Participatory Planning in Health as a Reflective Tool for Decision Making
Secretaria Municipal de Saúde de Florianópolis

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
The Unified Health System (SUS) in Brazil is the largest system of universal and public health in the world. Established by the Federal Constitution of 1988 it had important welfare advances such as the structuring and expansion of primary care, and the diffusion of medical specialties beyond the major urban centers; and important management advances, such as organizational contracts setting goals for State and Municipal management system, and establishment of health areas, so the municipalities can collaborate with services among each other. However, although many advances have been achieved, many others are needed to improve the quality of services provided to the population and rationalization of investments. Given the specificities of each type of assistance unit (basic unit, polyclinic, UPA, etc.) and its management, it is essential that each point of the care network is able to identify its unique problems and build action plans based on them. Considering the health sector characteristics and its dynamics, the financial incentive for the planning is already contemplated in the law which regulates SUS since 1990. Nevertheless the initiatives were not enough to make planning become an institutional culture in healthcare organizations. Believing in the potential of planning as a tool for overcoming the problems faced, Florianópolis Municipal Health Office started promoting since 2010, the planning of all working units (assistance and managerial), based on the initiative of the Health Ministry that started just over a year before. But it was necessary to develop planning methodologies aligned to the Municipal Health Plan in all units. The units built a matrix of intervention (action plan) from a survey of problems and setting goals. But it was evident the difficulty of these units in monitor the implementation of these planned actions. Thus, it became very difficult to ascertain results and if any, match them to planned actions. Thereby, the planning cycle PDCA (Plan, Do, Check, Act) was not executed to its fullest, compromising the process. So even though there could be an initial consideration of working processes it did not generate a system that could in fact promote significant changes for workers and for all users of SUS.

B. Strategic Approach

 2. What was the solution?
From the observation of this problem it was initiated the building of strategies so the planning of the institution could in fact (1) contribute to the rationalization of used resources, (2) speed up and integrate processes developed by different technical areas, (3) allow the reflection of working processes by the workers themselves, (4) make transparent the working processes in the institution for managers, workers and users, and (5) make all the developed work result in providing better services to citizen, which is the reason of the institution existence. In pursuit of these goals that we believe the institutional planning can help achieve, we draw some strategies as action lines: (1) align the planning of different working units with the Municipal Health Plan, (2) encourage the expansion and consolidation of planning culture in the Municipal Health Office, and (3) create a unified and simple platform that could facilitate planning and monitoring and evaluation. In order to these objectives be achieved, these action lines should reach all SMS (Municipal Office of Health) working units, including health care units, management and executive boards. Thus, considering the health network strategic planning occurred in a disjointed way among different units and their monitoring and evaluation were not systematically performed. In 2011 the planning of units was aligned with the objectives Municipal Health Plan objectives, directing workers efforts to common goals, shared by all operating units. To simplify the process of planning in the units, Florianópolis SMS Planning Board adopted a methodology easily applicable without compromising the option of performing complex analyzes. The methodology which was adopted was adapted from tools already used by public and private organizations, such as the Balanced Scorecard (BSC) and the Common Assessment Framework (CAF), so that they were consistent to the health sector, being the Municipal Plan itself developed based on these two instruments. The methodology also included, a quality management tool that allowed control and continuous analysis of working processes, the PDCA cycle (Plan, Do, Check and Act), initiating a planning monitoring program in which working units routinely sent reports for validation and construction of monitoring matrices. This process, however, was static, not allowing the evaluation with consequent reflection and adjustments of constructed actions (PDCA "C" and "A"). It is known that despite the good initiative, it was necessary to develop a tool that would provide greater agility and dynamism to the process. Finally, after a broad study and consecutive tests, in 2013 the use of the first version of the software PDCASaúde (HealthPDCA) began, which interface and simple operability enabled workers to devote more time for discussion and reflection of the planning process and spend less time to fill the system. Besides providing the beginning of the units planning monitoring, PDCASaúde workers became the protagonists of the process, transforming the established schedule in a dynamic process, subsidized by the reflection of the parties and allowing adjustments such as modification, inclusion and exclusion of actions set initially based on the scenario analysis.

