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 Discussion Paper 57L: Networking Collaboratively: The Brazilian Observatório on Human Resources in Health
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This publication should be cited as: Campos, F, E. and V. Hauck. 2005. Networking Collaboratively: The Brazilian Observatório on Human Resources in Health. A case study prepared for the project 'Capacity, Change and Performance'. (Discussion Paper 57L). Maastricht: ECDPM. http://www.ecdpm.org/dp57L
Study of Capacity, Change and Performance:
Notes on the methodology
The lack of capacity in low-income countries is one of the main constraints to achieving the Millennium Development Goals. Even practitioners confess to having only a limited understanding of how capacity actually develops. In 2002, the chair of Govnet, the Network on Governance and Capacity Development of the OECD, asked the European Centre for Development Policy Management (ECDPM) in Maastricht, the Netherlands to undertake a study of how organisations and systems, mainly in developing countries, have succeeded in building their capacity and improving performance. The resulting study focuses on the endogenous process of capacity development – the process of change from the perspective of those undergoing the change. The study examines the factors that encourage it, how it differs from one context to another, and why efforts to develop capacity have been more successful in some contexts than in others.
The study consists of about 20 field cases carried out according to a methodological framework with seven components, as follows:
- Capacity: What are the components of capacity, i.e. the capabilities, in a given context?
- Endogenous change and adaptation: How do processes of change take place within an organisation or system?
- Performance: What has the organisation or system accomplished or is it now able to deliver? The focus here is on assessing the effectiveness of the process of capacity development rather than on impact, which will be apparent only in the long term.
- External context: How has the external context – the historical, cultural, political and institutional environment, and the constraints and opportunities they create – influenced the capacity and performance of the organisation or system?
- Stakeholders: What has been the influence of stakeholders such as beneficiaries, suppliers and supporters, and their different interests, expectations, modes of behaviour, resources, interrelationships and intensity of involvement?
- External interventions: How have outsiders influenced the process of change?
- Internal features and key resources: What are the patterns of internal features such as formal and informal roles, structures, resources, culture, strategies and values, and what influence have they had at both the organisational and multi-organisational levels?
The outputs of the study will include about 20 case study reports, an annotated review of the literature, a set of assessment tools, and various thematic papers to stimulate new thinking and practices about capacity development. The synthesis report summarising the results of the case studies will be published in 2005.
The results of the study, interim reports and an elaborated methodology can be consulted at www.capacity.org or www.ecdpm.org. For further information, please contact Ms Heather Baser (hb@ecdpm.org).
Content
Acronyms
Summary
1. Introduction
2. Networking and capacity development
3. The political and institutional environment
4. The international scene
5. The Observatório and its stakeholders
6. Endogenous change and strategy development
7. An evolving mix of key capabilities
8. Performance: achievements and challenges
9. Reflecting on networks and networking
10. Conclusions
Bibliography
Annex 1
Annex 2
Annex 3
Annex 4
Study of Capacity, Change and Performance: Notes on Methodology
Notes
Acknowledgements
The authors wish to thank all of those who spared their valuable time to provide in-depth perspectives during interviews in Brazil and those who shared documents prior to, during and after the field research.
Special thanks go to Paulo Seixas, Coordinator of the Observatório workstation in São Paulo. From the onset, he recognised the usefulness of this study for the further development of the network and he facilitated the initial contact with the Ministry of Health and the office of the Pan-American Health Organization (PAHO) in Brasilia.
A word of appreciation also goes to Renata and Martin Koppensteiner, who assisted in the search for background material and documents on networks and networking in Brazil. The authors also thank colleagues from the State Secretariat of Health in São Paulo, from NESCOM in Belo Horizonte, and those at ECDPM in Maastricht who provided logistical and organisational support.
The authors wish to thank those who read and provided comments on earlier drafts of this paper, in particular Roberto Passos Nogueira, Researcher at IPEA (Institute of Economic Planning, Government of Brazil), and Romulo Maciel Filho, Director of the Centro de Pesquisas Aggeu Magalhães, Recife.
This case study was made possible by the support of the UK Department of International Development (DfID). The authors further acknowledge the support of Jane Haycock, Health Advisor at DfID, and Felix Rigoli, Regional Advisor for Human Resources at PAHO/WHO. Both suggested that the Observatório case would prove an important contribution to the wider ECDPM study on Capacity, Performance and Change.
A final word of thanks goes to the ECDPM core team for the study, especially Heather Baser, ECDPM Programme Coordinator, and ECDPM associates Peter Morgan and Tony Land who provided stimulating comments and reflections prior to and during the writing of this report.
While this study contains many inputs from various stakeholders and the study team, sole responsibility for the interpretation of data and the analysis rests with the authors.
Francisco Eduardo Campos (NESCON) was Coordinator of the Observatório workstation at the Federal University of Minas Gerais, Belo Horizonte. In July 2005, he was appointed Secretary of Human Resources Management and Education at the Federal Ministry of Health, Brasilia.
Volker Hauck (ECDPM) is Senior Programme Officer at the European Centre for Development Policy Management, Maastricht, the Netherlands. He is a member of the study team for the wider ECDPM study on Capacity, Change and Performance.
Acronyms
ABRASCO Brazilian Association of Graduate Studies in Collective Health
BR-HsRefNet Brazilian Network for the Reform of Health Systems
BR-AcadNet Brazilian Academic Network
CADRHU Desenvovimento de Recursos Humanos em Saúde
CEBES Brazilian Centre of Health Studies
DfID Department for International Development (UK)
ECDPM European Centre for Development Policy Management
ECLAC Economic Commission for Latin America and the Caribbean (United Nations)
COC/FIOCRUZ Oswaldo Cruz Foundation
ICT information and communication technology
IEPE Educação Permanente em Enfermagem
ILO International Labour Organization
LACRSS Latin American and Caribbean Regional Health Sector Reform Initiative
LA-ObsNet Latin American Observatory of Human Resources in Health
NESCON Núcleo de Estudos em Saúde Coletiva da Faculdade de Medicina da Universidade Federal de Minas Gerais
NGO non-governmental organisation
OECD Organisation for Economic Co-operation and Development
PAHO Pan-American Health Organization
PMDB Brazilian Democratic Movement Party
PREPPS Strategic Programme for Development of Personnel in Health
PT Workers Party (Brazil)
ROREHS Rede Observatório de Recursos Humanos em Saúde
SSAM Brazil's complementary medical care system
SUS Systema Unico de Saúde
UERJ University of Rio de Janeiro
UFMG Federal University of Minas Gerais, Belo Horizonte
UFRN Federal University of Rio Grande do Norte
UnB University of Brasilia
UNDP United Nations Development Programme
USAID United States Agency for International Development
WHO World Health Organization
Summary
The Observatório is a network of university institutes, research centres and one federal office dealing with human resources questions in the health sector of Brazil. Today, the Observatório consists of 13 so-called network "nodes" or "workstations" as the network members call them, which are coordinated via a secretariat consisting of staff members of the Ministry of Health and the Brasilia office of the Pan-American Health Organization (PAHO).
The idea for a formal network on human resources for the health sector came to Brazil in 1998 as part of a PAHO initiative to improve human resources
policymaking throughout Latin America. At that time, policy for human resources planning, development and management in the health sector had become a key concern in various Latin-American countries. This was partly because the market-based policies pursued in the region in the 1980s and early 1990s had led to broad neglect of this theme.
Earlier networking experiences among several health institutes from as early as the 1970s provided a foundation for the Observatório's implementation in Brazil. With the political liberalisation of the 1980s, networking among public health specialists gradually intensified - a process subsequently accompanied, facilitated and modestly supported by projects and programmes of the PAHO regional office in Brasilia. In 1999 the Brazilian Ministry of Health legally recognised the network as a mechanism to contribute to and inform development, regulation and management of human resources in the health sector and related policy.
The Observatório is nationally and internationally recognised as a unique and successful case of state-non-state interaction in health. The network has produced a substantial amount of valuable information and analyses from its productive interplay between Brazil's Ministry of Health, PAHO and the network working stations, as well as from intense horizontal cooperation between network members. Most of these members are active in other health networks as well, which has created an environment in which intense exchanges and collaboration on issues in public health have been initiated and developed.
The network's success has attracted the interest of regional and international observers from the health sector, from network specialists and from development agencies dealing with institutional development. The Brazilian experience also raises questions about the relationship between capacity and networking. This is what inspired the inclusion of this case in the sample of the wider ECDPM study on Capacity, Change and Performance. More precisely, this case sheds light on the creation and sustenance of capacity and capabilities in the context of networks. It provides insights on what capabilities are needed to make networking function and how capacity created in the context of networks leads to performance.
