Hospitalizations Due to Conditions Sensitive to Primary Care and Performance of the Care Network

Methods: This is an exploratory descriptive research, with a qualitative approach, carried out with technical directors from the sanitary districts of the municipality of João Pessoa-PB. A semi-structured interview was conducted through a questionnaire containing information about personal data and planning and evaluation of management actions. The analysis was performed using Fiorin's speech analysis technique.


Introduction
The primary health care (PHC) is considered essential for the effectiveness of health systems and ensuring improvements in the health status of the population [1].It is the gateway to access to the health system to meet the demands of users, based on health care over time, for all types of conditions, acting as coordinator of care and establishing integration between the other levels of care according to the needs of users [2].
PHC shares characteristics with other system services, such as responsibility for access, quality and costs, prevention, treatment and rehabilitation, length of care and teamwork.It is an approach that underlies and determines the work of all other levels of the health system, that is, it organizes and rationalizes the use of all resources, both basic and specialized, aimed at promoting, maintaining and improving the quality of health [2].
An adequate primary care system is able to reduce the occurrence of situations indicative of unsatisfactory care, such as the absence of disease prevention and health promotion actions, long intervals for segment visits, difficulties in accessing referral services, and Excess of hospitalizations due to problems that can be resolved at this level of care.These situations allow the identification of a suitable primary care [3,4].
Due to its importance for the care and functioning of the health system, evaluation and monitoring of the effectiveness of PHC can be observed by identifying hospitalizations for conditions that are sensitive to primary care (ICSAP) that are health problems that can be treated by actions inherent to this level of health care and that in situations of absence of effective and timely care, the use of specialized services requiring hospitalization of patients is required [5].
In Brazil, the Ministry of Health, following an international trend, created a list of conditions sensitive to primary care that reflect the reality of health in the Brazilian territory and that should be used to evaluate primary care and/or hospital care, aiming at the evaluation of health system performance in national, state and municipal levels [6].
The use of assessment tools is essential for the analysis of the health situation, for making evidence-based decisions and programming health actions [7].It is known that high levels of ICSAP are directly related to problems of coverage of health services or low response capacity of the PHC [6].
Thus, in view of the need to advance the discussion on health indicators to support managers in the decision-making process regarding the adequate planning of health actions; And based on the assumption that the verification of the current situation of the ICSAP in the municipal health services and its reverberation in the management of the services can encourage the current use of this indicator as well as the solution of a series of problems related to hospital admissions.As a result, the present study aims to investigate, from the managers' perspective, the performance of the care network of the city of João Pessoa-PB considering the profile of the ICSAP.

Material and Methods
This is an exploratory descriptive research with a qualitative approach carried out in the municipality of João Pessoa, Paraíba, Brazil.The investigated population was composed of the five technical directors of the five health districts of the municipality in question.These managers were chosen because they are responsible for discussing the health indicators with the Family Health Teams under the responsibility of each health district, they also assist in the decision making for health actions in Primary Health Care.The municipality of João Pessoa is made up of five health districts that provide health care at the primary level and has approximately 88.3% coverage of the Family Health Strategy [8].
For the data collection, a semistructured instrument (questionnaire) was developed exclusively for this research.This questionnaire was applied to managers and was composed of eight objective questions that included personal data, schooling, length of service and five subjective questions, where the participants discussed the planning and evaluation of management actions of the ICSAP in the districts under their management.
The semi-structured questionnaire was validated by two specialists who worked in the management of primary care in the city of João Pessoa, for more than five years each, aiming at the insertion of possible suggestions, and thus, certified the academic scope of the instrument.After the validation of the pilot, the five technical directors of the health districts were contacted and invited to participate in the study, with prior appointment of the interviews according to the availability of the interviewee.On the day and at the scheduled time, the Informed Consent Form (TCLE), which was signed by the participant, was delivered.Anonymity was guaranteed in all stages of the study, for which the managers were presented with the letter "G" followed by the numbering from one to five (G1, G2, G3, G4, G5) in their speeches in the text, not implying This number in the order of the interview, so little in the corresponding sanitary district.
Data were collected by a single specialist researcher through a recorded interview that lasted between 14 and 30 minutes, at the participant's workplace in a reserved room where only the researcher and the interviewee were present.After the interviews, the material was transcribed in its entirety and analyzed based on the technique of discourse analysis in the strand proposed by Fiorin [9].The text is an organized whole of meaning, in a certain universe of signification.The meaning of the text is given both by its internal structure, which is the grammatical rules, and by the historical context of the moment in which it was produced.For this reason, the text is an integrally linguistic and integrally historical object [9].
The analysis of the data occurred after the identification of themes/figures, in the speeches, on the issues elaborated.Afterwards, the texts were decomposed and organized into blocks of meanings by coincidence/thematic divergence.
The research followed the ethical precepts demanded by Resolution 466 of December 12, 2012 that regulates the conduct of research involving human beings.The project was submitted to the Ethics and Research Committee of the Faculty of Medical Sciences of Paraíba, under protocol number 1.172.740and CAAE: 4575131540000.5178.

