Dinâmica da gestão em saúde em contextos complexos: um framework adaptativo para decisão em emergências de saúde pública

Abstract

A public health emergency (PHE) is an event that generates uncertainty and challenges government decision making, with a shift in policies and strategies that condition the management area in the macro-processes of preparedness, prevention, response and recovery (PPRR). Studies on decision-making in PHE have intensified in recent years, with the emergence of Zika (2014), wild yellow fever (2017) and the COVID-19 pandemic (2020), with implications for the development of analytical frameworks to interpret the context and its determination for health, and to produce scenarios based on the behaviour of an emergency and the limits of the health system. The decision follows a non-linear approach, conditioned by the planning of the health-nursing-care process, whose complexity deals with the dynamics of variables and the interaction of actors in the analysis of a problem. The objective of this study was to develop a framework to support decision-making by public managers at the strategic level of health in PHE, producing scenarios for interventions adapted to the level of complexity of health systems. A mixed-methods study was carried out, with confirmatory and exploratory focus groups of experts and health managers. A systematic literature review evaluated existing models. The description of complexity variables followed the mapping of conditionalities, based on the guidelines of the World Health Organization (WHO) and the cooperation strategies of its member-states in tackling PHE. The structure of the framework integrated System Dynamics and the Cynefin Framework, concepts of dynamic approach and complex systems in decision support. The results show that the development and application of the PHE framework is effective if it presents a structure capable of incorporating the country's governance model, the hesitations of decision-makers, ethical aspects and evidence in the planning of PPRR macro-processes, as a permanent and scalable cycle in the relationship between the disease and the health system, in projections adapted to the context. 631 conditionalities were analysed based on WHO guidelines and the strategies of 112 countries in tackling PHE, such as attention to population characteristics, the One Health approach, the International Health Regulations, and human resources and information as structuring axes. The study reinforced the importance of planning in the PHE preparedness cycle, according to the vulnerabilities and capacities of the context, for equitable access to countermeasures and health goods and services. The model developed was applied to the case of the city of Manaus, Amazonas, Brazil, during the COVID-19 pandemic, and evaluated by experts. The results showed that the development of the analytical structure, called the Framework for Decision Support in Health Emergencies (FADES), made it possible to integrate the modelling of the complexity of management in PHE, according to the variables of interest and the interpretation of structures and behaviours of the health event, in a systemic and adaptive approach that expands the understanding and decision-making capacity of health managers.