It is clear that the Observatório experience helped to shape multiple capabilities. These developed incrementally over the years, with some having their roots three to four decades before the network was recognised by law. These capabilities were shaped, connected, structured and nurtured. The process was not orchestrated, but it was accompanied, facilitated and stimulated by a number of personalities from within Brazil as well as from abroad. As such, a mix of technical, internal, external and so-called "soft", or generative capabilities emerged, which accounts for the unfolding and sustenance of the network. But there are differences in the importance and use of the various types of capabilities over time.
The technical and professional capabilities of the network members and their motivation to make the human resources issue a key element of public health sector reform provided a cornerstone in the creation of this network. Building and nurturing these capabilities was vital during the network's infancy and remains so today. The focus on content helped network members to remain intellectually independent and shaped the sense of autonomy that continues to characterise interactions of the workstations.
These capabilities were initially catalysed by a number of soft capabilities, such as flexibility, creativity, pragmatism, inventiveness and entrepreneurial spirit - simply because this was the only way the network could find its way. The context of political repression and the lack of support for health sector workers were part of what forced the largely informal network initiative to develop this way of working. This working culture remained significant throughout the years and can be discerned even today.
This dynamic process resulted in group learning and consolidated shared ideas that reinforced the technical and professional capabilities mentioned above. Moreover, it informed a shared thinking about the enhancement of internal and external capabilities which grew in importance from the mid-1990s. An internal strategy of facilitation and stimulation was set out and pursued by the Ministry of Health in cooperation with a well-informed PAHO office in Brasilia and supported by PAHO headquarters.
The enhancement of internal capabilities translated into a degree of formalisation, institutionalisation and secure funding in the late 1990s. Network architects immediately recognised the strategic importance of the Internet and introduced this tool to enhance the quality of interactions internally, as well as with other networks in the region. Today, exchanges with other networks within Brazil and internationally have intensified, helping to boost the productivity and profile of the network both within the region and beyond.
The Observatório case demonstrates the important role that motivation and group learning play in the creation of capacity in the context of networks - and in transforming this capacity to performance. Motivation, in this case, took two forms: professional and political. Vibrant professional interest in investigating the relevance of planning, management and training in human resources for the health sector galvanised with political ideas and a conviction that society needed fundamental change. The pattern of continuous interaction and exchange functioned as a catalyser, or engine, to shape and assemble the complex capabilities puzzle into a functioning network, or - using the study terminology - into overall capacity.
While the Observatório case shows that informal networking can develop into networks with more formal structures delivering outputs and outcomes and potentially impacting the well-being of society, we should recognise that the capacity development process of the Observatório is far from complete. New demands and challenges need to be dealt with, as the recent political turmoil caused by accusations of bribery within the Lula government has shown. There are also demands from within the network for an intensification of the exchange in terms of content and policy relevance, and for introduction of monitoring and evaluation mechanisms to ensure quality and relevance of the network's outputs. Now, with the emergence of institutionalisation and the provision of substantial resources, the 'hour of truth' has arrived, as one network member put it. Expectations for better outputs and outcomes have been created which need to be fulfilled now that the government has fully subscribed to the Observatório idea.
It seems evident that the further development of the Brazilian Observatório will rely on endogenous processes. Outside actors are welcome to assist, but they must take care not to tear the fabric of the network, which was woven through an inimitable interaction of internal forces and external assistance. Much will depend on the internal steering of the movement in the near future. In this regard, network members are vigorously carrying forward the strategic planning exercise in a process that bodes well for the future.
1. Introduction
1.1 What is the Observatório all about?
The Observatório is a network of university institutes, research centres and one federal office dealing with human resources issues in Brazil's health sector. In 2004, it consisted of 13 so-called network "nodes", or workstations, which are coordinated via a secretariat consisting of staff members of the national Ministry of Health and the Brasilia office of the Pan-American Health Organisation (PAHO). Most workstations are located in the south-eastern part of the country, reflecting the current distribution of wealth, knowledge and technological resources in the country. 1
The network was established in 1998. A year later, in 1999, the Ministry of Health legally recognised it as a mechanism to exchange information with which to inform policy and develop, regulate and manage human resources in the health sector. But the network was not created from zero. A long history of multiple processes shaped the cooperation arrangement. Many of these processes have internal roots and were driven by the motivation and commitment of individual network members. But there have also been moments when external support and intellectual inputs proved crucial to the network's flowering. The PAHO has been particularly instrumental, as it has facilitated, balanced and stimulated interchanges among actors through its long-term presence in the country.
Policy for human resources planning, development and management has become a key concern in the health sectors of various Latin-American countries, including Brazil. Before 1995, the region pursued market-based policies, and human resources policy was largely neglected. The market was expected to regulate the dynamics of the health sector and its professions, rendering state intervention unnecessary. Practitioners from Latin America criticised this policy because 'in many places the combined effects of downsizing and underestimation of the human resource planning function have led to a situation where government has lost the ability to regulate and govern' (Passos Nogueira and Paranaguá de Santana 2003: 74-75). The relevance of the human resources situation for the health sector is evident in the proportion of national health budgets spent for personnel in Latin America, which is some 60 to 70 per cent on average (Rigoli 2002).
The evolution of the Brazilian health-care system since the early 1990s reflects a gradual breakthrough in thinking and political commitment regarding the role of the state in the health sector. The idea now is that the state should become more involved in organising and regulating health-related goods and services. However, to perform its guidance, orientation and facilitation tasks, the state needs data and analyses with which to appropriately conduct decision processes. It is this basic reasoning that mobilised the support that transformed the idea for the Observatório network into reality. Thus, though the Observatório idea came to Brazil as part of a regional PAHO initiative to improve human resources policymaking, the network was also shaped and informed by initial experiences from within Brazil.
The Observatório is nationally and internationally recognised as a unique and successful case of state-non-state interaction in health. The network has produced a substantial amount of valuable information and analyses from its productive interplay between Brazil's Ministry of Health, PAHO and the network working stations, as well as from intense horizontal cooperation between network members. Most of these members are active in other health networks as well, which has created an environment in which intense exchanges and collaboration on issues in public health have been initiated and developed.
1.2 Why this case?
The functioning and performance of the Observatório network has raised interest among regional and international observers from the health sector, as well as among network specialists and development agencies concerned with institutional development. Through the Observatório network, members of the Brazilian public health community have managed to create and sustain an important interface between the research sector and the policy arena. While the network facilitates horizontal collaboration among members, it also encourages strong vertical working relationships that extend beyond the immediate community to encompass government, PAHO and research and funding institutions abroad.
This raises questions about the relationship between capacity and networking and is what inspired the inclusion of this case in the sample of the wider study on Capacity, Change and Performance (see box 1). More precisely, this case provides fertile ground for learning more about the creation and sustenance of capabilities and capacity in the context of networks - a relatively under-researched topic but one of increasing importance in capacity development thinking, policy and practice.2 In this vein, little is known on a number of aspects:
• What forms does capacity take in the context of networking?
• What capabilities are needed for networking and to make networks function?
• How does capacity created in the context of networks lead to performance?
• Are there underlying factors which can help to explain the creation of capabilities leading to the emergence of networks?
• How did networking and networks in the case of the Observatório help to bring about change leading to performance?
• Why do networks emerge in certain cases, as in Brazil, and why do similar attempts fail in others?
With these questions in mind, this paper looks at the relationship between capacity and networking from an angle that goes beyond the narrower topic of human resources capacity development and the efforts undertaken by the Observatório network to improve the human resources situation in Brazil's public health system. It uses a wider systems perspective lens to examine the issue of capacity development through networking and how networking can lead to performance.
Box 1: The ECDPM study on Capacity, Change and Performance
This paper contributes to a wider study on Capacity, Change and Performance that is being coordinated by the European Centre for Development Policy Management (ECDPM) under the aegis of Govnet, the working group on governance and capacity development of the OECD's Development Assistance Committee (DAC). The wider study, grounded in some 18 case studies from across the globe, seeks to provide insights into how external partner organisations can support endogenous capacity development processes. Through experiences from the individual cases, the wider study also seeks to facilitate a better understanding of the meaning of capacity, the complex relationship between capacity and performance improvement, and the processes through which capacity is developed. See www.ecdpm.org/dcc/capacitystudy |
Observatório members readily subscribed to the broader scope of the study questions. They saw the potential for a discussion on these to contribute to further internal reflection and learning and to answer questions about why member institutions work together and establish cooperative ties, instead of continuing to compete and separate. Various questions were raised along these lines:
• How do participants set aside their autonomy in favour of working together on a complex issue?
• What drives them to collaborate and to formulate a common working plan?
• What makes the Brazilian effort larger and more visible than similar efforts elsewhere in Latin America, though all were nurtured in the same nest?
