Does Health Service Networks Need Engineers of Connections?

Transcription

1 Does Health Service Networks Need Engineers of Connections? From Administrative Prescription to a Reflexive Pedagogy of Bridging Health Services Networks

2 Work in progress This presentation is based in: A) an reflexive essay developed by Egleubia Oliveira, Gisela Cardoso and Elizabeth Moreira dos Santos B) an article developed by: Egleubia Oliveira¹, Gisela Cardoso² and Elizabeth Moreira, Marly Cruz², Elizabeth Santos², Angela Casanova², Aline Duque², Carlos Leonardo Cunha², Gladys Alves². 1. Institute of Colective Health Studies, Rio de Janeiro, Brazil. 2. National School of Public Health, ENSP/DENSP, Rio de Janeiro, Brazil.

3 Brazil: 200 million people and a Public Health Service System (SUS)

4 * Fonte: SIGTAP/DATASUS, dados de 2012, sujeito a alterações A dimensão do SUS SUS National Health Services System 3,7 bilhões de procedimentos R$ ambulatoriais/ano* 531 milhões de consultas médicas/ano* 11 milhões de internações/ano* 3.7 billion outpatient procedures/yr* million in doctor visits/yr* 29.6 million in million hospitalizations/ yr* 722 thousand in 2012 Largest public organ transplant system in the world Maior sistema público de transplantes de órgãos do mundo 98% do mercado de vacinas é movimentado pelo SUS 32,8 milhões de procedimentos oncológicos ( )* 97% dos procedimentos de quimioterapia são feitos no SUS 98% of the vaccine market is run by SUS 6.4 million doses in million oncological procedures*( ) 2.9 million % of chemotherapy session are administered by SUS* 4,7 milhões de OPM ambulatoriais (cadeira de rodas, aparelho auditivo, 5,8 milhões de OPM ambulatoriais (wheel chairs, hearing aids, ostomy bags, prosthetic eye, crutches, canes) 141,1 mil bolsa de ostomia, prótese ocular, muletas, bengalas)

5 The QualiSUS-Network: Strategy to Induce Health Care Networks Aims to improve quality of care, management, and development of technologies by organizing regional and thematic networks that focus on quality of care. Training and quality improvement project, implemented by the Ministry of Health and The World Bank; Support the establishment and development of 15 local (municipalities) projects and the improvement of quality of care in health regions;

6 QualiSUS Network: Description 15 Initiatives 17 Brazilian States 382 Municipalities 20% of the Brazilian Population US $50 Million Budget

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8 Supportive Supervision Professionals : Key Actors in QualiSUS Network QualiSUS Network Evaluation Evaluation of implementation of the 15 initiatives accounting for diversity During the evaluation integrated supportive professionals (apoiadores) emerge as key actors to negotiate different interests and controversies Need to understand and monitor the competence and performance of apoiadores

9 The Apoiadores : profile Negotiation skills (needs assessment, GPS, symbolic mapping actors/stakeholders analysis etc.) Project management experience (preferably with training in public health area) Required knowledge and skills in the following areas: 1. Management 2. Health Care Services 3. Education

10 Expected Interactions: Weaving formal and informal links among partners M&E (activities and research) Supervisors Driving Group Apoiador Project Management Municipality Department of Health State Department of Health

11 Much More than Supportive Supervision: To create and maintain connections between social entities that were previously unconnected Engineers of network connections?

12 Who? Graduate background such as Masters in Public Health and some with masters/specialization/phd in related field Diverse undergrad background (Psychology, Nursing, Dentistry, Economics, Social Work, Nutrition, Speech Pathology, and Biology) Professional experience in the following areas of health sector: Management of Health Care Teams Consulting Teaching Research

13 How to Evaluate these professionals performance? Traditional theories not enough Theories of knowledge translation: Knowledge transferring towards a co-construction of knowledge Sociology of intermediate actors Actor-network theory

14 Theories that Address the Macro and Micro Relations of Health Networks Three theoretical models (Clavier et al, 2011): 1. Action-network theory (Latour, 2005; Callon,1986 ): Emphasizes mediation process and the alignment of interests between actants (humans and nonhumans) through 4 operations: (Problematisation, interestment, enrolment and mobilisation); 2. Expanded knowledge transfer theory (Bowen et al, 2005; Leeuw et al 2008): Highlights how academic knowledge is translated into public policies and interventions. This implies building knowledge alongside the management process, movement, and transformation process. 3. Sociology of intermediate actors (Nay and Smith, 2002): Distinguishes the strategic and cognitive dimensions of intermediation in the process of knowledge acquisition. One side would handle brainstorming and disseminating ideas and the other would be in charge of handling negotiations.