 3. How did the initiative solve the problem and improve people’s lives?
The incentive strategy, integration and planning monitoring developed by the institution, mixes difficult elements of traditional business planning strategies with lighter strategies to approach people, among them the institutional support. This strategy is put forward as an alternative to supervision and seeks grants and favorable environments to reflection and importance of the labor process. Therefore planning is developed by the people who are experiencing the reality of the service, breaking the dichotomy between "who thinks" and "who runs the things". The self-assessment process conducted annually and that precedes the definition of the main goals to be worked, awakens the reflection on progress and difficulties that occurred over a year of work. The prioritization aligned to the Municipal Health Plan causes workers to feel part of a greater institution achievement. In addition, PDCASaúde proposes a new format for monitoring that encourages reflection on the working process and the review of actions which can adapt to the dynamics of the territory. Still, through the record available to any citizen, the system favors social control because anyone can follow the execution of the planning in the units.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
In the end of 2009, as soon as the Municipal Secretary of Health considered the strategic planning a essential tool for overcoming problems in the organization, an effort to raise awareness in the working units also began, so the planning would be done systematically. The effort to raise awareness was performed through meetings with workers of all health facilities from the Municipal Health. Meetings always occurred in the first quarter of the year with the goal of encouraging the planning, showing the power that it has to make changes and improvements. In parallel, the project was designed containing the methodology of Strategic and Operational Planning for units who voluntarily decide to realize it, containing the details of activities, distribution of responsibilities, forecasting and resources scheduling. And finally, during the year 2010, succeeding specific training for teams instruction and facilitating the process, the planning in some local health units began. From October to November in 2010 the development of the Municipal Health Plan, using a methodology adapted from the BalancedScorecard (BSC) and the Common Assessment Framework (CAF) started. The Municipal Health Plan is prepared every four years, at the end of first year of the municipal manager mandate, through workshops with the participation of managers, employees and representatives of the Municipal Health Council. With the approval of the Municipal Health Plan in December 2010, it began in 2011 the process to align the planning of the units with the main Plan through the Annual Health Program (PAS). Done the alignment with the planning of the Municipal Health Plan a larger number of working units engaged the strategy; the attempts to monitor its implementation by systematically sending reports for validation and construction of monitoring matrices also began. Finally, in 2013 the construction of PDCASaúde system was completed, an electronic system for monitoring the planning / Annual Health Program, in which the working units insert prioritized goals, targets and indicators related to actions planned to get to these goals and objectives, monitoring them monthly. As predicted, the new Municipal Health Plan was built in late 2013, with the strategic and operational planning for the 2014 already on the go. To contribute to the confronting of the problems faced by the units, support is offered by systematically sending data of the teams’ interest and facilitating meetings to discuss planning.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The entire project was coordinated by the Planning Board, a Florianópolis Municipal Health sector. Nevertheless, the construction of this planning form with the units involved workers from various sectors, both in management and operations unit. The construction of the Municipal Health Plan involved the participation of management workers, assistance units and users, in extensive discussions. That same process has involved the Municipal Health Council. It is important to say that the IT development company – a partner - which has a contract with the City Department of Health, was responsible for the development of PDCASaúde system, an important element in this construction. Nevertheless, the State University of Santa Catarina (UDESC, in portuguese) has conttributed on several steps to improve the planning process, including the use of CAF (Common Assessment Framework) and process mapping. This partnership was established through a technical cooperation agreement between both institutions.
 6. How was the strategy implemented and what resources were mobilized?
The main resource used was the effort of a significant number of people to recast the management processes that involves developing aligned with participatory and dynamic planning in a public institution. The investment here was initiative, labor and time. The raise of awareness and mobilization of professionals from all units (69 units in total) demanded organization and willingness to propose this change. In addition, time was needed over the past four years so this proposal could take its shape and show that it was possible to be done in all environments of the institution. To this end, many hours to study planning methodologies were needed; study the experiences from other locations, both public institutions and health institutions (public and private). Due to the limitation of the planning team (average of four people in the period), the construction of schedules and working plans was a major challenge. These schedules and working plans required the team to review the methodologies to be used in the planning of the units; workers training for the methodology use and other tools; the way to approach individual units and their scenarios; key moments to give support to the planning of each unit; the way to assist in monitoring the construction of a general scenario. The software development (PDCASaúde) did not generated additional cost to the institution, because there is an ongoing maintenance and modification of information systems contract with a private company, which agreed to develop such system without additional costs.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Throughout this time, the way of planning at the Municipal Health was built in a participatory and voluntary manner, with continuous improvement of the methods employed. Thus, this construction would only exist if there was adhesion of working units to the proposed method. This way, the main outputs are detailed below: - 95% of working units performing planning (construction and implementation of the intervention matrix): raise of awareness held together with reliable practical methods and data provided to the units (health indicators), culminated through a historic construction in a high rate of adherence of units to the planning. We believe that this accession was the result of a unique work that was able to promote the intentionality of change in workers. - 70% of the units monitoring the implementation of the plan: building a system easy to use, such as PDCASaúde, enabled the majority of health units to monitor the implementation of the planning. Just as the planning itself, this success only happened by understanding the importance of the initiative by workers, which enabled the continuous reflection of the working processes. Likewise these two points are results of the process and also are the reasons for the success of this initiative because they occurred simultaneously. - Reporting to the Municipal Health Council aligned among the director boards: filling out, monitoring and use of the system PDCASaúde which accountability (statement of expenditures and actions taken) to the Municipal Health Council was held in an integrated manner with the SMS various sectors of management, providing greater clarity and quality control on the population health management. - Improvement of health indicators: the planning led to two direct interventions on indicators: (1) the agility in obtaining indicators improved their generation because of the data use by employees in self-assessments and promoted the analysis and consequently the critique (which was a good to raise healthy discussion) about the indicators; (2) the lead of the planned actions for projects / goals so far undeveloped and therefore fragile. The concentration of targeted efforts meant there was an improvement in services and, consequently, the related indicators also improved. - Extensive transparency in the planning and execution of actions: any citizen can have access to planning of any working unit through PDCASaúde with a quick and simple registration which does not require the number of personal documents. This way, the system presents itself as a mechanism for wide transparency to citizens.

