A Rede ou as Redes? Dados e perspectivas sobre a rede de atenção oncológica em uma região de saúde na cidade de São Paulo
Data
2021
Autores
Souza, Morris Pimenta e [UNIFESP]
Orientadores
Reis, Ademar Arthur Chioro dos [UNIFESP]
Tipo
Dissertação de mestrado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Introdução: A rede de atenção oncológica no Estado de São Paulo surge como um arranjo organizativo que visa a aprimorar o acesso ao diagnóstico e tratamento com vistas à redução da mortalidade por câncer. Seu funcionamento guarda uma série de peculiaridades e a forma como essa rede é percebida pelos seus atores, em especial pela operacionalização do seu protocolo de acesso, pode ser muito variável, distanciando-se na prática do desenho proposto. Objetivos: Analisar o processo de implementação da rede de oncologia na Região Leste da Cidade de São Paulo, o modelo de regulação de acesso adotado e seus efeitos na gestão do cuidado oncológico. Verificar se, em pacientes oncológicos, os múltiplos itinerários previstos pelas RAS se operacionalizam de fato; analisar os efeitos assistenciais do modelo vigente de regulação do acesso, em especial quanto às dimensões de regionalização e porta de entrada preferencial do sistema, bem como analisar, de forma comparativa e qualitativa, o funcionamento dessa rede na perspectiva dos gestores, trabalhadores e usuários.
Percurso metodológico: Foi realizado um estudo de caráter quali-quantitativo com adoção de múltiplas técnicas para a produção e análise de dados. Utilizou-se indicadores epidemiológicos para analisar a evolução da capacidade instalada, acesso ambulatorial e hospitalar, regulação assistencial e mortalidade. A presença do tema no planejamento dos gestores foi investigada nos planos de saúde. A perspectivas de gestores, trabalhadores e usuários sobre essa rede foi também analisada a partir de 24 entrevistas. Resultados: A análise dos indicadores epidemiológicos demonstrou que houve avanços no acesso ambulatorial e hospitalar relacionados ao câncer, associados a um incremento e melhor adequação da capacidade instalada na região, repercutindo, dentre outras coisas, na redução das taxas de mortalidade padronizadas por idade. Percebe-se, no entanto, que ainda restam grandes assimetrias entre as regiões e entre grupos oncológicos específicos, bem como oportunidades de melhoria quanto ao planejamento. Os gestores possuem uma perspectiva heterogênea e crítica sobre o processo, sendo o desfinanciamento da rede oncológica um dos principais problemas apontados. A perspectiva dos trabalhadores se torna mais crítica conforme seu grau de especialização, sendo mais críticos os que atuam nos hospitais . Os protocolos de acesso são bem avaliados pelos trabalhadores da Atenção Básica, porém muito criticados pelos dos hospitais. Os usuários desconhecem os protocolos e os desenhos formais da rede e operam seus mapas de cuidado de forma autônoma, muitas vezes compondo com o uso do setor privado e apoio de profissionais do SUS. Conclusões: O estudo demonstrou avanços importantes na rede de câncer na região, porém não há de fato gestão em rede do fluxo da assistência ao câncer. Observam-se significativas assimetrias entre as regiões. Diversos problemas, como o financiamento insuficiente do cuidado oncológico no SUS, bem como a alta fragmentação da gestão e do relacionamento entre os serviços permanecem muito além do desejável, o que se expressa em oportunidades de melhoria de acesso tanto para o diagnóstico quanto para tratamento. Tais fatos contribuem, dentre outras consequências, para um acesso pouco regionalizado e com forte viés pelas portas de urgência. Como esperado, as perspectivas dos atores são heterogêneas e demonstram baixa institucionalidade dessa rede no cotidiano, sendo ignorada por usuários e simplificada por trabalhadores, que a tratam como sinônimo da regulação de acesso.