Results and Discussions
For the development of the following analysis, the empirical material was related to the pertinent literature and reverberated the social position of the respondent subjects in relation to the subtopics extracted from the speeches.The identification and analysis of the subtopics by the technique of discourse analysis resulted in the following empirical category: Planning in management: from gestures to practices that reveal the fragilities of the system.

Management planning: from gestures to practices that reveal the weaknesses of the system
Participants were aged between 26 and 45 years, graduated more than three years in some of these three areas, Nursing, Psychology or Physical Education, and among them four reported having a postgraduate degree.The search for information about the time of performance in the position of manager revealed that, all worked more than a year in their respective managerial positions.
In the analysis of the data that made up the profile of the interviewees, the diversity of training was highlighted, as well as the short amount of experience reported in relation to the exercise in a managerial position of such magnitude.Such revelations were of concern, with the knowledge that none of them received any type of training or permanent education upon assuming their positions, and knowledge about their exercise would be acquired with current practice.
During the analysis of the speeches it was possible to observe that the planning for the prevention of ICSAP is not part of the activities developed by managers and the demands are resolved as they are presented circumstantially.
There was no discussion here, no, the question is day by day, we did not even stop to do the planning... (...) we do not really have a plan that was done, thought, accomplished, there is a discussion, but to sit like that for planning has not yet.

G2.
In health, planning is essential, since the objectives are complex, uncertainties are present, situations are dynamic and everything is constantly changing.Added to these circumstances, the fact that healthcare managers dealing with human lives and not performing the planning or the occurrence of failures in the process can result in illnesses, disabilities and even deaths [10].
The act of planning in the field of health must be a permanent process in order to facilitate the direction of actions, the correction of directions and the confrontation of unforeseen events.Planning can be understood as a social practice that, while it is technical, it is also political, economic and ideological [10].
It is possible to perceive that there is something similar to a process of invisibility of the planning in the management of the ICSAP.However, sanitary district managers understand and reverberate their understanding of ICSAP planning, as well as how it is developed in the territories over their responsibility.
Planning is working within the team.Planning is basically done by the team, according to the user's need, of the family, taking into account this whole context.

G3.
Planning works with prevention -the primary goal of basic care-prevention and promotion, and all actions taken by the family's health are aimed at preventing hospitalizations...

G4.
Planning is always with matrix support, we are always pushing the issue of care so they can equip it in teams, so teams have the utmost care of patients...

G5.
Planning as in the vast majority of family health units, is done not only through the programmatic demands made by the follow-ups, prenatal care, childcare, in short, all programs, as well as home visits by health workers, Finally teamwork...

G1.
The number of challenges faced by managers is almost uncountable, since they are responsible for the decisions and development of health actions.Thus, planning is essential to assist managers in decision making inherent in this complex and dynamic process [11].
It is imperative to have a method of planning so that it is possible to understand and share the same idea for the participation of all those involved in the work process.The absence of a method practically unfeasible complex organizations, such as health [12].
Health management offers a number of challenges, and planning requires that difficult decisions be made for qualified and effective action.Therefore, it is important to make use of tools, in a continuous way and with the participation of workers and users, to assist the managers in the systematic and evidence-based decision making.
In this perspective, the managers apologize to the processes of popular participation and associate the success of the planning to these participations.
(...) to bring the user closer to the network, to make more aware of users in relation to the flows that have to be followed, of their responsibility as SUS builder, because everyone is responsible for their health...
(...) to make the user to be coparticipated, to be co-responsible, of those activities, doing what was oriented (...) When the planning instruments are drawn up with the participation of all stakeholders and when it is possible to obtain their commitment to the development of the actions, a greater chance occurs in the achievement of the objectives outlined.The identification of health problems and the discussion of the means to overcome them cause people to develop health awareness, and this fact encourages political mobilization of stakeholders for health [10].
However, it is evident that, at some point, managers find that popular participation ceases to be collaborative and becomes a collector of resolutive actions, making clear that responsibility for individual health is also the users of the system.
(...) many say," I have the right, I have the right, "but the community is also co-responsible, it has its share (...) G3.

