RESEARCH ARTICLES

Healthcare and productive restructuring: effects of increased flexibility on maternity hospitals in the Cegonha Carioca program

Jane Márcia Progianti^I; Juliana Amaral Prata^II; Pedrita Machado Barbosa^III

^I Ph.D in Nursing. Associate Professor of the Department of Mother and Child Nursing, Faculty of Nursing, Researcher in the Research Group on Gender, Power and Violence in Health and Nursing, Researcher of the Prociência Program of Rio de Janeiro State University. Brazil. Email: jmprogi@uol.com.br
^II M.A in Nursing. Doctoral student of the Faculty of Nursing, Rio de Janeiro State University. Brazil. Email: juaprata@gmail.com
^III Undertaking M.A, Faculty of Nursing, Rio de Janeiro State University. Brazil. Email: barbosa.pedrita@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2015.12540

ABSTRACT

This documentary study conducted on Brazil's National Register of Health Facilities (CNES) database discussed the effects of productive restructuring on municipal maternity hospitals in the Cegonha Carioca Program, and thus on nursing. The process fostered more flexible service management, which in turn enabled the network of labor care facilities to expand through partnerships and management contracts. In human resource terms, more jobs were created for nurses to work in maternity hospitals, and diverse new types of employment relationship emerged. It was concluded that, although this program does represents significant expansion in the labor market, it reasserts public sector flexibilization by permitting fragile employment relationships, thus contributing to labor instability. In this scenario, regulation and professional development for these professionals pose challenges for managing the implementation and continuity of public childbirth care policies.

Keywords: Obstetric nursing; work; humanization of care; policy.

INTRODUCTION

In the beginning of the 1970s, the transformations in capitalism led to a worldwide crisis, characterized by the exhaustion of the Fordist model of production, which lasted until the end of the decade, when the neoliberal ideology conquered the developed countries and was shown to be the ideology most appropriate for supporting globalization and productive restructuring, processes which constituted a response to the crisis in Fordism, and in the reconfiguration of the capitalist mode of accumulation^1-3.

Neoliberalism brought proposals which aimed to reform the social welfare States, including containing social costs, privatizations of nationalized companies or industries, flexibilization of the work, and deregulation of the market^4,5. In parallel, globalization contributed to the neoliberal advance, through allowing the mobility of capital at a global level⁶. These processes benefited from the productive restructuring which, based on structural transformations in the ambit of production work, introduced new standards of management and organization in these sectors ^1,2.

As a principal characteristic of productive restructuring, flexibility translates into the liberation of the production based on the just in time method, involving rationalization, efficiency and cost reduction. Accompanying this conception, the market is configured through the flexibilization of the working days, the remuneration and the social rights, changing the professional training through proposals which involve the development of skills and competencies, with a view to the constitution of a qualified workforce^2,7,8.

In spite of being distinct phenomena, neoliberalism, globalization and productive restructuring are articulated through the transformations which have been occurring in capitalism in recent decades, as they share the ideal of flexibilization in the varying sectors of society^3,4.

In the perspective of the management of Brazilian health, in spite of the consolidation of the Unified Health System (SUS), the policy of economic adjustment, implanted in the 1990s, determined the reduction of costs and of financing, the absence of investments, and underpayment for services and professionals, resulting in a drop in the quality of the care^4,9.

This panorama catalyzed the confrontation among the conceptions regarding the role of the State, and the standard intervention on society, favoring the appearance of new models of management of health units, which resulted in the deregulation of the labor relations^10-13. Hence, with the promise of debureaucratization and efficiency of public management, capitalism, through financialization, instituted productive restructuring in the health field, based on the flexibilization of the structures and forms of organization of labor relations^14,15.

Besides these effects of productive restructuring, in the dimension of health production, this process has to do with changes in the way of producing care, based on innovations in the productive systems^16,17. Thus, in spite of the hegemony of the medical practices, which transformed Brazil into one of the champions in terms of cesarean sections, the obstetric field has been changing based on the valorization of a work process centered on the living labor and the use of light technologies to the detriment of focus on the dead labor and on hard technologies, in which nursing has contributed to re-signifying the way of caring in obstetrics.