Introduction: The oncology care network in the State of São Paulo emerges as an organizational arrangement that aims to improve access to diagnosis and treatment with a view to reducing cancer mortality. Its functioning has a series of peculiarities and the way in which this network is perceived by its actors, in particular by the operationalization of its access protocol, can be very variable, distancing itself in practice from the proposed design. Objectives: To analyze the implementation process of the oncology network in the eastern region of the city of São Paulo, the adopted access regulation model, and its effects on cancer care management. Check whether, in cancer patients, the multiple itineraries provided by the RAS are operationalized; analyze the care effects of the current model of access regulation, in particular regarding the dimensions of regionalization and the system's preferred gateway, as well as analyze, in a comparative and qualitative way, the functioning of this network from the perspective of managers, workers and users. Methodological path: A qualitative-quantitative study was carried out with the adoption of multiple techniques for the production and analysis of data. Epidemiological indicators were used to analyze the evolution of installed capacity, outpatient and hospital access, care regulation and mortality. The presence of the theme in the planning of managers was investigated in health plans. The perspectives of managers, workers and users about this network were also analyzed based on 24 interviews. Results: The analysis of epidemiological indicators showed that there were advances in outpatient and hospital access related to cancer, associated with an increase and better adequacy of the installed capacity in the region, resulting, among other things, in the reduction of age-standardized mortality rates. It is noticed, however, that there are still large asymmetries between regions and between specific cancer groups, as well as opportunities for improvement in terms of planning. Managers have a heterogeneous and critical perspective on the process, and the lack of funding for the oncology network is one of the main problems identified. The perspective of workers becomes more critical according to their degree of specialization, with those who work in hospitals being more critical. Access protocols are well evaluated by primary care workers but are highly criticized by hospital workers. Users are unaware of the protocols and formal designs of the network and operate their care maps autonomously, often using the private sector and the support of SUS professionals. Conclusions: The study demonstrated important advances in the cancer network in the region, but there is in fact no network management of the flow of cancer care. There are significant asymmetries between regions. Several problems, such as insufficient funding for cancer care in the SUS, as well as the high fragmentation of management and the relationship between services, remain far beyond what is desirable, which is expressed in opportunities to improve access for both diagnosis and treatment. Such facts contribute, among other consequences, to poorly regionalized access and with a strong bias towards emergency doors. As expected, the actors' perspectives are heterogeneous and demonstrate low institutionality of this network in everyday life, being ignored by users and simplified by workers, who treat it as synonymous with access regulation.
Introduction: The oncology care network in the State of São Paulo emerges as an organizational arrangement that aims to improve access to diagnosis and treatment with a view to reducing cancer mortality. Its functioning has a series of peculiarities and the way in which this network is perceived by its actors, in particular by the operationalization of its access protocol, can be very variable, distancing itself in practice from the proposed design. Objectives: To analyze the implementation process of the oncology network in the eastern region of the city of São Paulo, the adopted access regulation model, and its effects on cancer care management. Check whether, in cancer patients, the multiple itineraries provided by the RAS are operationalized; analyze the care effects of the current model of access regulation, in particular regarding the dimensions of regionalization and the system's preferred gateway, as well as analyze, in a comparative and qualitative way, the functioning of this network from the perspective of managers, workers and users. Methodological path: A qualitative-quantitative study was carried out with the adoption of multiple techniques for the production and analysis of data. Epidemiological indicators were used to analyze the evolution of installed capacity, outpatient and hospital access, care regulation and mortality. The presence of the theme in the planning of managers was investigated in health plans. The perspectives of managers, workers and users about this network were also analyzed based on 24 interviews. Results: The analysis of epidemiological indicators showed that there were advances in outpatient and hospital access related to cancer, associated with an increase and better adequacy of the installed capacity in the region, resulting, among other things, in the reduction of age-standardized mortality rates. It is noticed, however, that there are still large asymmetries between regions and between specific cancer groups, as well as opportunities for improvement in terms of planning. Managers have a heterogeneous and critical perspective on the process, and the lack of funding for the oncology network is one of the main problems identified. The perspective of workers becomes more critical according to their degree of specialization, with those who work in hospitals being more critical. Access protocols are well evaluated by primary care workers but are highly criticized by hospital workers. Users are unaware of the protocols and formal designs of the network and operate their care maps autonomously, often using the private sector and the support of SUS professionals. Conclusions: The study demonstrated important advances in the cancer network in the region, but there is in fact no network management of the flow of cancer care. There are significant asymmetries between regions. Several problems, such as insufficient funding for cancer care in the SUS, as well as the high fragmentation of management and the relationship between services, remain far beyond what is desirable, which is expressed in opportunities to improve access for both diagnosis and treatment. Such facts contribute, among other consequences, to poorly regionalized access and with a strong bias towards emergency doors. As expected, the actors' perspectives are heterogeneous and demonstrate low institutionality of this network in everyday life, being ignored by users and simplified by workers, who treat it as synonymous with access regulation.
Descrição
Citação
SOUZA, M.P. A Rede ou as Redes? Dados e perspectivas sobre a rede de atenção oncológica em uma região de saúde na cidade de São Paulo. São Paulo. 264 f. Dissertação (Mestrado em Saúde Coletiva) - Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo, 2021.