• Does its visibility make it stronger, more effective and more reliable?
1.3 About this paper
This case study looks at the contribution of the Observatório and its members to the development of the public health sector in Brazil. Yet it is important to note that it is not an evaluation and it does not seek to pass judgement on any of the organisations or networks to which it refers. Following the approach of the wider ECDPM study, this case study was undertaken, in as far as possible, from the perspective of various Observatório stakeholders, including members of research institutions, government officials and staff of international organisations. As such, the report attempts to tell "the capacity development story" of the Observatório from the inside. In so doing, it seeks to contribute to learning and reflection among internal and external network actors about their role in successfully dealing with human resources issues in the health sector.3
Before looking at our case in more detail, section 2 provides a brief overview of the concepts of networking and capacity development. Sections 3 to 5 then provide background on the context within which the Observatório network functions: What was the role of external actors and developments in the emergence of the network, and how does the network function internally and in relation to its stakeholders? Sections 6 to 8 analyse the network dynamics and internal change, as well as the emergence of capabilities among individual members and in the network as a whole. They highlight evidence of performance and then go on to outline future challenges. Section 9 brings some reflections to bear on networks and networking based on the Observatório experience. Conclusions are drawn in section 10.
2. Networking and Capacity Development
2.1 Networking and networks
Networking is done among individuals as well as organisations. Networking can also take place within an organisation. It should be seen as a process which might lead to networks, but which can also result in other outputs and outcomes. Networks can thus be seen as the result of institutions, organisations and individuals dedicating time and energy to join forces and build relationships with one another (Engel 1993).
The wide variety in networking activities makes it difficult to derive a common definition for networks (see box 2). All networks are in one way or another formed around a common set of concerns: to pursue a common goal, to inform a particular sector or group of stakeholders, or to share knowledge, goods and experiences. We can categorise the different forms of networks into three main types (Engel ibid.):
• networks for service provision, to supply information and training to a group of actors, a sector or an institution;
• networks for learning, to exchange information so as to enhance the knowledge and skills of individual stakeholders or of the network as a whole (these networks are sometimes called "communities of practice" or "knowledge networks");
• networks for advocacy or lobbying, to promote, for example, transformation, social change and reform.
In reality, many networks do a bit of everything, as they provide a mechanism by which different goals can potentially be pursued. Good service provision, for example, requires regular exposure to up-to-date knowledge and information. Networks also generally have a unit, or secretariat, that manages and facilitates the networking process. Most essential in successful networking, however, is knowledge networking, learning and advocacy (Ranaboldo and Pinzaz 2003). In short, it is content that matters. Networks set up for an instrumental purpose have limited added value and sustainability.
Box 2: Definitions of networks and networking
• Creech and Willard (2001) - 'A formal knowledge network is a group of expert institutions working together on a common concern, to strengthen each other's research and communication capacity, to share knowledge bases and develop solutions that meet the needs of target decision-makers at the national and international level.'
• Plucknett et al. (1990) - 'A network can be defined as an association of independent individuals or institutions with a shared purpose or goal, whose members contribute resources and participate in two-way exchanges or communication.'
• Engel (1993) - 'Networking is the process resulting from our conscious efforts to build relationships with each other… networks are more or less formal, more or less durable relational partners that emerge as a result of such efforts.
The core business is not the manufacture of products or the provision of services, but social learning, communication and the making of meaning.'
• Nelson and Farrington (1994) - 'Information exchange networking is a collaborative process of information exchange, around a central theme, carried out by actively interested parties.'
Source: From Zee and Engel (2004). |
The Brazilian Observatório network has features of each of the types. It is knowledge-based and it derives its momentum from a group of academics and practitioners which have their roots in learning and research. It was formed around a common vision of political and social change in the health sector, which has helped it to pursue policy issues within the sector. Also, it provides services for the Ministry of Health as well as for other federal health authorities.
2.2 Framing capacity development
To fully understand the development of the Observatório network and how it contributes to the wider evolution of the Brazilian health system, we depart from an understanding of capacity development that was current in the mid-1990s. At that time, the UNDP (1997) defined capacity development as follows:
[t]he process by which individuals, groups, organizations, institutions and societies increase their abilities to: 1) perform core functions, solve problems, define and achieve objectives and 2) understand and deal with their development needs in a broad context and in a sustainable manner.
This definition was useful for developing frameworks to guide capacity-building efforts towards internal and technical strengthening, with organisational effectiveness and functioning as the ultimate goal. It was less effective, however, in answering questions of why and how certain capacities could develop.
Meanwhile, a broader thinking about capacity development has emerged which commonly sees capacity as the general ability to perform.4 In this view, capacity is an overall, aggregate outcome of a series of conditions, assets and relationships that are part of an organisation or system - its structure, identity, culture, procedures, tangible and intangible resources, staff, legitimacy, pattern of incentives, confidence and leadership. In an effective organisation or network, these conditions combine to produce capacity, or the general ability to implement activities and programmes or deliver something of value to others.
Building on this perspective, an organisation or system can be understood as a collection of more specific abilities, distributed at various levels and drawing strength and effectiveness from the deeper conditions of the organisation or system of which they are a part. As such:
• Individuals have personal abilities and attributes or competencies that contribute to the performance of the organisation or system.
• Organisations or broader systems have capabilities to do things such as manage stakeholders, mediate between warring parties, participate in global negotiations, manage financial resources, listen, learn and empower staff. Capabilities can be understood as the building blocks of an organisation's overall capacity to perform.
• Organisations or systems try to connect these competencies and capabilities into coherent combinations or systems that enable them to perform. We describe this state as capacity.
For our analysis of the emergence of capacity in the Observatório case (section 7), we apply this thinking on capacity in combination with a recently developed framework to analyse capacity building in NGO networks. The framework identifies capacity for NGO excellence as a combination of four areas of capacities, namely, external, internal, technical and the so-called generative capacities or, as we will call them in this study, "capabilities".5 Box 3 summarises these areas.
Box 3: Four areas of organisational and network capabilities
External capabilities are needed to interact with the wider institutional and organisational environment:
• to engage in partnerships, alliances and networks;
• to undertake public relations and outreach work;
• to maintain relations with stakeholders, including funding agencies;
• to pursue lobbying and advocacy;
• to exchange knowledge with other organisations and networks.
Internal capabilities are relevant for the internal functioning of the organisation or network:
• to develop visions and strategies;
• to agree on a governance structure;
• to set up and use management systems, including financial management;
• to undertake monitoring and evaluation;
• to engage in resource generation, including raising funds.
Technical capabilities are essential for undertaking the actual work, specialisation or profession of the organisation or network:
• to develop and execute service delivery;
• to advance sector policies through research, dialogue and information;
• to create, disseminate and apply systems, procedures and practices;
• to build internal skills and knowledge and create capacities in others through e.g. training;
• to raise the quality and standards of projects and programmes .
Generative or "soft" capabilities are underlying attributes needed to let activities and processes develop smoothly and comprehensively:
• to act with agility and dynamism;
• to manage cooperation and competition;
• to work across boundaries and across hierarchical levels;
• to balance autonomy with interdependence;
• to develop and act with a systems view;
• to learn how to learn;
• to envision the future and lead along new ways.
Source: Adapted from Liebler and Ferri (2004: 38) who make use of the work of Edwards in Romo Rodriguez (2004) and the ECDPM Interim Report (Morgan et al. 2005). |
3. The political and institutional environment
3.1 Brazilian political and social change over the past 40 years
The ideas and approaches that led to the creation of the Brazilian Observatório network emerged in the context of a gradually developing public health system over the past 40 years or so. This process saw inputs from international actors, but it also paralleled to some extent the changing political and social situation in Brazil over time.
The political ideals of President Gétulio Vargas, partially inspired by European nationalist and socialist thinking of the 1930s, were terminated in the years after his suicide in 1954. Despite initial economic and cultural successes, the two subsequent presidents, Juselino Kubitschek and Joao Goulart, failed in implementing Vargas-inspired development models. This led to a brutal military coup in 1964 which installed in office a group of generals who held power until 1985. In the years following the coup, all political parties were prohibited except two, the ruling party and the opposition, which was represented by the moderate PMDB (Brazilian Democratic Movement Party). Constitutional rights were abandoned, parliament was dissolved and death squads were given a free hand to act, in particular after the social unrest and student protests of the late 1960s. Terror ruled the country during this period.
As of 1978, the military leaders gradually withdrew from power, identifying General Figueirendo as president. Independent movements inspired by syndicalism and democracy saw the light. In 1982, political parties were again allowed and presidential elections brought civilians back into power as of 1985. Several unsuccessful presidencies followed culminating in 1992 in the overthrow of the demagogic and corrupt Fernando Collor (himself from a large landowning family in the north-east) by a broad and deeply disappointed civic movement. Collor's successor, Itmar Franco, was also unsuccessful. He was swept from office in the 1995 elections which brought the neo-liberal Fernando Henrique Cardoso into the presidency, which lasted until 2002.
