ORIGINAL RESEARCH

Managing the process of implementing men's health policy

Áurea Christina de Paula Corrêa^I; Isabele Torquato Mozer ^II

^I Ph.D. in Nursing. Associate Professor of the Federal University ofMato Grosso. Cuiabá, Brazil. E-mail:aureaufmt@gmail.com
^II Master's Degree in Nursing. Assistant Professor of the Federal University of Mato Grosso. Cuiabá, Brazil. E-mail: isabele.mozer@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2016.9483

ABSTRACT

Objective: taking gender as its theoretical frame of reference, this study examined Cuiabá Municipal Health Department documents and actions of its management team members who guided implementation of the national comprehensive men's care policy. Method: it is a qualitative, descriptive research. The empirical study material were the department's annual work plans and management reports from 2009 to 2013, and semi-structured interviews of 13 management team members. Policy analysis was applied as a methodological tool, and thematic analysis was performed. Results: the results showed repetition of actions proposed over the period, suggesting a lack of understanding of what is needed for the process. Conclusion: funding was indicated as responsible for the insufficiency of actions that should be directed not only to increasing service supply, but also to re-signifying masculinity.

Keywords: Health planning; gender and health; men'shealth; health management.

INTRODUCTION

This manuscript discusses the implementation process of the National Policy for Integral Men's Health (NPIAMH) in Cuiabá, Mato Grosso . The NPIAMH¹ was elaborated with the reference to the existing scientific literature and taking gender as a theoretical framework that justifies its institution, assigning to the hegemonic male behavior the reason for the low demand of man for health services that focus on health promotion and aggravations prevention, and the units of the family health strategy (FHS) identified as a privileged space for its execution.

Such behavior is characterized by the belief in invincibility, use of violence, use of physical force and certainty of not getting sick, being careful with the health a behavior considered female. Studies from the man's perspective as a user of the Unified Health System (SUS) show that they also want to take care of their health, but are faced with issues relating to the reception and forms of services organization².

Assuming gender as a lens for the apprehension of the world is possible to recognize the existence of attributes related to male present in the daily routine of health services, from social and cultural values of professionals and users. Attributes such as invulnerability, low self-care and adherence to health practices, impatience, among others, make these gendered spaces and enhance social inequalities, making impossible to meet the health needs and men's demands, reinforcing the stereotype that the services of Primary Health Care are feminized spaces^3.4.

The culture of the dominant gender, as well as the pillars that support the policies advocated by the feminist movement aiming to break the historical inequality surrounding the women⁵, contributes to the marginalization of men in the context of health services. Reflections resulting from the feminist field little problematize men and their masculinity, lighting up the debate about autonomy and women's body ⁶.

It is necessary to move on this discussion, producing reflections about masculinity and femininity, as gender relations point more to "diversity than the difference in response to the dichotomy and inequality" ^7:46.

The social construction of masculinity outlines as the practice of being a man around their position in the structure of gender relations⁸, recognizing the existence of various ways to express masculinity and femininity, extrapolating the usual way, socially determined and culturally established without losing its legitimacy.

Facing the sociocultural constructions concerning gender it is allowed to consider that health policies can contribute to overcoming obstacles of health care arising from gender inequality; therefore, it is necessary to recognize the impossibility that policies are neutral related to such inequalities: not responding to them would mean to contribute to their maintenance⁹.

Recognizing the influence of these inequalities in the implementation process of NPIAMH, this study aimed to analyze the municipal documents and the actions of members of the management team that guided its implementation in Cuiabá.

LITERATURE REVIEW

Brazilian law provides the development and periodic updating of the plans at each level of SUS, making in programming instruments and budget management¹⁰, which should be drawn from the assessment of the health needs of the population. After its implementation a management report should be prepared to report the progress and retrocession of the previous management, which should be used in planning¹¹, serving as a guide for new plans.

The NPIAMH provides that municipal management develops mobilization strategies and men awareness regarding their health needs to denaturalization of gender culture and meeting these needs, hitherto invisible to the services.

Despite NPIAMH define gender as a central concept, its National Action Plan does not point in that direction, since the proposed actions show a tendency to male body medicalization, along the lines of the proposals for the female body¹².

Here, gender is designed as a cross-theoretical element for the analysis of health event¹³ because it processes in the family, in the labor market and institutions and social and political organizations¹⁴.