 8. What were the most successful outputs and why was the initiative effective?
By 2011, at the beginning of this progressive process of reshaping the way of planning in the SMS, there was no monitoring of the implementation of planned actions. So, workers performed a self-assessment and planed actions to be performed throughout the year, but did not monitor its implementation. The two main consequences of this is that (1) the actions often ended up not being implemented, because with the daily routine people would forget what they had planned as strategies to cope with problems, continuing in the same line of action they had before; and (2) people did not measure the changes generated from the actions taken, so there was a risk of a large expenditure of energy in low-impact actions. By knowing this problem, in 2011 attempts to monitor the planning implementation in the working units were initiated. But only in 2013 it was completed the construction of a simple, agile system and with a reasonable usability for workers of all units, so they could monitor the execution of the planned actions: PDCASaúde system. Through this system, it is done monthly monitoring of the proposed actions – the ones that worked and the ones which did not. This monitoring is used in monthly planning meetings (which happens in all units once a month) to be analyzed, discussed and, if necessary, redesigned from the implementation of actions and the dynamics of the scenario. In other words, the use of PDCASaúde system provides the realization of the final two parts of this planning cycle that seem so expensive for most organizations: the "C" (Check) and the "A" (Act). And it is precisely in this reflection on the planned / executed that is the power of this cycle. Through this system, health facilities insert prioritized goals, targets and indicators related to planned actions designed to achieve the goals and objectives, monitoring them monthly, as previously mentioned. To improve this process, the Planning Board on a quarterly basis sends the calculation of both: related indicators and results of the processes, so workers are still able to verify the impact of actions carried out directly on the indicators, performing a more complete planning evaluation. Still, the Planning Board constantly monitors and evaluates the use of the system, trying to identify difficulties that some units might have. Thereafter it is performed the support for these units in an attempt to contribute with the approach of the problems they face.