The slowly evolving political climate from the late 1970s onwards opened space for the formation of the Workers Party (the PT), founded in 1980 and led by Luiz Inacio Lula da Silva, better known as "Lula". The PT had its origin in the clandestine union movement and the big strikes taking place between 1979 and 1981. It soon attracted all of the radical and leftist movements that had been suppressed under the military dictatorship. Lula and his PT were beaten in several presidential elections in the 1980s and 1990s, but the party grew continuously and finally managed to win municipal elections in several big cities and federal states as of the early 1990s. The growth of the PT in the 1990s also led to a polarisation of the political landscape, with the middle class and big landowners gathering around the neo-liberal thinking of Cardoso. The PT, on the other hand, developed a political vision inspired by social and social-democratic thinking. After defeats in three presidential elections, it finally managed to take power in October 2002. This was a historic achievement. Lula became the first president originating from the political left.
3.2 The public health system
In step with the gradual democratisation of the society, the importance of public health was recognised in the 1970s as a crucial factor for the county's further development. In the 1980s, a number of health experts and members of the health reform movement occupied key positions in ministries responsible for health services. Among their major reform proposals were schemes to decentralise the health system and to unify control of the health sector across the various levels of government (Elias and Cohn 2003). Building on formal and informal exchanges within the sector, the 8th National Health Conference in May 1986 decided to create a unified health-care system, the Systema Unico de Saúde ("SUS" for short).
With its legal basis set out in the 1988 Brazilian Federal Constitution, the SUS promotes universal access, free care and full coverage for health-care services. It has since developed into one of the world's largest national health systems. The SUS operates in a decentralised manner. Responsibility for the overall direction of the system is with the federal government, but the states and municipalities execute health programmes and manage ser-vice delivery. Though the SUS provides some care directly, it finances substantial amounts of services through non-governmental providers, both for-profit and non-profit.
In the early 1990s, the SUS provided care to some three-quarters of the Brazilian population. However, the public generally rated the quality of care as not very good. Wealthier people and those with jobs providing insurance coverage made use of the better facilities and services provided through the complementary medical care system (the "SSAM"). This left those who depended on the SUS with a generally lower quality of care, a situation that persists today.
With the mounting political successes of the PT in the 1990s and its promise to improve access to social services for all Brazilians, public health rose higher on the political agenda at the federal, state and municipal levels. The statistics on health service provision in box 4 provide an idea of the political weight of the sector.
Box 4: Health service statistics
In practical terms, two health-care systems operate in Brazil, the SUS and the SSAM. The SSAM provides coverage to a group of Brazilians that is overall younger, presents lower risks and has higher purchasing power. The SUS operates throughout the country. Its 475,699 health professionals serve a population of 174.6 million with 5,714 hospitals and a total of 439,577 beds. These are in addition to 62,865 ambulatory care centres. By comparison, the SSAM serves some 33 million Brazilians who make use of 4,000 hospitals and 90,000 physicians.
Source: Figures from the Ministry of Health, cited in Elias and Cohn (2003). |
Three principal factors influenced Brazil's focus on human resources in the health sector from the 1990s onwards. First and foremost was the growing recognition that the development of human resources in the health sector could not be left to market forces. Instead, a guiding and regulating state was needed, since human resources were so crucial to the sector's further development.
The second factor derives from the decentralisation process. Most of the legal and financial aspects of decentralisation were resolved after the introduction of the tripartite federal system (with its federal, state and municipal levels). However, major challenges remained regarding essential aspects of human resources planning in health, such as the formulation of effective policies, the planning of training, the delegation of responsibilities and the partition of human resources across the three layers of the political system.
Finally, there was increasing recognition in Brazil and internationally that human resource issues are crucial in health-sector development. This upset a previous international trend in which other health system components, such as financing, pharmaceuticals and facilities, were seen as the main players. Despite attention to these components, in much of the world human resources problems in the health sector have continued, such as the attrition of health professionals due to inadequate education, unbalanced skill mixes, brain drain through migration, and mortality from infectious diseases. International and bilateral organisations alike are increasingly pursuing initiatives to build capacity at the country level to address these problems.6
3.3 Origins of networking on human resources in public health
In step with the gradual political liberalisation from the late 1970s, public health programmes in Brazil started to organise their interactions more systematically, creating health institutions and networks. In 1976, the Brazilian Centre of Health Studies (CEBES) was founded with the vision to fight for social democratisation with a particular focus on health.7 CEBES brought together intellectuals and public health advocates to support health reforms in the country. Its members were formed by the philosophical, political and social ideas of various thinkers and academics of the times (see box 5).
Box 5: Political thinking and social action shaping a public health movement
A mix of international and national thinking, movements and reforms put their stamp on the Brazilian public health specialists who stood at the cradle of the ideas leading to the Observatório. Philosophers like Michel Foucault and Ivan Illich had a distinct influence on thinking about institutions and related change processes. Active in public health were Vicente Navarro, who is now professor of public policy, sociology and policy studies at the Johns Hopkins Bloomberg School of Public Health, and Senator Giovanni Berlinguer, who was promoting health system reform in Italy. A special role was played by Juan Cesar Garcia, a consultant to PAHO headquarters who supported the establishment of graduate studies in social medicine by bringing together some of the leading intellectuals from the region and giving them an institutional platform. There were also cross-links with other movements, such as the psychiatric reform promoted by Franco Basaglia in Italy.
At the national level, Gentile de Melo contributed many newspaper articles criticising the market-based organisation of medicine in Brazil. Other leading thinkers were Cecilia Donnangelo, a professor who studied the relation of the medical profession to the market, and Hesio Cordeiro, professor at one of the main graduate training centres in São Paulo and Rio de Janeiro. Most essential, however, was the political work of Sergio Arouca, medical doctor and politician who is considered the father of public health reform in Brazil. Arouca was an outstanding leader with the capacity to unite very different groups of people dealing with public health, such as health managers, student leaders, health workers unions, academics and customers of health services. |
Another milestone was the founding of the Brazilian Association of Graduate Studies in Collective Health (ABRASCO) in 1979.8 While its primary aim was to link academic programmes with post-graduate studies, ABRASCO also became the place to discuss strategies for more vibrant interaction between academia and government. According to practitioners active at that time, there was a need for associations and networks which could provide a platform for dialogue with health policymakers without being dependent or controlled by these. The idea to establish associations was informed - among others - by the practice of the Canadian and American associations of public health.9
Being present in many fora, ABRASCO and CEBES became the institutional hubs from which health reform proposals were launched and discussed in the public and during sessions of the government's National Health Council. ABRASCO also became the home of a working group dealing specifically with the topic of human resources in health. Many members of the present Observatório network were in fact active in ABRASCO at that time. They see the origin of their interest and engagement in the topic of human resources in health as dating back to this period - a time imbued with the dynamics of social and political change.10
4. The international scene
4.1 Regional developments and initiatives
Brazil had produced a strong public health community from its own academic institutions and networks. Over the years this group was exposed to regional and international developments through information, meetings and exchanges, such as the placement of Brazilian public health experts in international organisations, notably the World Health Organization (WHO) and PAHO.
Early on, the Cuban Revolution and its ideas about social policies influenced Brazilian public health planning. Later, during the 1970s, discussions focused on the risks and advantages of introducing market forces into the national health-care system. In addition, the United Nations' Economic Commission for Latin America and the Caribbean (ECLAC) was at that time promoting the formulation of national development plans. Part of this push resulted in the commissioning of national studies to facilitate the planning process, including in public health. The WHO and PAHO assisted some Member States in organising human resources studies covering a broad array of topics, ranging from the number of schools to the available health workforce and its demography, and forecasting future trends.
Of more immediate importance in creating a community dealing with human resources in health in Brazil, however, was the Decennial Plan for Health in Latin America, signed in Santiago, Chile, in 197211 by all the health ministers of the Americas. This was the first attempt to draw up a holistic agenda for state-based intervention in the health sector, and specifically for human resources (see box 6).