METHODOLOGY

This is a descriptive study of qualitative approach, a case study, classified by proposing the specific analysis of the implementation process of NPIAMH in Cuiabá, pilot municipality selected by the Ministry of Health (MH) for its implementation.

The municipal political and administrative management in the early 2000s was marked by changes that determined the discontinuity of the actions proposed by the management teams of the Municipal Secretary of Health (MSH), because each new Municipal Health Secretary, who assumed the folder, new technical teams were formed and new intervention projects developed with the priorities established by the new manager, with no linearity in the processes conduction.

The data were extracted from municipal documents produced in that context - Annual Work Plans (AWP) of 2010 and 2013 and Annual Management Reports (AMR), 2010 and 2011, and the AMR-2012 was not available at the time of this study. Semi-structured interviews were conducted with professionals who occupied the managements, coordinators and technicians responsible for the area in primary care (PC) and secondary (SC), between 2009 and 2013 (since the launch of NPIAMH to data collection), totaling 13 subjects. The meetings took place in places defined by the subjects. The interviews were recorded and transcribed by the researcher.

The policy analysis was used that defines the dimensions ofcontext, actors, content and process, as a methodological tool ¹⁵ guiding the processing of data for the deployment of NPIAMH. However, this article shows only the content dimension analysis involving the projects, specific activities, goals, objectives proposed for the implementation of a health policy, actions coherence, as well as the resources required for this purpose.

The proposal thematic analysis¹⁶ followed for the analysis of the data. The analysis process was initially through an exhaustive reading of the empirical material to identify the most relevant ideas. Later, the mapping of individual speeches was performed, referenced by the content dimension and finally, the relevant subjects were grouped, which originated the categories: the projected, the executed and the evaluated and financial resources and progress of actions. The concepts of gender and masculinity were used as a lens for the interpretation of the data.

Aiming to preserve the identity of the subjects, their lines were identified as UA (units of analysis), followed by the chronological order of the performed interview (UA1, UA2...). The research was approved by the Research Ethics Committee of the University Hospital Júlio Muller under number 179,098/2012.

RESULTS AND DISCUSSION

The projected, the executed and the evaluated

Changes require managers and team, the knowledge of reality about the context the health care organizations are located, as well as the conditions of the internal environment of each management¹⁷.

The data show that there was no recognition of the local reality related to men's health or any identification of needs for the design of actions to be performed. Rather, the planning of actions for the realization of NPIAMH was not prepared based on indicators and/or psychosocial context of men but adapted to other Brazilian reality. A study conducted in a municipality of Santa Catarina, which proposed to analyze the conceptions of nurses on NPIAMH and to know the developed actions identified reality similar regarding the lack of identification of regional needs for planning actions for the male population¹⁸.

According to AMR-2010, the NPIAMH was 100% implemented in the municipality, corroborating the speech of one of the subjects of the study:

I think the plan was achieved [deployment], 100% up to where I assumed the Management of Primary Care, it was responded. [...] 100% implementation, 100% of qualified units, 100% of sent tests and 100% of the answers from the experts. (UA 9)

According to the speech, the launch and the awareness of policy implementation occurred in 2010, when it was considered implanted. Although all the teams have been invited to the awareness event, not all attended, according to another team member. The offer of tests and specialist consultations for the man also did not correspond to the expectations, as reports.

In the subsequent years, according to the documents, the main goal was to implement the policy, i.e., to create conditions for its operation through its deployment in procedures such as:

To elaborate the Action Plan for Men's Health Attention; to disclose the Integral Care Municipal Policy to Men's Health in the BHU; to develop a Municipal Protocol to Men's Health care; to facilitate the access of the male population in BHU; to perform screening for prostate cancer in Primary Care. (AWP 2011)

To implement the Action Plan to Men's Health care; to disclose the Integral Care Municipal Policy to the Men's Health in the BHU; to develop a Municipal Protocol to Men's Health care; to facilitate the access of the male population; to perform screening for prostate cancer in Primary Care; to ensure the prevention tests of prostate cancer. (AWP 2012)

The actions proposed in the AWP-2012 were the same as 2011 Plan, plus the assurance of tests for the prevention of prostate cancer, understood as early detection of disease. The excerpts generate questions, one about the implementation described in AMR-2010 and confirmed by the management of that period, like 100%. Whereas the proposed actions in the years 2011 and 2012 are similar, it appears that did not happen the desired deployment.