(...) The big issue is accountability. The user today only goes to the unit when he needs to renew the prescription does not have that continuous care (...)
G2.
The practice of planning must take into account both the different health situations, as well as, its determinants and social conditions, given the inseparability of health and social environment [13].
Each social actor has a different capacity to act on a particular situation and this involvement determines the possibilities of success.Thus, only the elaboration of a set of actions and goals is not enough to achieve the objectives, it is also necessary to build the viability of the actions, considering the needs, capacities and engagement of all the actors involved in the execution of the actions [14].
To think of the actors as autonomous subjects is to consider them as protagonists in the processes they are part of, that is, as co-responsible for the production of themselves and the place in which they live, for that it is necessary to establish solidarity bonds, the construction of cooperation networks and collective participation in the management process [15].
Working in the Health Care Network (HCN) as a coordinator and care coordinator is one of the main functions of PHC.It is possible to perceive that there are weaknesses in the scope of PHC that can lead to the search for avoidable hospitalizations, a fact that causes hospital overload, shortage of beds and tension in the communication between the services integrating the HCN.
There is the fragility of the system, it exists, that we know it is reality...

G2.
We need to improve the supply of these health units, in the inputs, I think if we could keep the units with what they need, they would do this preventive and health promotion work... ...we know that we have to try to improve the service offer, we know that we have to try to improve the offer specifically of examination services, for a more concise follow-up...

G3.
We know that there is a hard job beds available and all (...) (...) We have difficulty in relation to the reference counter, fails, there is still so that monitoring is more reliable in fact, that sometimes there playing specialized care, there blame the primary care, there Is in this game of who is really to blame (...)

G2.
The HCN is characterized by the organization of services centering on the PHC, since this service is focused on the health needs of the population and act with full and continuous attention; Multiprofessional care; focus on objectives and commitments to improved health and economic outcomes [16].
Due to the effective organization of the health system, it is essential that they be organized in networks and that they work in an integrated and permanent way.For this, the communication between the services must be continuous, always using the safe reference and receiving the counter reference of the other services of the network [17].
In this research it was possible to identify also that the managers perceive that in some cases there is the insecurity of some professionals in the diagnosis and treatment of some causes of ICSAP and that this fact can lead to unnecessary referrals to other levels of health care of the network, However, claim that they are constantly working with the qualification of professionals and this should not be a problem.
(...) I feel that there is a little fragility to really know the cause, the diagnosis, the treatment, and because of this, it is often difficult to follow this user in primary care, which is why often Referencing for the specialty service.
(...) in relation to the orientation to the professional, if there is an insecurity we try to enable it to avoid making a new insecure referral...

G1.
In addition, I think we bring a lot of training to the professionals every month and even fortnightly... they can not say that they are out of date in any information, because both the NASF matricia and the people also enables.

G4.
The health area is very dynamic and the knowledge and technological know-how is renewed at great speed.This fact makes the continuous updating of workers become too complex and extremely important that not only managers but also professionals build habits of teamwork, learning to learn, as the object of individual learning, collective and institutional [18].
In order to solve problems related to qualification, the National Policy on Permanent Education in Health was created as a strategy to carry out changes in labor practices, aiming to valorize critical, reflexive action, with commitment and efficient technique, respecting the characteristics of each territory and the needs training every professional [19,20].
In this sense, it is important to emphasize that, permanent education is an instrument for restruc-turing health care, which should be the main planning strategy for SUS managers for the training and development of workers and social actors prepared to work in the health system, which Focus on the user and their real needs.
It was observed during the study that for managers, there is an understanding that health professionals are responsible, in addition to caring for the population, for the health and epidemiological situation of the territories under their responsibility.
(...) the problem is that we also need the co-responsibility of this professional, his will, his work process, to ensure that actions are made feasible, that the overload of the routine does not let that upset (...) ...that he takes responsibility for the action with this community, but unfortunately it is not all professional, and that is beyond our responsibility of direction.
(...) we advise that the evaluation be careful that the doctor touches, that the doctor asks for an evaluation, observe in more detail, but unfortunately goes from the work process of the professional who sometimes head low the way Is, does not make a careful assessment on the user (...)

