Challenges for the management of health work in the public sector

The discussion concerning the management of health work has increasingly occupied the agenda of health managers and researchers and has become a critical point for implementation of the Brazilian Unified National Health System (SUS) in Brazil.

A major challenge for the management of health work has been to adjust the workforce to the health system’s new demands for training, professional qualification, and employment.

The growth of the Third Sector (or nongovernment public sector) has gained force in Brazil since the country’s re-democratization in the 1980s, leading to a considerable increase in the outsourcing of public services, especially in health, through management contracts with Social Organizations (“OS” in the Portuguese-language acronym).

The Master Plan for Administrative State Reform (PDRAE), passed in 1995, proposed a management-based configuration for public administration, introducing new legal and administrative modalities. These included the “OS” model, created under Law n. 9,637 of May, 15, 1998, to enable public-private partnerships for the implementation of public policies through management contracts that define and establish mutual commitments between government and outsourced entities, based on the justification of ensuring efficiency and guaranteeing results through such contacts ¹.

With regard to labor regulation, the changes resulting from the establishment of outsourced relations (through contracting-out to private institutions) has placed health workers in a vulnerable position, since work contracts are negotiated without workers’ participation and few contracts are regulated or establish timeframes for the employment relationship. In addition, since the standards and rules for job admissions, laying-off/firing, contracting, and qualification are determined from outside, they can violate the basic principles of labor relations in the public sector, such as job stability and career advancement. The new model directly impacts the employment structure and work process.

How to maintain quality as measured by the acquisition of indispensable skills for proper professional performance? How to guarantee decent working conditions and job stability, essential for retaining health professionals and guaranteeing continuity and bonds “with” and “in” health services? What is the nature of, and control over, these so-called non-profit organizations?

These are some of the questions that have been raised towards this new model of public-private relations in health services provision. The model has not only been criticized by workers and legislators, but is now also the object of inquiry by oversight agencies, especially in the State of Rio de Janeiro.

The article Workforce Management in Emergency Care Units: Government Strategies and Profile of Healthcare Professionals² in this issue of CSP shares the results of a study on the implementation of Emergency Care Units (UPAs) in Rio de Janeiro, where the state opted for the “OS” outsourcing model.

The study was launched in 2007, and fieldwork was conducted from November 2012 to January 2013, interviewing 41 administrators involved in emergency care policy at the federal, state, and municipal levels.

By giving voice to health system managers, the study provided a closer and more in-depth look at the reality of health work in this context, identifying (from the perspective of the subjects of such work), the problems encountered in management of the actual work, the predominant forms of employment relations, and the factors that influenced the choice of the “OS” as a management strategy and model.

The results raise relevant questions such as: difficulty in retaining physicians and deploying them outside metropolitan areas; high job turnover; uneven distribution of health professionals; and insufficient qualifications for the work, among others.

From a macro perspective, the results provide food for thought on health work’s social perspective and the state’s social responsibility as manager of work in the health field.

The challenge for both management and researchers is to consider strategies and mechanisms that can contribute to the protection of health work, considering its political, educational, economic, and subjective dimensions.

Maria Inês Carsalade Martins
Departamento de Ciências Sociais, Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil. [e-mail]

• ¹
  Martins MIC, Carneiro CCG. Política de gestão do trabalho e a atenção em saúde: um estudo de caso sobre a experiência de contratualização da Atenção Básica no Município do Rio de Janeiro. In: Martins MIC, Marques AP, Costa NR, organizadores. Trabalho em saúde, desigualdades e políticas públicas. http://www.lasics.uminho.pt/ojs/index.php/cics_ebooks/article/view/1901.
  » http://www.lasics.uminho.pt/ojs/index.php/cics_ebooks/article/view/1901
• ²
  Machado CV, Lima LD, O’Dwyer G, Andrade CLT, Baptista TWF, Pitthan RGV, et al. Gestão do trabalho nas Unidades de Pronto Atendimento: estratégias governamentais e perfil dos profissionais de saúde. Cad Saúde Pública 2016; 32:e00170674.

Publication Dates

• Publication in this collection
  2016