It should be emphasized that during the process of formulation and implementation of policy emerged a challenge to be overcome by management: instability in the exercise of political power and the various exchanges of leaders teams were facts that hampered and undermined both the coherence of the formulation, as the implementation and planning of medium and long-term. Those who participated in the preparation of plans not necessarily participated on its execution, influencing the process when printing different views in different historical and political moments.

It is corroborated the idea that setting goals is an illustration of the importance of having internal coherence in the implementation of a policy ¹⁹, which did not happen in this city.

A study performed in 26 pilot municipalities for the implementation of NPIAMH observed through the analysis of their action plans, repeating the text of the policy, and having scarce references to the social, economic, demographic or epidemiological of the municipalities that justify the proposed interventions. Neither alludes to the reality of health services in the municipalities or the men access to this services ²⁰, a situation similar to that reality.

The AWP should list general actions to be performed annually to guide the actions implemented by the professionals working at the local level, and in the system tips²¹. Thus, each year a new AWP should be elaborated based on the evaluation of the implemented actions, which can demonstrate fragilities, being necessary to overcome them through the provision of creative strategies; their potentialities need to be valued in the new plan. It is essential to consider the constant changes in the political and social situation as the population's needs directly interfere in the proposed actions²².

The repetition of actions allows to an inference that may not have been occurred a proper assessment of the process or that the planned actions have not been carried out, as AMR-2011 features no clarification. The absence of coherent AWP with planning strategies put at risk the planning of actions in men's health in the city and consequently, the implementation of NPIAMH.

The data also indicate that, possibly, monitoring is a problem in the city, given the absence of information about the implementation of the policy at different levels of health care. Proposals for implementation of the constant NPIAMH of AWP (s) are generic, without epidemiological or diagnostic justification for its proposal, i.e., not necessarily respond to the health needs of the male population.

Another need treated in AWPs was the construction of a system of reference and against the reference, question pointed by the subjects as a difficulty. Although the early detection of prostate cancer has been identified in the AWPs as a priority goal, it did not materialize because the necessary tests have not been available, as admitted in speeches.

It is important to note that even if the AWPs and AMRs have not been elaborated in accordance with the basic guidelines of the administration area, they are official, unlike what was found in a study conducted in Bahia, where it was not found any mention of NPIAMH in municipal plans and reports between the years 2010-2012²³.

The speeches analysis, plans, and reports show that the actions planned and performed to implement the NPIAMH in the city are vague, without specifics, compared with the proposals related to policies/consolidated programs.

[...] Always that is any events involving the Department of Health, we [primary care technicians] are there, with women's health, condoms, talking about STD/AIDS, talking about pregnancy [...] we don't publish even a pamphlet to men's health [...]. (UA 3)

The manager points out the lack of educational and informative material interfering with the progress of actions; however the theme men's health can be inserted in all the areas mentioned in the speech, showing little knowledge about crosscutting that the NPIAMH propose¹. The weakness in disclosure was evidenced as limiting in the city, a fact also occurred in two municipalities with full management, in Rio Grande do Sul, as reported by basic units of nurses who participated in the study which examined the actions and limitations for policy implementation²⁴.

It is possible to evidence the importance attributed by the management team to men's health in other provided policies:

[...] Because there exists a lot of programs, a lot of intervention at the same time, we sincerely do not remember [the Men's Health Policy]. It's happening so much at the same time, it's feature, you have to run after things that are already working, then this [the NPIAMH] that is stopped, will always aside. (UA 11)

The data demonstrate that goals, priorities, and actions have been redefined based on the individual interests of the involved actors, in the available resources, in disputes, in social pressure among others, common in the implementation process²¹. Thus, greater importance was given to other policies already in consolidation process and more fundraising, being the NPIAMH left aside. Critiques are made to federal management which regulations for formulation and implementation of health planning favors the not establishment of large commitments to solving problems, creating a certain discredit among managers since it becomes a theoretical proposal²⁰.

The planning for the implementation of NPIAMH, in the study period was similar to those performed in other regions of the country in different areas, being

[...] Vertical, ritualistic, make-believe, a kind of 'for-not-saying-that-I-did-not-talk-of-Flowers' without the commitment to recovery practices, with the emancipation of the subject and the population health^20:839.

Financial resources and progress of actions

The subjects indicate the financial resources as encouraging factor for the beginning of the NPIAMH deployment process.