In the light of the above, with the aim of contributing to reflections regarding the repercussions of this new configuration of the market on the process of nursing work, we propose to discuss the effects of productive restructuring in the municipal maternity hospitals of the Cegonha Carioca Program and its nexuses with nursing.

METHODOLOGY

This is a documentary study undertaken using the National Health Facilities Census (CNES), specifically, the nominal search for establishments¹⁸ . This survey considered the period available from 2007 – 2014, operationalized through the consultation with the establishments' technical files, with emphasis on the maintaining entity, and on the annual consultation of professionals by competency, using the expression nurse so as to recover the quantity of nurses recorded on the system and the labor relation established with the institutions.

Based on the Brazilian Classification of Occupations (CBO), we used the word nurse instead of obstetric nurse, as, as weak points of the study, we had difficulties in identifying – in some maternity hospitals – the nurses who worked specifically in the area of obstetrics. In addition to this, as the CBO recorded on the system is not always consistent with the work profile of these professionals in practice, we opted for the expression nurses who work in maternity hospitals for the analysis and discussion of the data.

As the inclusion criteria, we adopted the municipal maternity hospitals of the Cegonha Carioca Program, consulting the website of the Municipal Health Department of the Prefecture of Rio de Janeiro (SMSDC/RJ). Thus, we found one birth center, six maternity hospitals, and four general hospitals which had maternity units¹⁹.

As exclusion criteria, particularly for the discussion of the labor relations of the nurses who work in maternity hospitals, we considered the weaknesses found in the database and excluded those establishments considered general hospitals.

For analysis of the data, we use publications of the Brazilian Institute of Geography and Statistics (IBGE) and of the Human Resources Observatory ^20-24.

RESULTS AND DISCUSSION

Based on the survey in the CNES, two categories of analysis emerged as effects of the productive restructuring in the municipal maternity hospitals of the Cegonha Carioca Program: increase in the network of establishments for birth care, and the appearance of different modalities of labor link for the nurses who work in maternity hospitals.

Increase in the network of establishments for birth care

Since the 2000's, a broadening of the care network has been verified in all the administrative spheres and in the different levels of care²⁵. In this regard, data from the IBGE point to the appearance of new health establishments in Brazil, with emphasis on the municipal and private network ^20-22.

This increase took place as a response to the need for the expansion of the SUS, in a context marked by the decentralization of the services to the states and municipalities. However, the issue of the financing of the policies appeared as a challenge for putting a quality public service into effect, given that the neoliberal reforms characterized by social cuts resulted in redefining the role of the State^4,25.

This situation intensified with Constitutional Amendment N. 19/1998, which implemented administrative reform, configuring the concept of flexibility in health and in Labor Relations in the public sector^4,10-12,25. Among the modifications introduced by this legislation, emphasis is placed on the following: the reviewing of the stability of the statutory civil servants, the changes in the system for remuneration of public officials and the introduction of the executive agencies and the social organizations (SO) in public management²⁶.

This last point of the reform entailed significant changes in the structure and the dynamics of the services, as it allowed the establishment of consortiums and agreements of cooperation in the ambit of the Union, the States and the Municipalities. As a result, it viabilized associated management, as well as the total or partial transferences of expenses, services, staff and essential goods¹⁴.

This regulation allowed the appearance of mechanisms of flexibility, which, gradually, were adopted by the management of the health services, and for the contracting of staff. This being the case, in the light of the policy of reduction of the State, the local governments, although opposed to the reform, adopted flexibility in the public sector, mainly through partnerships with non-profit-making entities and SO^4,10-12,14.

In the perspective of the health policies, the network's expansion, accompanied by the flexible tendency in the management of the services and of the human resources, can be verified in the Family Health Program and in the Cegonha Network, as initiatives of the Ministry of Health (MS), operationalized by the municipal administration, which were born in the ambit of these new managerial formats, presenting varying models of institutional link ^{11,14,25,27,28}.

The Cegonha Network was launched in 2011, and Rio de Janeiro was a pioneer in the implementation of the strategy, which seeks to organize a network of care for women and children, involving the three administrative spheres²⁹. This new model calls for the financing of reforms, extensions and acquisitions through passing on funds from the Union and private participation through social health care charities³⁰.