Box 6: Decennial Plan for Health in Latin America
The Decennial Plan for Health in Latin America acknowledged the general scarcity of health professionals in the region (an average of seven physicians, three nurses and eight auxiliary personnel per 100,000 inhabitants). Recognising that changes in health care were necessary, it proposed six goals to be accomplished within 10 years:
• to develop in each country a human resources planning system integrated in health planning in general;
• Ito build teaching capacity at all levels, including the research level, concentrating efforts on the bottlenecks identified in each country;
• to better organise human resources by impro-ving health teams' outcomes and rationalising their geographical distribution, proposing compulsory work for newly graduated professionals and developing continuous professional education;
• to improve knowledge about the education, stock and use of the physician workforce in order to achieve a distribution of eight doctors per 10,000 inhabitants and to be better prepared to address national needs;
• to increase the availability of dentists and their auxiliary personnel, especially where there are shortages;
• to produce 125,000 nurses (14,000 of these in the English-speaking Caribbean) and 360,000 assistant nurses. |
4.2 The Pan-American Health Organization
PAHO has provided considerable inputs to the development of the Brazilian public health system and to the country's human resources community over several decades. In the mid-1970s, when Brazil's public health human resources were in disarray, PAHO helped to set up the Strategic Programme for Development of Personnel in Health (PREPPS). This programme was simultaneously linked to the Ministry of Health, the Ministry of Education and the Ministry of Social Security, and PAHO provided its secretariat. The programme was based on the holistic understanding that human resources are a key component of health system development. It addressed three issues in particular:
• institutionalisation of human resources planning at the decentralised levels;
• training of auxiliary nurses;
• integration of academia into health service activities.
Despite these efforts, however, ongoing baseline information on human resources in the health sector remained scant. Each time PAHO needed information for reports about health sector conditions in the region, special data collection schemes were required to gather the statistics. To tackle this problem, PAHO created a post for management information to improve data analysis capabilities. Although availability of data and analyses subsequently improved, little use was made of these resources before the early 1990s.
The real shift came with the Miami Summit of Heads of States of the Americas in 1995, at which politicians acknowledged that the previous policies, which had put full confidence in the functioning of the market, had not produced the desired outcomes. For the health sector, PAHO was mandated to keep track of trends and reforms in Latin America. In Brazil, PAHO translated this into a number of initiatives, among them the Brazilian Observatório network, which was part of a wider regional effort to address the deep imbalances in the availability, composition and distribution of health personnel (see box 7).
Box 7: Regional initiatives on human resources in health
In 1998, PAHO and WHO, together with the United States Agency for International Development (USAID), started a joint programme to monitor health sector reforms in the Americas. This initiative, called LACRSS, aimed to promote equity and effectiveness in health sector reforms. It did this by working in partnership with decision-makers in the region to build capacity to address health sector problems and to design, implement and monitor reform programmes.
Coinciding with PAHO's efforts to monitor health sector reforms, the International Labour Organization (ILO) expressed concerns about the impacts of reforms on health workers in the region. This led to human resources themes being incorporated into LACRSS. The strategy defined by PAHO to propel this dimension was the implementation of the Latin American Observatory of Human Resources in Health (see Rigoli and Arteaga 2003). |
Thus, the Observatório was an internationally instigated programme that built substantially on experiences and data already accumulated within Brazil. Some institutions, which later became members of the Observatório, had already been working on topics such as "workforce trends", "regulation" and "the education market" from as far back as the mid-1970s.
5. The Observertório and its stakeholders
5.1 The Observatório network
The Observatório Network on Human Resources in Health12 began to function under that name in Brazil in 1998 following a proposal tabled at a PAHO-convened meeting in Santiago, Chile. Today, the Observatório consists of 13 independent members and a secretariat housed at the federal Ministry of Health in Brasilia. The network consists of public as well as private organisations, most of which are academic institutions, though service institutions are also represented. These function at both the federal and state levels (table 1).
Table 1: Composition of Observatório workstations
 | Academic institutions | Service institutions | Total |
Federal level | 9 | - | 9 |
State level | 2 | 2 | 4 |
Total | 11 | 2 | 13 |
Many federal and state-level institutions were working on human resource issues well before the Observatório was formally created. As such, no
precise timeline can be drawn for the network's creation; the process unfolded gradually.
As early as the mid-1970s, some individuals, many employed by health research and teaching institutions, began working on human resources topics. From then on, a community of specialists on human resources in the health sector began to emerge as part of a steadily growing movement to reform Brazil's public health system. The previous section described this movement. The accumulated experiences of half a dozen research and training institutes were brought into the network when it was launched in 1998. On PAHO's invitation, other institutions joined over the years to cover specific knowledge areas like nursing and history and regions that had not been adequately dealt with before but for which the secretariat had identified a need for more research and analysis. These new institutes brought experience and complementary perspectives from other public health networks of which many were also members (see figure 1 on intensity and growth of the network).
Figure 1: Intensity and growth of the network
Most of the Observatório's current members are concentrated in the south-east, following the distribution of Brazil's academic, technological and economic resources (see map). Network members also maintain contacts with other academic institutions in the northern and western-central parts of the country. The secretariat expects these exchanges to enhance the capacities of institutes located in the poorer parts of Brazil.
From the onset, the network was composed of a heterogeneous mix of institutions. In the absence of a single institution that could cover all topics in the field of human resources in health and in view of the wide array of issues that needed to be dealt with, the idea was to construct a matrix of experiences, with some institutions working more along thematic lines and others more regionally driven. This matrix structure would also facilitate mutual and decentralised strengthening of the different institutions and thereby help to increase the network's impact on dialogue and policymaking related to human resources in health. Table 2 presents the logic of the matrix (the list of themes is incomplete).
Table 2: Observatório's matrix structure
5. 2. Collective functioning facilitated by a secretariat
What members of the Observatório network describe as their "secretariat" is in fact no more than the combined efforts of two individuals. The first holds the position of coordinator of the Observatório unit within the Ministry of Health's Secretariat on Management of Education and Work in Health. This positioning enables the Observatório to coordinate its own activities and functions under the Ministry's Department of Human Resources Planning. The other secretariat staff member is a PAHO advisor who is in charge of the Human Resources Development Programme of the Brazil PAHO office. Both staff members are based in Brasilia, and the proximity has facilitated intense collaboration and coordination.
The Secretariat on Management of Education and Work in Health (previously the Secretariat of Human Resources) has seen a regular turnover of key staff during the years due to Brazil's rapidly changing governments. The PAHO office, on the other hand, has been able to keep in place its advisor dealing with human resources. The employee is a Brazilian national who spent his early career as part of the community of public health specialists initiating attention to human resources. Some thirty years ago, in 1976, he was recruited locally as a PAHO technical assistant/advisor, a position he has since held continuously except for an eight-year break during which he worked at a federal ministry.
The continuous presence of a local expert on the topic of human resources in health and of a secretariat member sensitive to and knowledgeable about ongoing developments in the sector played a key role in carrying the Observatório idea forward. The network's official recognition in Brazilian law drew institutional ties between the Observatório members and the Ministry of Health tighter, since the Observatório became the only public health network with a legal base (see box 8).
Box 8: The legal base of the Observatório
The Observatório was officially recognised by Presidential Directive (Portaria) 26, signed by the Secretary of Health Policies on 21 September 1999.13 More recently, this directive was replaced by the Ministry of Health's Official Directive Number 1, dated 11 March 2004,14 which stated that proper information is needed to regulate, manage, develop and pursue policy on human resources in the health sector. The objectives of the network are stated as follows:
• to develop studies and methodologies to support analysis and policymaking in managing, educating and regulating health professions and occupations in health;
• to follow up social, demographic and socio-political aspects of supply and demand of professions and occupations;
• to analyse, assess and establish guidelines for strategic and methodological development in training and education on human resources for health;
• to follow up and analyse employment and working conditions in the health sector;
• to develop studies, methodologies and indicators that allow assessment of efficiency, efficacy and effectiveness of work in health sector;
• to foster the development of mechanisms for managing the health workforce, especially rela-ted to recruitment, remuneration and incentives;
• to monitor demands for regulation of professional practices and health occupations;
• to support all levels of government in establishing sound policies and practices regarding management, regulation and education in health. |
With the arrival of the Lula government in 2002, the institutional and financial base of the human resources in health community enjoyed a boost unprecedented in history. The Observatório network's coordination unit was strengthened and funds for the Ministry of Health's Secretariat on Management of Education and Work in Health were increased more than ten-fold, to some US $150 million annually.
Almost all funds for the network's functioning originate from the Ministry of Health's budget but are channelled via the PAHO's regional office to the network members. This "administrative assistance" by PAHO has been a point of friction between the Brazilian Court of Audit and the Ministry of Health. Though cumbersome, this is a pragmatic and flexible solution to reduce the risk of bureaucratic regulations delaying the execution of important auxiliary work. PAHO's contribution to the Observatório is its financing of the technical assistant, who deals with a range of human resources support programmes, of which the Observatório is one. It also offers some seed money for activities and meetings and ICT support to keep the Observatório present on the Internet.