[...] Which facilitated at the beginning was the possibility of the city to collect more with the implementation of the program and the productivity that the units would have after receipt of funds due to these actions to men's health. (UA 12)

[...] My objective as a manager was to deploy, do not miss the resource [financial]. (UA 9)

The excerpts show the intention of the team: fundraising, since the inclusion of men, as a target of priority actions would be the consequence, from the perspective of managers. The financial viability is an important factor that defines policies to be developed, and that may even interfere with the theoretical concepts that support it²¹.

For the subjects of this study, the amount available for the implementation of NPIAMH would not be enough to meet the demands of the biological order of men, since it would increase the supply of specialized services.

[...] Money has to come. We are moved by money, if we don't have money, we can't perform the treatment. (UA 5)

The lack of funding, according to the professional, was related to the impossibility of hiring new services, not showing concern for the quality of care that requires changes based on gender conception. Such changes should be worked among managers, professionals, and society to stimulate the discussion about health care by men since the existence of policy for men²⁵ or the provision of specific services is not a sine qua non-condition for adherence to promotion practices to health²³.

The manager associates the implementation of NPIAMH to the biomedical model, referring to the practice of curative medicine, going against the National Policy of Primary Care²⁶, in which the development of actions for the man health is inserted, with a focus on health promotion and promotion of injuries²⁷.

[...] The Ministry gave the first feature to deploy and then it was the municipality that had to keep it. Do you think the council will want to keep? Do you understand? But if it would be to continue sending resource based on data [...] then maybe yes. (UA 10)

The MH has provided the incentive for the implementation of strategies and health actions focused on the male population²⁸, and not the compensation of the performed actions. The financial resource was seen as the main propellant, demonstrating certain ignorance of the ways of PC financing. A study conducted in Santa Catarina with small municipalities found that FHS nurses unknown forms of financing in PC, also attributing the failure of men's health actions to scarce financial resources¹⁸. Considering that this research worked with PC and SC managers, the ignorance of financial management becomes notorious because it is expected that the professional who occupies such a position becomes aware of SUS management practices.

The Base of Primary Care (BPC) should be used to finance the PC actions proposed in the Municipal Health Plans²⁹, so these resources should also be applied to the implementation of NPIAMH, as the preferred space for its implementation. Funding should be distributed among the teams that lead to PC and SC, optimizing the resources available by the MH. However, only one of the subjects of this study showed that knowledge, positioning for better use of BPC, an important variable for the strengthening of attention to men's health.

In the MH Management Report in 2011, the delay in financial transfers to municipalities and selected states is explicit by setting up as a vertical fault in the NPIAMH deployment process, as the great value given to this query by the managers of the Mato Grosso capital. The financial resource was also considered by the subjects of study in Jequié, Bahia, as a great difficulty in planning actions to men's health. However, we corroborate the idea of the authors that the effectiveness of the Policy is attributed not only to financial resources and its application but also "the planning and operationalization of male inclusion strategies with recognizing the sociocultural and epidemiological reality of each region of the country"^23:638.

The financial resources, in fact, is a limiting factor in the implementation of public policies, but managers have to rely on creative strategies to reframe the concepts of masculinity that affect the health care of men. The articulation with the sectors of industry and commerce, recognized as a place of concentration of men, is considered as a valid proposal as they meet managers interest - to bring knowledge and attempts to health promotion practices - and employers who see the decline absences for illness and consequently the increase in their workforce. In this case, even with different purposes, both have common interests, and, therefore, essential that this relationship between employers and Health Departments occur strategically and planned²⁶.

CONCLUSION

The use of the content dimension in the analysis of policy implementation allowed to sign the importance of AWPs and AMRs in the conduct of actions, through their consistency with NPIAMH, fulfilling the proposed objective. The proposals should be directed not only to the increased supply of services but also to the man and woman image reframing in the context of health services. This reframing cannot be restricted to users, and need to involve professionals and managers who are also influenced by the relational aspects of gender since they lead the municipal actions from their experiences in this field.

To point out the scarce financial resources as the main obstacle to the realization of NPIAMH means a mistake translating the incomprehension of the theoretical conception that motivated its institution, the male behavioral characteristics that interfere in health care, that is, the exercise of masculinity, culturally established a social practice, placing men in a vulnerable condition.

Due to the territorial and cultural diversity, including in municipal management processes cannot apply the findings of this study to all Brazilian municipalities; however it is expected that the research will contribute to the rethinking of management practices to contemplate the actions of men's health promotion in the list of priority actions.

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