Decentralizing referral prioritization to general practitioners at the primary care level: A qualitative case study based on the Grounded Theory.

BACKGROUND: Patient referral prioritizations is an essential process in coordinating healthcare delivery, since it organizes the waiting lists according to priorities and availability of resources. OBJECTIVE: This study aims to highlight the consequences of decentralizing ambulatory patient referrals to general practitioners that work as family physicians in primary care clinics. METHODS: A qualitative case study was carried out in the municipality of Rio de Janeiro. The ten health regions of Rio de Janeiro were visited during fieldwork, totalizing 35 hours of semi-structured interviews and approximately 70 hours of analysis based on the Grounded Theory. RESULTS: The findings of this study show that the obstacles to adequate referrals are beyond the management of vacancies, ranging from the standardization of prioritization criteria to ensuring the proper employment of referral protocols in diverse locations assisted by overloaded health workers with different backgrounds and perceptions. Efforts in decentralizing patient referral to primary care still face the growing dilemmas and challenges of expanding the coverage of health services while putting pressure on risk assessment, as well as sustaining the autonomy of physicians' work while respecting the eligibility when ordering waiting lists. CONCLUSION: A major strength of this work is on the method to organize and aggregate qualitative data using visual representations. Limitations concerning the reach of fieldwork in vulnerable and hardly accessible areas were overcame using snowball sampling techniques, making more participants accessible.

Prospecção das condições de trabalho do Samu-192 fluvial em cenários de crise a partir da resiliência no enfrentamento à Covid-19 no Alto Solimões / Investigation of the working conditions of the river-based SAMU-192 in crisis scenarios based on resilience in the face of COVID-19 in Alto Solimões

RESUMO Esta pesquisa teve como objetivo prospectar as condições de trabalho das equipes de socorro do Serviço de Atendimento Móvel de Urgência (Samu-192) fluvial das áreas ribeirinhas e costeiras da região do Alto-Solimões, a partir da análise sistêmica das atividades no serviço de embarcações popularmente chamadas de 'ambulanchas' durante os picos da Covid-19 no estado do Amazonas, quando o sistema de saúde funcionou sob o estresse provocado pela pandemia. Os dados foram obtidos a partir de um desenho transversal exploratório, baseado em dados qualitativos coletados por meio de entrevistas e observação do funcionamento normal do sistema antes da pandemia. A partir daí modelos de dois cenários foram elaborados mostrando o funcionamento do serviço de ambulanchas ao lidar com a pandemia de Covid-19 e o impacto nas condições de trabalho das equipes de socorro interprofissionais de socorro. Entrevistas remotas com trabalhadores das ambulanchas após a pandemia indicaram que a prospecção das condições de trabalho a partir das instâncias dos modelos corresponderam ao funcionamento real do sistema durante a pandemia de Covid-19.

ABSTRACT This research aimed to prospect the working conditions of the rescue teams of the Mobile Emergency Care Service (SAMU-192) at the fluvial areas of the Alto Solimoes region, trough the systemic analysis of the activities of the water ambulances service popularly called 'ambulanchas' during the peaks of COVID-19 in the state of Amazonas, when the health system functioned under stress caused by the pandemic. Data were obtained from an exploratory cross-sectional design, based on qualitative data collected through interviews and observation of the normal functioning of the system before the pandemic. From there, models of two scenarios were developed showing the functioning of the water ambulances service when coping with the COVID-19 pandemic and the impact on the working conditions of the interprofessional rescue teams. Remote interviews with workers after the pandemic indicated that the prospection of working conditions from the instances of the models corresponded to the real functioning of the system during the COVID-19 pandemic.

Complex systems design based on actual system functioning: Coping with variability in a national water ambulances service.