The Observatório is an open network. Its founding presidential directive spells out that all teaching, research and service institutions willing to participate can do so. Today, prospective members must submit a letter of intention to the Ministry of Health stating that the institutional profile, academic production and proposed activities are compatible with the Observatório's objectives. Also required is a summary of the institution's professional staff and its experience in the field of human resources in health over the past five years. To become a member, institutions must agree that the national health system may use all outcomes from their network-related activities. Member institutes are further required to produce an Internet site which makes all of their products electronically available to the network and to the public, an obligation that not all institutes have realised so far. PAHO's regional office has set up a gateway for the websites.15
Decisions are taken collectively (box 9). There are two network meetings per year at which the secretariat and members approve biannual working plans which identify tasks and priorities. Task forces made up of staff at different workstations are formed to address particular themes or projects. This is the main way of working, as there is a need for interdisciplinarity and specialisations are spread throughout the country. This matrix structure might mean that a staff member at Workstation 1 takes the lead on Theme A, whereas a colleague at Workstation 1 participates as a member of another task force, on Theme B, led by Workstation 2. But it could also mean that a workstation carries out a task entirely on its own, with its own staff. Research proposals are discussed at these biannual meetings, and those that do not fully correspond with a theme are - if rejected - referred elsewhere for funding.
Box 9: Working collectively
To ensure that agendas are set jointly, stakeholders working in public health identify tasks to be accomplished and studies to be undertaken and propose them to the network members and secretariat. At a recent Observatório meeting, for example, stakeholders identified three themes as priorities:
• development of local-level managerial capacity to deal with human resources issues;
• types of institutional links and contractual arrangements between workers and health institutions;
• Ministry of Health outsourcing practices and their impact on the services delivered.
Once the priorities were identified, the network was invited to intervene. The network formed three task forces comprising members of different institutes to look at these sets of issues. |
The prioritisation and selection process is informal. Network members know one another well enough to decide who is best placed to do a job. Multilateral agencies and development banks have attempted to make this process more transparent through tender procedures. But because the network is not homogeneous and there are still strong and weak workstations specialised in the different areas, they generally form consortia to bid for a contract. Afterwards, tasks are divided similar to the way it would have been done without the formal bidding process.16 As the number of members is still relatively small, there has been no clear competition between them so far.
5.3 Observatório members
Most Observatório members are academic institutions linked to a university. On average, each member has three academic staff associated with the network (per institution, this varies between two and five persons). In addition to research and service delivery executed from within the Observatório's work portfolio, these staff may also be involved in teaching and other research at their mother institution. It is quite common for these staff to serve in other public health networks as well.
Work executed within the Observatório work plans is done on a project or research programme basis and the network secretariat provides funding. The stronger and better established workstations enjoy a reasonably solid institutional and economic base within their own institutions. This facilitates academic independence and the ability to engage in research and policy dialogue on topics which the institutes themselves consider relevant and important. However, funding from the secretariat is the main source of income for most of the institutes associated with the Observatório. But the institutes still feel they can maintain independence, since budgets that would allow them to engage in similar research programmes are also available from other government sources. On average, some 75 per cent of members' budgets originates from the secretariat.
Thematically, the projects and research programmes represent a wide range of topics relevant to human resources in health. Examples are "labour market quality and statistics", "legal aspects", "education and training", "productivity and quality of services", "governance and labour conflict", "history of the labour market" and "demographic, social and political trends". Table 3 summarises specialisations per Observatório workstation.
Table 3: Observatório workstations and specialisations
5.4 Public health networks and institutions
The Ministry of Health, PAHO's regional office and the respective workstations are all actors in and stakeholders of the Observatório. In addition, a number of other national and international institutions and networks take an interest in the Observatório's functioning (see also figure 2 on interlinking networks).
At the international level, the Brazilian Observatório is part of the Latin American Observatory of Human Resources in Health (LA-ObsNet), which was constituted under the PAHO umbrella and encompasses 20 of the region's 38 countries. Though the regional Observatory provides no financial support to the Brazilian network, its role in providing content support and advocacy is perceived as important by the members. It interacts with the Brazilian workstations and other national networks via the Internet and at annual meetings, at which the synchronisation of approaches across countries is reported on and discussed. The Latin American Observatory formally belongs to PAHO's Human Resources Development Programme, for which PAHO headquarters in Washington, DC, also provides secretarial support. The Brazilian Observatório is cofounder of the regional Observatory and is generally seen as its most active member. Peers closely follow the Brazilian network's functioning, since it is seen to have achieved nationally the objectives formulated by PAHO for the overall Observatory network idea (box 10). Most other countries in the region lag considerably in Observatory activity and outputs.
Box 10: Excerpts from the 134th meeting of the PAHO Executive Council
The regional Observatory of Human Resources in Health was launched in 1999 to raise awareness of the importance of placing human resources issues on the health policy agenda and to support the participatory development of the related policies. The regional network promotes active networking and collaboration among relevant institutional stakeholders at the national level to discuss and analyse data, monitor trends, prioritise issues and build consensus on policy interventions.
Source: From official documents CE134/11, 18 MAY 2004 presented to the PAHO Executive Committee. |
Within Brazil, the Observatório is part of several academic and service networks in health. First is the Brazilian Academic Network (BR-AcadNet), an informal network of all the institutes that teach pubic health in Brazil at the undergraduate or graduate level. This is an informal meta-network which deals with an array of public health topics. Some BR-AcadNet members are formal institutes which, for instance, teach accredited master's and doctoral degree programmes in public health. Others are more thematically oriented, for example, linked to multidisciplinary research proposals or specialised courses. BR-AcadNet is informally coordinated through ABRASCO, the Brazilian Association of Graduate Studies in Collective Health. The network maintains strong academic and personal ties with the Observatório mainly through its working group on human resources in health.
Both the Observatório and BR-AcadNet are embedded within a much broader informal network, the Brazilian Network for the Reform of Health Systems (BR-HsRefNet). This network is made up of academics, practitioners and policymakers active in the reform of the Brazilian health sector. It interacts intensively with Parliament, the Ministry of Health, decentralised health organisations, service providers and academic institutions. Since its inception in the mid-1970s, it has developed into an umbrella network encompassing various schools from the left to the centre of the political spectrum. As mentioned, the Brazilian Centre of Health Studies (CEBES) and ABRASCO serve as hubs, from which content discussions and initiatives are launched, directed and pursued up to the policy level.
Within these broader networks exists - next to the Observatório - a series of thematic networks and working groups related to human resources in health. The PAHO regional office in Brasilia has been instrumental in setting these up and in keeping them going.17 They are seven:
• the network associated with the national course to improve training in human resources in health (CADRHU - Desenvolvimento de Recursos Humanos em Saúde);
• the network of academic institutions linked to health services;
• the network on managerial skills for health units in the SUS (GERUS - Gestão de Unidades Básicas do SUS);
• the network of technical schools linked to the SUS (RET-SUS - Rede de Escolas Técnicas do SUS);
• the forum of institutions working for educational changes (FMG - Fórum Mudanças na Graduação);
• the network of collective bargaining on working conditions (NCT - Negociação Coletiva do Trabalho);
• the network on continuing education in nursing (IEPE - Educação Permanente em Enfermagem).
Figure 2: Brazil's interlinking networks in the public health sector
While the Observatório exists alongside these other networks, it is important to note that it is the only one with a legal base and strong ties to the Ministry of Health. It is common for member institutions of the Observatório, or their individual staff members, to be linked to the other networks mentioned above.
The Observatório is thus embedded simultaneously in the Latin American Observatory initiative and in a Brazilian academic network that itself is closely linked to an informal meta-network which nurtures health sector reform in the country. At the same time, regular interactions exist with other smaller public health networks, as well as with other cooperative processes not associated with the PAHO-supported networks. There are dozens of such initiatives, including networks of healthy cities, networks to promote health and social participation, networks of university hospitals, and so on. This conjunction of networks is spread throughout the country, like the interlocking pieces of a jigsaw puzzle. Some institutions participate in several of these networks but not necessarily in all of them, others participate in just one. As such, the boundaries between what is inside a network partnership and what is outside are fluid. Actors that are outsiders today used to be insiders, and vice versa. What holds them together is the common desire to improve the national health system. They pursue that aim through this very complex web of groups, platforms and networks in which interactions are ongoing and the formation of shared ideas is continuously nurtured.
6. Endogenous change and strategy development
6.1 Network dynamics
An initially slow and hidden growth process
The Observatório emerged in a specific socio-political and cultural context. Its seeds date back to the 1970s, at which time developments in the Brazilian health sector were carefully and modestly stimulated from outside of the country. The network gained momentum in the context of civil society's movement towards democratisation and emancipation as of the 1980s. It was during these years that public health advocates in the country linked their desire for political and societal change with the specifics of health sector reform.
