articulation ability.
Another theme associated with the attitude category was the “empathic availability” which managers must-have, especially in their relationship with the community. These data corroborate with the work of Marinho and Borges (2020), who considered the empathic skills of managers, such as being available to support, putting themselves in the other’s shoes, and being open to dialogue, an important and desirable resource to be used in the relationship with other team members and users. However, the research participants addressed this topic, indicating that it is desirable to deal with “lovingness” with users. In this regard, it is important to reflect that the nature of the relationship between health professional and user determines the type of bond, which can be oriented toward the protagonism and autonomy of the subjects, as well as for the damping and objectification (Galavote et al., 2016), just as a loving position can be invested. It is necessary to envisage that all the subjects in relation demonstrate expectations and desires, which makes each meeting between the management team and users a partially unpredictable and uncontrollable event (Merhy et al., 2019). In this sense, it is warned that empathy is not used as a tool that limits participation and social control.
The theme of “professional self-realization” was identified as one of the motivations for continuing the role. Loch (2019) argues that the work of primary care managers involves a high degree of stress and tension, suffers interferences in their work schedule which come from the interest of different social agents, their actions are marked by the immediacy and fragmentation of the processes and have low financial autonomy and innovation. Pires, Vandresen, Forte, et al. (2019) highlight that the current model of primary care based on territorial accountability and community participation increases the demand on the work of BHU managers, which requires a high burden and action on multiple processes with little governance over many of them. And when managers fail in their assignments, they usually face professional losses (Henrique et al., 2019).
Adding the adversities inherent to the primary care management function, we can also relate the data of the participants of this research, which indicated that all managers are hired by the commissioned position model, which is characterized by positions created from specific laws, for the performance of management or advisory functions, with provision for free appointment and dismissal, and, thus, provisionally occupied. This model of contract can be taken as an exception to the rule for access to public offices, which does not guarantee all the rights provided for in the labor legislation. In particular, this type of contract does not guarantee the right to advance notice and the indemnity corresponding to 40% of the Guarantee Fund for Length of Service when exonerated, but access to holidays and 13th salary is not usually guaranteed either. Although the purpose of this type of contract is to facilitate the staff provision to perform duties considered provisional in the public sector, in general, it ends up being used as an agent of “a regime of political-clientelistic regulation” (Galavote et al., 2016, p. 995). In this way, it leads the action of the contracted manager to act not only to fulfill the duties of the position for which he was hired but also to legitimize the interests of some party-electoral projects in the daily life of health services, which are a large extent unconnected, when not contrary, to the interests of the health policy itself. Otherwise, the need to enforce the labor rights of primary care professionals was also highlighted in studies that identified the lack of public tenders for hiring staff and precarious work bonds as factors that favored the discontinuity in primary care policies in the municipalities surveyed (Henrique et al., 2019; Schimith et al., 2017). In this sense, it is necessary to advance a staff policy for managers that offers greater security and autonomy to act by the NPCP. For Campos (2018) SUS sustainability depends on a staff policy that respects professional expertise, but also induces interdisciplinary practice, to weaken professional corporatism in health, make the characteristics of the professionals work more in line with the level of health they operate and strengthen the dialogue with users.
Finally, it is necessary to consider that the reforms proposed based on the New Management Public model are ongoing in Brazilian health policy (Morosini et al., 2020; Rizzotto & Campos, 2016), model which advocates the replacement of state provisions by public funding from private providers and focuses attention on management and accountability instruments—or accountability—with the promise of delivering a better quality of services at lower costs (Sisto & Fardella, 2018). In this sense, the very emergence of the post of primary care manager is, at least in part, based on the intentions and promises of such a reform project. What can be identified in the analysis topics of this research is the understanding that the manager must have competencies that enable him—“processes and workflows,” “emotional preparation,” “leadership,” “active posture,” and “empathic availability”—to mediate the tension that occurs between the goals established at BHU and what the team considers the objective of their work. Fardella et al. (2016) consider this an unresolved tension, under which the instruments of control and accountability of quantitative results indicators tend to dominate labor relations. Morosini et al. (2020) indicate that the Federal Government has published in recent years norms that guarantee legal support in primary care for the financing model focused on assistance to individuals and payment for performance and incentives—in the manner of accountability—which would mean an effort not to be directly accused of privatizing public services but offering all the formal instruments necessary to put this process into action. This context highlights the risk of prioritizing aspects of the manager’s competencies that allow them to comply with health goals and indicators and devalue those aspects that allow them to be better attentive to local health needs, the latter of which may even be understood as unbound competencies, which hinder or deviate the process of accountability.
Therefore, the need is emphasized that competencies that favor the identification and resolution of local health problems are also valued and guaranteed, which in this study, partially, are highlighted in the theme “territorialization.” This would allow managers to promote inquiries about the relevance and local impact of the quantitative indicators that must be achieved, which are often designed by professionals unrelated to that reality (Fardella et al., 2016), and to make the necessary changes and arrangements in the organization to get attention at the local level. It also includes, although it did not appear in the research results, the need for managers to develop skills for teamwork and to promote popular participation, as these are understood as paths to institutional democratization in primary care services.
Final Considerations
In the present study, we identified the perception of FHS managers regarding the competencies needed to perform this function, based on three domains: knowledge, skills, and attitudes. In the first domain, it was identified that the participants emphasize the need for specific knowledge in the field of health, establishment of close links with the territory, and ownership of workflows and processes, which includes knowing the health objectives of the service and the competence of each team professional.
Regarding skills, an emphasis was placed on emotional preparation, to mediate the tensions that are generated from the disputes between management, staff, and users for different health interests, and leadership, so that it prints a hierarchical action based on persuasion and team building. The attitude domain was linked to the need for an active posture to ensure the daily provision of maintenance assistance, empathic availability with the needs and reality of users, and professional self-realization, indicating that the benefits of current employment contracts are not determinant for permanence in charge.
It was considered that the skills valued by the participants fit the emphasis of the accountability model and performance incentives, a proposal that transposes business management practices to the public service, simplifies work management to indicators, and assesses the quality of assistance, as it links the financing, to the fulfillment of such indicators. In the field of primary health care, this suggests that it may mean a retraction for the implementation, backward of the practices of integral health care adopted as a political orientation since the consolidation of the SUS, and a reorientation of the route that goes back to the model of care by doing centered on the SUS, individual and procedures, limiting care to biomedical care—a phenomenon that has been increasing in recent years in Brazil.
As limitations of the study, we emphasize that the information was generated by participants with accumulated experience in the role of BHU manager, but the selection for hiring these included a selection process or public tender with broad competition—this being currently the hegemonic way of hiring to fill of these positions in Brazil. In this way, carrying out other investigations in scenarios that allow including participants who exercise the role of manager only after meeting technical criteria of knowing and doing in management, as well as in the area of primary health care, can complement and contrast the results of this article.
In this sense, to maintain the principles of primary care and to produce a counterpoint to the reform processes that threaten the integral right to health in Brazil, we conclude that it is essential that the competencies for the manager role include knowledge about the ways of life and relationship in the territory, as well as for the establishment of teamwork, intersectoral, intersectoral and network, as well as attitudes for the effective action of popular participation in the identification of needs and definition of local health priorities.
Footnotes
Author Note
This article was prepared within the framework of the PhD in Person and Society in the Contemporary World, of the Social Psychology Department, of the
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical Approval
This research was approved under number 4.248.457, by the Ethics and Research Committee, of the Alagoas State University of Health Sciences (UNCISAL). All participating had given written informed consent after receiving written and oral information.