To this scenario of flexibilization in the public sector and in parallel with the Cegonha Network, one can add the creation of the Cegonha Carioca Program in the municipality of Rio de Janeiro, characterized by the linking of the prenatal consultation to the maternity hospitals, transport, embracement and classification of risk by the nurse³¹. These initiatives have led to partnerships and established varying labor relations, as well as investing, through the National Residency in Obstetric Nursing Program, in the training of specialist nurses for their later insertion in the SUS ^15,27,32.

As an effect of these new modalities of management which consolidate the advance of productive restructuring of public health, currently, the obstetric field of the municipal network of Rio de Janeiro has 11 establishments for assistance with birth inserted in the Cegonha Carioca Program, these being 10 Maternity Hospitals and one Birth Center, with nurses working in all these units.

Observing the period 2007 – 2014, in Figure 1, one can perceive that the increment in this administrative sphere, verified in the obstetric field, occurred based on various management arrangements of the institutions.

FIGURE 1 : Birth care establishments in the city of Rio de Janeiro according to sustaining entity
Key: SMSDC/RJ - Municipal Department for Health and Civil Defense of Rio de Janeiro
SO - Social Organization
Source: CNESNET, 2014.

We observed that, until 2007, the SMSDC/RJ directly managed all the childbirth care establishments, demonstrating that, until that time, the managers had not adopted flexibilization in the managerial structures, although this process had been legitimated by federal provisions since 1998.

From 2008, we verified that there was a gradual broadening of the care network, accompanied by partnerships with non-profit-making entities and with SO. This modality of associated management intensified with the publication of Law N. 5.026/2009, which regulated the functioning of SO in the management of health units³³. In the light of this apparatus and the incentives of the Cegonha Network and the Cegonha Carioca Program, we can infer that the flexibilization was accepted by the municipal management, resulting, in the ambit of childbirth assistance, in the creation of three new municipal units.

In this regard, it may be noted that the flexible model adopted for the management of the municipal maternity hospitals increased the number of positions, such that, by 2007, the number of nurses working in the establishments for childbirth care was 275, reaching a total of 607 by June 2014¹⁸.

Appearance of different labor links for the nurses in maternity hospitals

In Brazil, although regulation of labor is guaranteed by the Consolidation of Labor Laws (CLT), the deregulation of the market viabilized the establishment of contracts, which were often poor. In the public sector, the phenomenon of the flexibilization of the forms of work conform with the defining of the role of the State as a regulator, based on the transformations introduced by Constitutional Amendment N. 19/1998, which allowed the appearance of new modes of link for the human resources^10-12.

Added to this provision, the containing of costs with staff in the public sector intensified, in 2000, with the Fiscal Responsibility Law, which regulated the costs in the administrative spheres, specifying the highest percentage for the municipal level³⁴.

In the ambit of health, accompanying the tendency of labor relations of other sectors, the flexible contracting practices found a favorable environment in the light of the policy of reining in the machinery of state allied with the processes of decentralization and municipalization, as well as the new policies and programs for local undertaking^14,35. This scenario caused changes in the form of contracting and structuring of the workforce such that the municipal public administration was induced to contract professionals through atypical arrangements^{4,10,11,35,36}.

Subsequent to the productive restructuring in the field of health, the flexibilization of the management of human resources contributed to the labor market of the nurses being configured heterogeneously. In the work microspaces, it may be perceived that the workforce conforms in a fragmented way in relation to the type of labor link, to the managerial structure, and even in terms of salary¹⁰.

In this regard, the municipal maternity hospitals of the Cegonha Carioca Program are presented as exemplary scenarios of consolidation of flexible management in the services and in the human resources. Furthermore, as a recommendation of the public policies, this Program invests in the work of nurses in care during labor and birth, although the SMSDC/RJ has been adopting alternative practices to contracting these professionals¹⁵.

In observing the evolution of labor relations of nurses in the maternity hospitals of the SMSDC/RJ, in Figure 2, in the period 2007 – 2008, there was a proportional inversion of various links for the statutory scheme, which suggests the permanent contracting of workers for the public service. It is noteworthy that, in 2008, an open public examination was held for the post of nurse, to be called up until 2012, explaining the increase verified in the statutory scheme in the decline of the various links in this interval.