BACKGROUND: In Brazil, the Mobile Emergency Medical Service (SAMU) is a model of mobile assistance and care for emergencies standardized throughout the country. The water ambulance service within the SAMU operates in riverside and coastal areas, and faces challenges and peculiarities that increase the complexity of providing a high-quality and safe emergency care service. OBJECTIVE: To develop organizational design guidelines aiming to improve resilient performance of complex systems, with an application to riverine and coastal mobile emergency care in Brazil. METHODS: Data collection followed an ethnographic approach. Fieldwork was carried in a participatory way, based on worksite technical description, semi-structured interviews with managers and emergency care teams' professionals, and work observation whenever possible. Five regional SAMU coordinations were visited. Data coding employed content analysis and grouped data excerpts according to concepts of capacity and demand. Interfaces were identified between demand and capacity elements and adaptations led by system agents, orienting the proposal of guidelines for organizational design as solutions to face the verified gaps. RESULTS: Design guidelines produced spanned composition and training of both intervention teams and dispatch central teams, uniforms and personal protective equipment (PPE), decentralized water bases, means of communication, intervention protocols, biosafety and inter-sector actions. CONCLUSION: The approach enabled framing and assessment of specific design elements according to resilience engineering concepts, which in turn showed paths for improving the service and reconciling work-as-imagined and actual system functioning.

Community health workers' non-technical skills for delivering primary healthcare in low-income areas.

BACKGROUND: To overcome the poor conditions of low-income areas in developing countries like Brazil, Community Health Workers (CHWs) are required to exceed the regular set of formal skills they are used to employ. OBJECTIVE: In this study, we aim at identifying the non-technical skills CHWs must develop to cope with the extraordinary situations that occur in vulnerable communities. METHODS: 41 CHWs based in two primary healthcare clinics in Brazil underwent two rounds of in-depth interviews. The analysis was carried out using the Analytical Hierarchy Process, resulting in the prioritization of social skills according to their calculated importance to house calls. RESULTS: Among the ten higher-scored skills, we find communication and advocacy skills being of high importance. Civility was found to be the most important attribute, confirming that community action relies strongly on the relationship between health professionals and the community. CONCLUSION: The results of our study contribute primarily to the improvement of community-based primary care programs as it helps to identify major skills required for community action.

On the brink of disruption: Applying Resilience Engineering to anticipate system performance under crisis.

As COVID-19 spread across Brazil, it quickly reached remote regions including Amazon's ultra-peripheral locations where patient transportation through rivers is added to the list of obstacles to overcome. This article analyses the pandemic's effects in the access of riverine communities to the prehospital emergency healthcare system in the Brazilian Upper Amazon River region. To do so, we present two studies that by using a Resilience Engineering approach aimed to predict the functioning of the Brazilian Mobile Emergency Medical Service (SAMU) for riverside and coastal areas during the COVID-19 pandemic, based on the normal system functioning. Study I, carried out before the pandemic, applied ethnographic methods for data collection and the Functional Resonance Analysis Method - FRAM for data analysis in order to develop a model of the mobile emergency care in the region during typical conditions of operation. Study II then estimated how changes in variability dynamics would alter system functioning during the pandemic, arriving at three trends that could lead the service to collapse. Finally, the accuracy of predictions is discussed after the pandemic first peaked in the region. Findings reveal that relatively small changes in variability dynamics can deliver strong implications to operating care and safety of expeditions aboard water ambulances. Also, important elements that add to the resilient capabilities of the system are extra-organizational, and thus during the pandemic safety became jeopardized as informal support networks grew fragile. Using FRAM for modelling regular operation enabled prospective scenario analysis that accurately predicted disruptions in providing emergency care to riverine population.

Unveiling conflicting strategies in the Brazilian response to COVID-19: A cross-sectional study using the Functional Resonance Analysis Method.

By the time the present study was completed, Brazil had been the second epicenter of COVID-19. In addition, the actions taken to respond to the pandemic in Brazil were the subject of extensive debate, since some diverged from recommendations from health authorities and scientists. Since then, the resulting political and social turmoil showed conflicting strategies to tackle the pandemic in Brazil, with visible consequences in the numbers of casualties, but also with effects on the resilience of the overall health system. Thus, this article explores the actions taken in Brazil to cope with the pandemic from a systems analysis perspective. The structure of the domain was analyzed using Work Domain Analysis, and the activated functions were analyzed using the Functional Resonance Analysis Method, identifying the variability resulting from the conflicting strategies carried out and the consequences to the capacity of the Brazilian health system to respond resiliently to the pandemic. Results of the study show that functions that overlapped the operation of the overall system were introduced, causing the health system to operate under conflicting objectives, in which functions were created to restrict the outcomes of each other during the entire COVID-19 crisis.