 9. What were the main obstacles encountered and how were they overcome?
It is natural that proposing changes in people’s labor routine causes some discomfort in the beginning, and with this planning proposal it was no different. Not all workers received it in a friendly way, understanding it as another activity to perform among many others already assigned to them. To try to minimize this impression, planning was presented as "voluntary," in order to be developed only by those who really understood it as a tool to overcome the weaknesses. Because there was not an institutional (or professional) culture of planning, the resistance was significant and immediate compliance was low. That was the biggest challenge over the past five years: demonstrate to employees that planning is a way to help them see and define problems, define their causes and to act, overcoming difficulties. To face this challenge, meetings with workers of all units were held to raise their awareness about these processes. In addition, the Planning Board promoted the sharing of successful experiences among units and was always available through different channels of communication, to support them in all aspects of planning. Another challenge was found associated with the use of PDCASaúde system: though the system was thought to be simple to use, some difficulties to manage it occurred in 2013 (and some still occur) when the system was put into practice. In an attempt to overcome these difficulties, in addition to annual training to use the system, the team frequently performs training on demand, whenever we are asked or when we find errors in the system monitoring.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The routine of health care services is quite intense. Therefore, it is common for workers in these environments end up focusing purely on the performance of services (primary function of these working units), leaving aside the management of working processes. Thus, there is the risk of putting forth great energy (time and labor) at things that have generated little result. Moreover, the population health dynamics requires work processes in health services to be also dynamic. For this reason, this way of planning that promotes the key role of workers brings the encouragement for reflection on how to build actions and it gives back to workers the analysis and construction of a process of work collectively thought from the local reality, as opposed to a normative organization from a central management. Through this move, it was possible to get more organized, structured and ready to meet the population’s needs for services, considering the specificities of the local population (49 basic health units) and citizens who are part of it, from the context in which these services were inserted. Still, from the reflection initiated by planning, several routines and flows were revised, streamlining working processes and the user direct services. Proof of this are the good health indicators achieved in recent years, indicators of process or result. Among the process indicators, we can mention the Ministry of Health Improving Access and Quality in Primary Care Program (PMAQ), through which 64% of our primary care teams were above average score. This program evaluates issues related to the access of people with acute and chronic illness, as well as priority groups. It also traces an overview of the service quality, including physical installation and users’ service evaluation, but in a small sample. To improve and expand the measurement of user satisfaction, the Federal University of Santa Catarina (UFSC) applied an instrument focusing on the following aspects: (1) access to services (hours and location), (2) ease, convenience and scheduling time when setting appointments, (3) privacy, security and respect during the service, (4) facilities and equipment and (5) quality of provided care. The final result shows that 73% of users rated the basic units of health as good or very good, and only 10% as bad or very bad, 90% of people say they feel respected by professionals in relation to their cultural habits, customs and religion. These results are of great importance to demonstrate the quality of selfless service by professionals who, through the cycles of reflection, monitoring, evaluation and planning, follow a process of continuous improvement. These results coincide with the great accession of workers in the planning cycle, and in the last year (2013), 91% of the working units used the cycle and over 70% of them fully utilized the planning monitoring system (PDCASaúde). All this effort also has direct effects on result indicators in health. A strong example is the infant mortality rate, which showed significant reduction, falling from 9.06 / 1,000 inhabitants in 2010 to 5.18 / 1,000 inhabitants in 2013, a reduction of 43%, placing Florianópolis at levels comparable to developed countries. Another important example is the decrease in the hospitalization rate for conditions sensitive to primary care, which fell from 59.35 / 10,000 inhabitants in 2010 to 49,33 / 10,000 inhabitants in 2013, a reduction of 16%. These indicators demonstrate the skills of the city primary care, especially if analyzing investments in the city health (adding federal, state and local funds), when adjusted with the inflation period rate, did not change (R$ 512.16 / hab. in 2010 to R $ 510.35 / hab. in 2013). We understand that this jump in quality is not only merit of the planning cycles in the units, because many health policies have been implemented or improved during the same period. But we are sure that the consequences generated by reflection and planning at every point of the health care municipality are important factors for these great services improvements offered to the population.