In spite of this attempt at regulating labor links in the maternity hospitals, from 2011 onward, subsequent to the Cegonha Carioca Program and the appearance of new units, there was a significant increase of various links, although from 2013 until the beginning of 2014, this modality of link begins to present a tendency for reduction for the coming years, given that a new open public examination took place in 2013, increasing the numbers of permanently-contracted nurses who work in maternity hospitals.

FIGURE 2 : Evolution of the labor relatos of curses in the birth care establishment of the SMSDC/RJ (2007 - 2014)
Key: SO - Social Organization
Source: CNESNET, 2013.
Note: The modelizeis of labor link which were numerically little significant werw included as "others links": cooperative, public employment CLT, autônomos, working for the state and verbal/informal contract.

Taking into account the entity which maintains the maternity hospitals and the type of the labor link established with the nurses, we perceive that, in spite of the statutory scheme prevailing as the main form of link, Figure 2 points to the proliferation of unstable links in recent years, in which atypical forms of work are the majority in institutions, where the SMSDC/RJ established partnerships and management contracts.

With the exception of the Birth Center which only has nurses under the statutory scheme, in the four maternity hospitals administered directly by the SMSDC/RJ, concomitantly with the predominance of the civil servant scheme, we verified the existence of other modes of labor relation, with emphasis on temporary contracts and professionals intermediated by SO. On the other hand, in the two establishments managed by SO, all nurses of these institutions had a labor link termed autonomous intermediated by Social Organization.

In relation to the contracts for specified time, Figure 2 presents the persistence of this type of labor link over the years, denoting a certain banalization of the legislation, which allows this type of contracting only to resolve situations of exceptional public interest, with specified or predictable duration, which cannot be met, at the time, with human resources from the public administration^4,12,37. However, temporary contracting, as a constant in the situation of human resources of the SMSDC/RJ, is illegal when configured as a substitute for an open public examination and an effective link.

We also note the considerable increase of contracting under autonomous intermediated by SO as a consequence of flexible management which, in the municipality of Rio de Janeiro, is materialized in Law N. 5.026/2009. This provision relates to the function of SO in health, only in the units created since the publication of the above-mentioned law³³. Hence, based in this legal apparatus, in 2012 and 2013, the municipality inaugurated two new maternity hospitals, responsible for the significant growth in this type of labor relation in the last three years.

In the period observed, the SMSDC/RJ has been simultaneously using different forms of link for the nurses, which may be characterized as protected work or typical employment and unprotected work or atypical employment. The first group possesses legal coverage, social protection and a labor relation which is not limited in terms of time, corresponding to the statutory scheme and to the CLT. On the other hand, the second group includes the set of temporary links, providers of autonomous professional services and other types of contracts which share weakness and absences of stability in the employment, without full protection in the ambit of legal rights³⁶.

This plethora of labor contexts relates to the notion of instability, as a phenomenon of weakening and loss of quality of the market, resulting from the neoliberal reforms which accentuated the flexibilization and deregulation of the work, the unemployment, and the levels of informality in the labor relation³⁶. As a specific characteristic of the economic development in late capitalism, the flexibilization of work, and the process of reducing job security, associated with lack of socio-legal protection, are presented as inevitable for the workers who, so as to avoid socially excluding unemployment, submit themselves to the unstable labor relations^3,25.

In this regard, the fragmentation of the links with the public administration of the health services is related to the instability of the work in the SUS. From the point of view of the link, the instability lies in the gaps in the protection of the rights and benefits of the worker, while, from the legal perspective, the failure to respect the norms of entrance into the institutions of the State configures an irregularity of the link in its origin^11,14,35.

In the micro-spaces of work of the SUS, the coexistence of different strata of workers generates instability in the job positions, compromising the professionals and institutions. In this scenario, the reduction in job security is visible in the physical and psychological exhaustion, in the demotivation, in poor performance, in absenteeism, and in lack of commitment to the establishment and to the quality of the care. On the other hand, as an effect of this process, the high turnover in the services is a context which affects the continuity of the public policies and the healthcare programs ^{4,10,11,15,25,35}.