15 Redes Sócio-Técnicas (Michel Callon 1986; Bruno Latour 1990) Socio technical networks:-ant Actants- Human and non human entities ANT a density of connections- a multi-dimensional filaments (rhyzome), as several local contigencies that can be either eliminated or mainteined, through solving the controversies in another words how one actant holds many others ANT its is not about traced networks, but about a network tracing process

16 The Translation Theory Michel Callon, 1986, 1989, 1999 Michel Callon & Bruno Latour, 1986 Autoria: Callon, M (1986). Elements for a sociology of translation L Année sociologique, Conceptions Network translation controversy Inscriptions 4 Operations problematisation interestment enrolment mobilisation

17 Translation Operations that describe how humans and no humans actants, that share a common problem, forge a cooperative solution, mediating and aligning the interest of heterogeneous network entities

18 Social identity Translation Inequality and diversity of stakeholders Interest and strategies Translation SOCIOGRAM Aligning of interests Network stability and expansion Socio-technical network Reconfiguration of controversies Inscriptions of accountability Problematisation Interessessment Enrollment Mobilization Negociated Levels of performance and quality TECNOGRAM Production, techical quality Production accountability and sustenability

19 Social identity Transcriation Inequality and diversity of stakeholders Interest and strategies SOCIOGRAM Intentionality Network stability and expansion Transcriation Socio-technical network Transvaluation Inscriptions of change Problematisation Interestment Enrolment Mobilisation Self reflexivity Negociated Levels of resignification and change Production of innovations TECNOGRAM Production: equivalence in the diference

20 ANT Framework: Analysis Translation to transcriation? Logs used in the analysis How it was problematized? How new alliances were built? How the mobilization occurred? Representations Intencionality Resignification Knowledge Practice (logistic) Strategic Knowledge and skills needed Coordination an implementation Harmonization of controversy and conflict

21 ANT Framework: Analysis Translation (DARAS and SSP) Logs How it was How the mobilization How new alliances problematized? occurred? were built? Knowledge Practices Strategies Too much information. Every week we got a change, a new thing about Rede Cegonha (child/maternal network), Rede de Urgencia e Emergência (emergence network) and so on Capacity building was essential, every week we had roda de conversas to discuss the newer guideline The first workshop addressed the mission of the Network Articulation Department (DARAS) and that was our reference

22 Engineers or sculptors?

23 Referências BRASIL, MS. Secretaria Executiva. Departamento de Economia da Saúde, Investimentos e Desenvolvimento. Projeto de Formação e Melhoria da Qualidade da Rede de Saúde. QualiSUSrede KUSCHNIR, R. Redes de atenção à saúde: contextualizando o debate. Ciência & Saúde Coletiva, 15(5): LATOUR, B. A Dialog on Actor Network Theory. Disponível em: LATOUR, B. On actor-network theory. A few clarifications plus more than a few complications. Sziale Welt, vol. 47,pp , MENDES, EV. As redes de atenção à saúde. Ciência & Saúde Coletiva, 15(5): SANTOS, EM et al. Monitoramento em promoção de Saúde:uma experiência de capacitação de adultos em um estado do Nordeste brasileiro. Educar em Revista, Curitiba, Brasil, n. 46, p , out./dez. Editora UFPR

24 Referências Clavier,C; Sénéchal, Y; Vibert,S and Potvin, L. A theory-based model of translation practices in public health participatory research. Sociology of Health & Illness, Vol. 34 No , p Nay, O. and Smith, A. (2002) Les interme diaires en politique. Mediation et jeux d institutions. In Nay, O. and Smith, A. (eds) Le gouvernement du compromis. Courtiers et ge ne ralistes dans l action politique. Paris: Economica. Bowen, S. and Zwi, A.B. (2005) Pathways to evidence-informed policy and practice: a framework for action, PLoS Medicine, 2, 7, Latour, B. (2005) Re-Assembling the Social. An Introduction to Actor-Network Theory. Oxford: Oxford University Press.

25 Thank you