Pierantoni & Garcia in Human Resources for Health 9:12
Review by Valeria Campos Da Silveira
This paper examines if the “National Secretary of Health Labour Management and Education” (SGTES, in Portuguese), created at the Ministry of Health in 2003, has generated or influenced changes in sub-national governments, and if federal level policy guidelines influence operational level.
Brazil is a federal republic with 27 States and over 5000 cities including municipalities. Each state and their cities have political and administrative autonomy in managing public policies. The national health system consists of a public funded sector – the Unified Health System (SUS) – defined in the 1988 Brazilian Constitution; and a private sector comprising various prepayment mechanisms (e.g. health insurances) and out-of-pocket financing. The SUS provides exclusive coverage for 78.8% of the population, and it is also responsible for health surveillance, disease control, and the regulation of the health industry.
As in many other countries, the Brazilian health reform focused on decentralisation, transferring decision-making authority to sub-national levels. In the HRH area this decentralisation is related to employment (hiring and firing, nature of tenure, defining compensation packages); to management (transfers, promotions, and sanctions); to skill-mix; and to training. Recent national experiences show that the federal administration keeps its importance in the formulation and regulation of public policies. Also, there is a federal agreement to cooperation among federal level, states and municipalities along with support of social and political actors of organised sub-national and federal managers.
The study combined quantitative and qualitative methods, using computer-assisted telephone interviews and focus groups; data analysis was performed using “Sphinx” software. Resulting data was triangulated with the results of two previous studies.
Data analysis showed that the majority (78.3%) of states and municipalities have a HRH unit following the SGTES model; almost half (48%) of these HRH units went through organisational changes as a result of SGTES policies; 47.8% do not have any career path plans, particularly at municipal departments outside the capitals. Some programmes developed by the federal level are important for the SUS: i) only 27% of managers are involved in the ‘Labour Negotiation Programme’ which allows independent discussions on labour relations and working conditions; ii) 42% of managers are not aware of the programme for reducing the number of jobs with no labour rights or social protection; iii) 77% are aware of the programme aiming at training HRH on management, development of information system and purchasing equipment; iv) 63.2% have a HRH information system however many only use payroll and administrative records, and in 3 regions of the country the system is very centralised in municipal administrations. Programmes for continuing education exist however participation in or knowledge of them are weak.
The study highlights the decentralisation process in Brazil, a process assured by specific legislation and norms and by necessity – considering the size, geographical and political diversification of the country – not developed at the same speed nor in an uniform manner everywhere. It shows the restructuring and developing actions taken by decentralised HRH units that go beyond traditional administrative activities and the expansion into a conceptual model for labour management and health education. It also notices that management capacity in the area of HRH is still low. The authors observe that HRH policies should also involve other areas such as education, labour, legislative and judiciary bodies; and they point to the need for the SGTES, central unit with an actual key role, to reinforce monitoring and evaluation.