This period also provided a playground for myriad informal exchanges among a diversity of actors concerned with public health. Oriented by a loosely formulated desire for reform, a set of decentralised actions shaped a pattern of unstructured cooperation and joint efforts carried forward via an ongoing professional exchange of information and ideas and disputes in the area of public health.
While these exchanges benefited from the existence of professional associations and networks that could provide platforms for discussions, never was any attempt made to formalise or to build hierarchies. The emerging networks paradoxically benefited in the late 1970s and early 1980s from the political leadership which opposed the emergence of participative structures and declined to provide institutional support to the work on human resources in health that was getting under way. This context stimulated creativity in terms of finding partners and colleagues, interacting and seeking out ways of doing things. One interviewee summarised this situation as follows: 'We [health professionals] organised in sub-groups and worked in different informal and non-structured ways because this was the only possibility for us to pursue our professional goals.'
Interactions between network members
The legacy of the 1970s and 1980s still informs the nature of today's interactions among network members and between the network and outside stakeholders. The web of interactions allows for continuous exchanges and learning, knowledge-sharing and creation of a common "mental model"18 among participants. This web has provided fertile grounds for nurturing capabilities and contributing to capacity development in the sector as a whole.
The past also created a culture of openness and willingness to test new ways of doing business. For instance, network members wholeheartedly embraced the introduction of the Internet in the 1990s. These new technologies in turn provided a major boost to the frequency and quality of network exchanges. Willingness to experiment and to connect to the broader Latin American Observatory introduced by PAHO can be seen in a similar light.
From the beginning, the Brazilian network took on a life of its own. Many of the participants interviewed stated that independent of the Ministry of Health, common projects started to emerge with various partners and at different levels of the health system - even with institutions outside of the health sector. No particular strategy or formal leadership was in place to guide the Observatório's emergence. There was rather a small movement of public health specialists dealing with human resources issues who benefited from inputs by intellectual leaders.
Today a number of groups have become well established in certain thematic areas. Because this makes it difficult for younger institutes to compete, the older institutes encourage those that are just starting to set up cooperative programmes and share in the established partners' knowledge and expertise. So far, some competition for research contracts has arisen, but it has not been fierce or aggressive. Most interviewees pointed out that so much work is left to be done that it is impossible to tackle all of the challenges, an ideal situation for cooperation to prevail over competition.
The growing demands for accountability and competition - for example, through bidding procedures - might change relations in the future. In view of these demands, and increased pressure for performance in terms of policy relevance, efforts are under way to formulate a strategy for the network. The strategy document will bring some order to the growing complexity of ongoing operations. It will help newer members to better integrate into the network and it will outline an approach to deal with outside actors and external demands. The strategy should also help to clarify the roles of the different network actors, in decision processes and in fulfilling accountability requirements, as many processes are currently based on interpersonal links and relationships. Interviewees agreed that transparency is needed to avoid protective, cartel-like practices which could undermine the network's very existence.
Relations with the Ministry of Health
The interactions between network members and the Ministry of Health have grown increasingly intense and productive over the past decade. A key element here has been the exchange and rotation of health professionals between public health institutes and ministries at the federal and state levels. Some professionals have gained international experience through work at PAHO headquarters and the WHO. This has enabled them to view the interactions between the Ministry of Health and network members from a more distant perspective. At the same time, it has built a cadre of professionals with a regional view and understanding of human resources problems in health.
The Ministry of Health has performed its facilitative and stimulating role without any attempts to instrumentalise the network. Nor has it misused the
network to serve political goals. Pragmatism and flexibility have prevailed, which led to the grounding of the Observatório in law and ensured that the results of the network's activities could serve policymaking and planning while leaving individual network members space to develop their own specialisations. Moreover, procedures and regulations which threatened to delay the execution of urgent work have been dealt with in a flexible and non-bureaucratic manner, as illustrated by the provision of funding through the PAHO office in Brasilia.
A factor that has facilitated the growing interaction between the institutes and the Ministry of Health is the existence of a degree of "thematic" or "content" space within the human resources for health topic. This has enabled institutes to specialise in certain sub-themes and provided incentives for new members to shape their profile, build their professional capabilities and carve out a space within the network.
Box 11: Guidance, participation and autonomy - a balancing act
Autonomy of the Observatório has arisen as a major issue between network members and the Ministry of Health. Network institutions depend primarily on the government for resources to sustain their work in the area of human resources for health. While state and municipal-level authorities call upon the services of Observatório members, they provide little funding. Nor does PAHO function as a financing partner. With both demands and funding coming primarily from the Ministry of Health, there are questions as to whether the Ministry's monopoly will bend members (particularly the weaker ones) to the demands of those in charge.
Questions on the network's intellectual independence have been posed, for example, by actors submitting proposals related to work areas outside the immediate priorities of the Observatório and for which few resources exist from other sources. If these proposals are rejected, then questions invariably arise as to the network's priorities. Yet the more general issue remains whether the network will be able to remain autonomous if academic vision conflicts with official priorities.
One way of addressing this concern is with the collective planning and priority setting process described earlier. However, because there are few formal rules and procedures, this collective process is difficult for outsiders to comprehend. |
Since the network is composed of a wide range of independent research and teaching institutions, representing a broad spectrum intellectually and, to some extent, economically, members agree that there must be other aspects enabling the network's growth. A key factor mentioned by interviewees was the constructive role which the Ministry of Health played to reinforce existing ties between the research and policy levels. The Ministry has helped to tighten links between research and policy. This process, though carefully managed from a distance by the Ministry in cooperation with PAHO-Brasilia, benefited from exposure to continuous efforts to safeguard the autonomy of the network (see box 11).
The role of PAHO
PAHO played a decisive role in the formalisation of the Observatório network. Most essential was the overall approach to assistance which the organisation developed and pursued over the years. The approach was characterised by the provision of guidance, setting out broad policy orientations and building on internal developments (box 12). This was complemented by targeted funding to initiate selected and strategically important processes, such as the pan-American initiative by PAHO and USAID to monitor health sector developments in the region.
Box 12: Building on existing dynamics
PAHO has encouraged horizontal interactions among the Observatório workstations and exchanges with the secretariat. But the organisation is not alone in this motivator role. Long before the Observatório came into existence, teaching activities had begun related to a course on development of human resources in health (CADRHU). CADRHU was initiated in 1967 to groom professionals who showed high commitment to the field of human resources.
Initially, the stronger and more consolidated institutes offered the course. Regional and state institutions participated at other levels, some assuming one or two training modules, others just acting as tutors. Many steadily expanded their involvement. At an intermediate stage some took on responsibility for the course, often drawing on external technical expertise.
There was thus a process by which institutes joined proactively at the level best suited to their current capacity. They decided what their level of involvement would be. The process was not prescribed. Both well established and new institutions found a place in the network. Finally, almost a dozen institutions were teaching the course largely independently. |
Starting in the early 1970s, PAHO provided seed money for a variety of activities to stimulate public health research and human resources planning. The idea was to bring schools of public administration together with health system planners, to stimulate thinking through exchanges between academics and health service professionals and to support the creation of health-related professional associations. Aware of its limitations as an external actor, PAHO invested time and resources to understand the specifics of the national situation and acted pragmatically as a part of the process shaping the public health reform. PAHO became integrated in the local dynamics, setting up a parallel in-country capacity with profound knowledge of the national context. With the aim of playing a facilitating role, the PAHO country representation became part of the intra-network dynamic, and even a co-shaper of it.
The Observatory network concept became a prominent example of PAHO-Washington's work and its understanding of the Latin American continent. As a strategy, the network was fully designed by PAHO headquarters, including its objectives and its approaches to implementation. Yet this broad policy initiative was taken up in its entirety by public health actors in Brazil, many of whom in the 1970s had been exposed to human resources issues and had worked on the topic in the context of PAHO-Brasilia programmes.
In terms of integration in the local context, PAHO's recruitment of a Brazilian technical assistant to promote attention to human resources in health cannot be underestimated. Based at PAHO's Brasilia office, the technical assistant was recruited in the 1970s, and he continues to work in that capacity today. While such an arrangement goes against conventional practice in development cooperation, decision makers at PAHO headquarters and in Brazil were convinced of the need for a staff member who understood the complexities of the sector, was professionally specialised in human resources and who could provide continuity in accompanying the sector.19 In view of the high turnover of personnel at the Ministry of Health, due to political changes, this safeguarding of capacities in an independent position proved decisive in the emergence of the Observatório.
Paying for this technical assistant was the PAHO's main financial contribution to the network, in addition to the seed money it made available to initiate of activities, the setting up and hosting of Internet facilities and limited contributions for meetings and conferences. With regard to content, the PAHO office in Brasilia was able to organise external intellectual inputs through its links with PAHO headquarters and the WHO.
What about leadership?