In the current panorama of the management of human resources in health, the absence of single legislation supporting these fragile labor arrangements, in the different Brazilian states, hinders the regulation of atypical employments. The existing norms are locally specific and are based on the evaluation of the achievement of preestablished goals, without there being regulatory norms for admission, dismissal and performance of the workers^10,11,25.

Considering that it is a consensus among managers and workers that the training, performance and management of human resources profoundly affect the quality of the public services, the regularization of the labor links in the SUS appears as an urgent question. To this end, in 2003, the Ministry of Health set up the National Interinstitutional Committee for the Reduction of Job Insecurity in the SUS in order to develop policies and formulate guidelines for confronting this issue³⁵.

The governmental initiatives in the field of management of the work resulted, in 2006, in the publication of the National Program for the Reduction of Job Insecurity in the SUS, with a view to sensitizing, and raising awareness among, managers regarding the importance of the policy of valuing the worker as a strategy for promoting the reduction of job insecurity and the consolidation of the SUS^25,35.

In this regard, with the aim of combating the instability of the work in health in the SUS, the municipality of Rio de Janeiro established some objectives; among these, emphasis is placed on investing in the qualification of professionals and in reducing turnover among them. In 2013, however, in spite of the efforts, the indicator proportion of workers who work for the SUS, in the public sphere, with protected links did not meet the agreed goal of 92%, reaching 77.73%³⁸.

Although the results are not in accordance with the expected tendency for reduction, it is interesting to note that the valorization and democratization of the labor relations in the SUS constitute part of the guidelines of the action plan of the municipality for the period 2013 – 2015.

We can infer, based in Figure 2, specifically in relation to the nurses who work in maternity hospitals of the SMSDC/RJ, that the consequences of these initiatives are promising for the year 2014, as the data point to a considerable reduction of flexible labor relations, although, for it to be possible to state this as a tendency, it is necessary that there should be, in the coming years, a proportional increase of typical and protected employments, mainly in the statutory scheme.

CONCLUSION

In Brazil, concomitantly with the consolidation of the SUS and the process of municipalization of healthcare, the strategies for confronting the crisis of world capitalism have resulted in administrative reforms, which have led to redefining the role of the State, as the undertaker of public policies with a social character.

Under the influence of neoliberalism, globalization and productive restructuring, the policy of the minimum State, implemented in the health field, has placed finance as an impasse for putting quality public service into effect, allowing the appearance of flexible models for the management of the services and the human resources in this area.

This flexibilization in the public sector allowed the establishment of partnerships and consortiums of cooperation, mainly in the states and municipalities, although it has brought new configurations to the labor market. If, on the one hand, these new modalities of management have led to the broadening of the network and of the job positions, on the other, they have corroborated the deregulation and reduction in stability of the labor relations in the SUS.

In this regard, the municipality of Rio de Janeiro is presented as an example of consolidation of the productive re-structuring in public health, as, in the light of the Cegonha Carioca Program, this administrative sphere entered into partnerships which allow the creation of new establishments for care in birth, as well as the increasing number of jobs offered for nurses who work in maternity hospitals. However, accompanying the tendency of other initiatives at the federal level, this Program is using atypical and unprotected links for the human resources.

In this perspective, although the Cegonha Carioca represents an important expansion of the labor market for nurses, at the same time, it reaffirms the flexibilization in the public sector, through adopting fragile labor relations, contributing to the destabilizing of the work in the SUS. Furthermore, in the light of the variety of labor relations existing in the SMSDC/RJ, the management of these professionals is configured as a complex question, in the plane of regulation and ongoing qualification, becoming a challenge for the implementation and continuity of the public policies for care in labor and childbirth.

In the light of the above, we suggest further studies to monitor the current efforts of the municipal managers so as to regularize the labor links in the SUS, with emphasis on the management of the human resources of the above-mentioned Program, as, as an initiative which values the work of nurses, it is important that it should take place also in the perspective of the labor relations, given that this issue is a determinant for the quality of the services and for the effectiveness of the actions, as well as for the regularity of the work in health.

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