Desempenho resiliente da longitudinalidade da atenção primária durante a pandemia da Covid-19: um estudo transversal em territórios vulneráveis do município do Rio de Janeiro / Resilient performance of primary care longitudinality during the COVID-19 pandemic: a cross-sectional study in vulnerable territories in the city of Rio de Janeiro

RESUMO O estudo avaliou o desempenho resiliente quanto à continuidade da atenção e ao cuidado longitudinal, às Doenças Crônicas Não Transmissíveis (hipertensão arterial sistêmica e Diabetes Mellitus) pelas unidades de atenção básica à saúde de uma região vulnerável do município do Rio de Janeiro, durante a pandemia da Covid-19. Trata-se de um estudo transversal, de métodos mistos, de abordagem quantitativa e qualitativa. Apesar de a interrupção total ou parcial potencialmente expor os usuários a complicações agudas e crônicas, o estudo aponta que as estratégias desenvolvidas pelo primeiro nível de atenção das unidades básicas de saúde do município foram efetivas para a redução de internações por essas enfermidades, demonstrando um desempenho resiliente.

ABSTRACT The study evaluated the resilient performance in terms of continuity of care and longitudinal care for Noncommunicable Chronic Diseases (systemic arterial hypertension and Diabetes Mellitus) by primary health care units in a vulnerable region of the city of Rio de Janeiro, during the COVID-19 pandemic. It is a cross-sectional mixed methods study, with a quantitative and qualitative approach. Despite the total or partial interruption potentially exposing users to acute and chronic complications, the study points out that the strategies developed by the first level of care of the basic health units in the municipality were effective in reducing hospitalizations for those diseases, demonstrating a resilient performance.

Shifting the management model of Brazilian health services: perceptions of major stakeholders on the participation of the private sector in public hospital administration.

In Brazil, public hospitals are managed according to several different models. The participation of private or third-sector organizations has been growing in a significant manner, especially in the past decade. The present study explores the perception of public administrators and health councilors on the main aspects of outsourcing the management of public health services to the private sector. The study shows that the main disadvantages are related to the reduction of the State's role as regulator, making it more difficult to size services up according to the demands of the population. Among the main advantages pointed out are contributions to reduce bureaucracy in the administration and more freedom for the management of physical, financial, and human resources. The present study contributes to transcend the political-ideological discussion on private sector participation in the management of public and universal constitutionally guaranteed services, presenting the point of view of administrators in Brazil, not very explored in recent literature.

Assessing community health workers' conditions for delivering care to patients in low-income communities.

In this paper we study the working conditions of Community Health Workers in performing house calls within low-income, violent communities in order to understand the challenges in delivering primary care in developing countries. We conducted field studies in two primary healthcare clinics and telephone surveys for 5 months in 2017 within systematic sample of 1690 community health workers based on clinics distributed along the health regions of the city of Rio de Janeiro, Brazil. A number of 759 interviews were completed, approximately 50% of the sample, 86% men and 14% women. Most participants are 30-39 years old (35%), followed by 27% of 40-49 years old participants. Results show that exposure to territorial violence and environmental or health-related diseases significantly affects CHWs. Moreover, CHWs have to develop a significant set of skills to cope with aspects of the territory, and those skills are not present in their training. As community health workers work on the sharp end of the healthcare system, responsible for outreaching, community education, counseling, and social support, our study presents contributions to government and management levels on working conditions inside communities, constraints in assistance, and difficulties in implementing primary care policies.

Effects of Urban Violence on Primary Healthcare: The Challenges of Community Health Workers in Performing House Calls in Dangerous Areas.

Community health workers in developing countries usually perform house calls in degraded and violent territories. Thus, in this paper we study the effects of urban violence in the performance of CHWs in poorly developed territories, in order to understand the challenges of delivering care to dangerous communities in developing countries. We conducted telephone surveys for 5 months in 2017, within a systematic sample of 2.000 CHWs based on clinics distributed along the health regions of the city of Rio de Janeiro, Brazil. We completed 766 interviews, approximately 40% of the sample, 86% man and 14% women. Most participants are 30 to 39 years old (35%), followed by 27% of 40 to 49 years old participants. As CHWs work on the sharp end of the healthcare system, responsible for outreaching, community education, counseling, and social support, our study presents contributions to government and management levels on working conditions inside communities, constraints in assistance, and difficulties in implementing primary care policies.