G4.
The work process in health is a small part of the daily work of health and is configured as the daily performance of the professionals involved in the production and consumption of health services.This fact allows the analysis from the structural aspects related to the agents responsible for the action, setting the working process [21].
The elements of the work process must be evaluated together, because only when articulated are configured as process and alone constitute innocuous attitudes.In this context, the object is portrayed as the matter that will be transformed, where focus actions on health and correspond to human needs [22].
It is worth mentioning, therefore, that managers should encourage workers to take an interest in the user care process, since a health professional who works automatically and mechanically with a focus on production will never be interested in health promotion and will present Levels of quality of care.
In the following statements it is evident that managers use different types of approaches to manage their interventions in relation to ICSAP, however, it is opportune to observe that they are punctual and fragmented actions for each group of causes, without following a planning....when there is some disease, some pathology that is most recurrent in that territory, we are already going to try to improve.(...) diseases preventable by immunization we have campaigns right...

G1.
Specifically ear, nose and throat infection I think is more waiting room and medication.Angina, we work with hypertensives so that we try to avoid...

G3.
In this practice, the organization of care and management of health services is characterized by a clear segregation of services, programs, actions and clinical practices, where it is evident that the components of the network are not articulated, actions are not effective and the system Is plastered.
In this way, it is worth mentioning that, for the proper functioning of the health network, it is extremely important that the actions developed by the PHC are resolutive, requiring a restructuring of the system as a whole, from the functional units to the professional practices.In this perspective, one should make efforts to improve the skills, organization and integration of actions and services, always focusing on the role of PHC [23,24].

Conclusion
From the perspective of the managers of health districts, it was possible to observe that the performance of the care network of the city of João Pessoa-PB considering the profile of the ICSAP, showed signs of a considerable fragility in the HCN that begins in the difficulties in providing inputs and services For PHC, to problems of access and communication between levels of attention.
The study pointed out that the five health districts hold differentiated knowledge about the health planning process and its use still falls short of the real possibility and necessity.There are distorted conceptions of how to process it and strong evidence of underutilization by both managers and service professionals.
It was also evidenced that permanent education needs to be considered as a strategic element for the viability of the work process of the actors of this system.Initiatives in this direction will lead to the reduction of ICSAP rates and will result in the improvement of all sectors in the different levels of attention of the system.
The implementation of punctual and fragmented actions by professionals and managers of the districts investigated was another finding of extreme importance.In addition to continuing education, it is necessary for managers to encourage health professionals to act creatively and autonomously, focusing on the production of subjectivities.
The limitation of the study is evidenced by the fact that it is a qualitative approach and thus it was not possible to formulate hypotheses considering that this approach seeks to analyze non-measurable facts.Thus, further studies of a quantitative nature would be necessary to enable a more complete analysis.
With the study it was possible to perceive that the ICSAP constitute excellent indicators for this evaluation, since it allows comparing the performance of several health services, besides raising investigations about difficulties of access and quality of services provided, between regions and communities, Thereby assisting the manager in decision-making based on scientific evidence and strengthening primary health care in the municipality, the main gateway to SUS

Contribution of Authors
Layza de Souza Chaves Deininger.He participated in the design and coordination of the study, analysis, interpretation and discussion of the data and the final review of the article.
Kerle Dayana Tavares de Lucena.He participated in the design and coordination of the study, analysis, interpretation and discussion of the data and the final review of the article.
Elaine Tôrres Oliveira.Participated in Discussion of the data and the final revision of the article.
Leidyanny Barbosa de Medeiros.Participated in Discussion of the data and the final revision of the article.
Bruna Taisa Melo Nobrega.Participated in Discussion of the data and the final revision of the article.
Roseana Maria Barbosa Meira.Participated in Discussion of the data and the final revision of the article.
Adriene Jacinto Pereira.Participated in Discussion of the data and the final revision of the article.
(...) we are always prioritizing what is most incident.G5.(...) every month we work with different themes in the units.G2.