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The management in the public sector of Brazilian health, unfortunately, has little data to conduct proper planning. When the data are considered, they are interpreted as purely numeric variables, disregarding such data (process or result indicators) are generated from the daily commitment of professionals and therefore their opinion, desires and wishes should be considered in production process of health services. That said, the biggest sustainability source of this project is the ongoing exchange of information with the health professionals, who are constantly experiencing the results achieved (or not) with the changes and reflections generated from the planning process. This way, the methodologies and technologies used are in constant use, evaluation and review, providing instruments closer to the professionals’ reality and at the same time they remain simple and objective. All this dialogue is only possible because over the years, the Municipal Health Office has maintained the staff of the Planning Board, so there is a continuity of this process. Thus, the political will allied with good response and collaboration showed by workers during this process have made the planning to be improved over the years. This process was responsible for the recognition of this initiative with a national award in 2013, offered by the Health Ministry to innovative practices, called InovaSUS Award. Our proposal has gained national recognition, even if the publicizing was not as extensive as well. We were also invited for inclusion of our project in the practice bank of SUS (IdeiaSUS), being available for any person. These publicizing targets, besides valuing the work of who is involved, show the possibilities of making a more dynamic, complex and collaborative planning in the health field. The use of PDCASaúde system was a fundamental step in this planning cycle that began less than two years ago. But there is already a proposal to use the system with the other departments of the Municipality of Florianópolis, so the planning across the city can become integrated. In addition, managers from other municipalities of Santa Catarina came to Florianópolis in the last two years to understand how our office conducts planning. We understand that our practice is perfectly reproducible. However, we also understand that it is not something that can simply be "implanted". It is a sensitive and continuous construction and it requires determination, because the obstacles are many. The PDCASaúde system, in particular, could be used at all levels (local, municipal, state and federal) and not just in the health sector, without the need of workers specific for that or increased labor demand. Understanding planning as a process of overcoming potential difficulties / obstacles is an important investment in the short / medium-term to have some significant and important gain in the medium / long term.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The process described here was developed collaboratively by a lot of people. There was a lot of energy, time and human effort involved, resulting in a rich learning process. We can say that besides the specific learning about planning conducted throughout the network of health care, there has been created spaces for dialogue and collaboration that did not existed before, with mutual respect and collective spirit. Still, perceptions about so called "insurmountable” problems have changed, as for the perceptions about governance, which caused workers to spend more time in actions with the potential to generate good results. Main lessons were learned and among them (1) the need for constant review of methodologies and other technologies, as well as their simplification: extremely comprehensive and complex tools are useless if people cannot make use of them; (2) the requirement of extensive dialogue for the construction of a larger collective project; (3) the continued offering of support to workers having problems with the process: as opposed to supervision with evaluation of results and obligations , we propose a process "with" people, as partners, with their contributions, generating great results for participation. As a counterpoint, we would like to have a specific developer for the system we use (PDCASaúde) because the possibilities for customization and adaptation to the process dynamics would be higher. However, this would involve greater financial resources and unfortunately, there is not a way of having it at the moment. Our outlook for the near future is to increasingly qualify the process of monitoring and evaluation of the units planning. It is a noticeable difference in the quality of planning done among units that adapted the new system since 2009 and those who started this year. We are sure that the internalization of this process takes time, but we also know that the combined efforts of workers are able to accelerate this development. Thus, we will continue to dialogue and work together, along with the data improvement in regards of quality and measurement of results, to build an open, inclusive planning and that can in fact assist workers in overcoming the problems and improve the quality of services offered to the population.

Contact Information

Institution Name:   Secretaria Municipal de Saúde de Florianópolis
Institution Type:   Government Department  
Contact Person:   Carlos Moutinho Junior
Title:   MD  
Telephone/ Fax:   +55 48 3239-1514
Institution's / Project's Website:  
Address:   Av. Henrique da Silva Fontes Avenue nº 6100
Postal Code:   88036-700
City:   Florianópolis
State/Province:   Santa Catarina

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