The intellectual and informal leadership which directed the early days of Brazil's public health reform movement still characterises the functioning of the Observatório. This leadership is not particularly embedded in any of the institutions, or workstations. Rather, it is present in a group of persons who share similar ideas and professional backgrounds and who today occupy leadership positions in the health sector.
According to some commentators, the Observatório is directed by an 'invisible steering group', or an informal governance agreement among key members of the network. This group is present within the Ministry of Health as well as at a number of the principal workstations. These members have frequently rotated across functions, which has helped to reduce distances and break down barriers. The group of public health specialists that operated in Brazil in the 1960s and 1970s was rather small. Much of this "first generation", which was spearheaded by the famous Sergio Arouca (see box 5), is now retired or has passed away.
It was replaced by a second generation, a rather decentralised group of some 100 professionals in leadership positions spread across Brazil but holding similar ideas about the health sector and how it should be shaped. Certain people take on the management or intellectual leadership at a given point in time, but reduce their proactiveness if (political) circumstances change or if others are better placed to move ahead. Hence, an interplay based on exchange and participation has emerged, resulting in leadership and governance of the network without overly formalised structures or procedures. The weakness of this system, however, became clear to network members and impelled them to formulate a strategic plan to keep the network running and effective.
PAHO plays a supportive, but also a proactive role. It contributes limited but targeted institutional support to strengthen the ongoing network process, but it has no distinct leadership position. Rather, it is facilitative, being well embedded and accepted in a collegial fashion within the network.
6.2 Factors explaining change
The triangular interaction between health institutes, the Ministry of Health and PAHO grew organically and interactively, with each of the parties taking on a distinct role.
Vibrant professional interest in the topic of human resources in health, combined with a keen underlying desire for social and political change, was the prime driver carrying the public health movement forward. This orientation on content was successfully managed through loose and flexible, but fully informed, coordination by the Observatório secretariat. One of the partners in the secretariat, PAHO-Brasilia, played a successful facilitation role which also provided for continuity and added professional quality. The Ministry of Health has acted as a distinct "operator" in the background ensuring political backing and financing, but doing so without directly interfering in the proceedings of the network.
Too much integration into the Ministry of Health would risk taking initiative and decision-making away from network members, thereby undermining their motivation. As it stands, intellectual and financial inputs are injected into the network, but enough space is left for independence, specifically the free development of ideas, priorities and action. This is a key concern of the proponents of the networking idea, who underline that independence is vital for 'the network to remain ours', as one interviewee said. Without independence, motivation and content production would fall apart. The careful balancing act by PAHO and the Ministry of Health between providing guidance and respecting independence is a major factor contributing to the success of the network.
Pragmatism and flexibility have prevailed both in the period preceding and after the formal inauguration of the Observatório network. This is evident in the role of PAHO and in the creation of informal sub-systems and networks (e.g. the setting up of various networks dealing with human resources in health) to complement the functioning of the Ministry of Health without undermining its role. Such complementarity could only arise in a climate of mutual trust and profound understanding allowing non-dogmatic solutions and flexible handling of system requirements. The rationale was simple: The system should not dictate goals; rather, the goals should inform how the system is utilised.
Without doubt, the availability of the Internet has been key in keeping the network moving, conserving momentum and increasing the quality of interactions. The technical possibilities of the innovative information and communication policies and technologies introduced in Brazil in the 1990s were immediately recognised by PAHO-Brasilia and incorporated into its approach to networking. Suddenly huge distances could be bridged and essential information shared in a decentralised manner at relatively low cost and within short timeframes.
A final factor explaining change is the openness of the triangular interaction. Perhaps most notable here is the ease with which the network accepts new members (though recognising that there is a limit to the number of institutes that can join). Network members have been similarly unreserved in cooperating with partners outside of the network. A further sign of openness is the exchange and rotation of knowledge and personnel between the various entities, in particular between academia and government. This has offered distinct benefits in consolidating understanding, engaging in joint action and building capabilities. Clear boundaries between academia, service institutions and policy are fading as professionals move back and forth across academia, services and government. Experiences accumulated at the managerial level become the subject of academic reflection and part of an informal feedback process that informs policy. Regular regional exchanges and interactions with the international public health community, including the posting of professionals in international organisations, reinforce this pattern and are still proving their added value today.
7. An Evolving mix of key capabilities
Similar to other research on networking and the emergence of networks, our analysis of the Brazilian Observatório network shows a mix of activities executed in three main areas:
• learning - research and information exchange;
• service delivery - information provision and training;
• advocacy - promotion of reforms and enhanced exchanges between the policy level and the academic community.
These activities are performed interdependently and in parallel, which requires a distinct mix of capabilities.
7.1 Different times, different capability requirements
Following the framework presented in section 2, we group capabilities into four types: external, internal, technical and generative, or soft (see also box 3). Each of the types is clearly present in the Observatório network, but there are differences in terms of their importance and use. The framework helps us to analyse the relevance of these respective building blocks in creation of the overall capacity of the network.
Capability development as of the early 1980s
Informal exchanges and joint action among public health specialists were established largely through the interplay of two types of capabilities: (i) the technical capabilities, or qualifications, of the network members, based on professional interests and specialisations and (ii) a range of generative capabilities which gradually developed in the context of social and political change in Brazil. The latter can be characterised as flexible, creative, autodidactic, entrepreneurial and inventive within a non-facilitative environment. Early on, openings had to be identified and taken advantage of as they arose. These capabilities were performed with a particular idea in mind on how the overall system should be shaped, but without fully envisioning the path by which to proceed.
The technical and professional capabilities formed the foundation of the entire exercise. They provided the platform on which members could develop a joint language as well as legitimacy in interacting with the outside. Research produced by individual institutes earned high acclaim, as did a variety of projects to deliver services to the public health system, such as in education and training. These activities grew organically and were combined with elements of advocacy for better public health policy. Ultimately, the advocacy element became so successful that the proponents of the human resources for health community entered into the health institutions and contributed to shape the legally recognised structure that the Observatório is today.
Regarding external capabilities, some advocacy and lobbying was facilitated through the delivery of high quality outputs and the initiation of an informed policy dialogue. But neither public relations nor securing outside assistance to get the network going was a priority. Contacts with actors at the regional and international levels existed but were construed merely as complementary inputs to an ongoing dynamic. These inputs were nonetheless used creatively and efficiently, as the cooperation with PAHO shows. From these a strategic partnership emerged (although this term was never used in the context of the Observatório's work), allowing the injection of incentives and ideas to nurture the networking exercise.
Of lesser importance in the initial period were the internal capabilities, such as structures and systems for interaction, financial management and the like. A governance arrangement emerged, but it was hazy and obscure - a situation which persists today. Associations were also created, but they were used only as a platform for exchange and dialogue. Most notable in terms of internal capabilities was the implicit agreement that the movement needed to get into the research and service institutions to be able to take decisions. But no explicit strategy was in place to spell out the steps to be taken or to orient the network members towards interacting to accomplish a set of objectives. It all developed organically.
A changing capability mix as the network matures
The legal recognition of the Brazilian Observatório in 1999 did not fundamentally change its character. Today it continues to display a mix of the four capability areas. But in the course of institutionalisation and growth, as of the mid-1990s, the internal capabilities - mainly executed by the Ministry of Health and PAHO - as well as the external capabilities grew in importance. This was an induced change through which formerly external actors became part of the network and able to share in shaping its course. An example is the request to the network to set up coherent reporting structures and procedures for managing research funds and monitoring their use. Similarly, demonstrating preliminary and final outputs and producing financial reports has become indispensable to keep options open for follow-up funding.
The increased interaction of network members with a government ministry, assisted by PAHO, has raised voices demanding clarification of the Observatório's governance structure: How are research funds allocated and work evaluated? Intense discussions are ongoing in this regard within the network, but no final suggestions are yet on the table for how to guarantee more transparent decision-making processes. What has emerged is the conviction among network members that a strategy should be in place to guide the network into its future. Work on this began recently, with the process viewed as key to sustaining the network in the longer term.
In the course of maturation, complementary external capabilities have emerged. For example, network members have intensified their engagement in partnerships and in networking with other institutions in Brazil. They have also strengthened their ties with members and stakeholders of the pan-American Observatory. At the same time, awareness has grown of the need for enhanced outreach to show that health investments do lead to valuable outputs as well as to greater performance of the public health system overall. The forthcoming strategy will note this need for outreach to the public.
Concerning technical capabilities, the individual institutes continue to invest in shaping and nurturing their knowledge through learning. But as voices grow louder demanding evidence of performance, members acknowledge their need to further beef up their capabilities in policy analysis and dialogue. Early on, technical information on human resources in health was welcomed as a primary input to public health planning. Now, however, there are demands for more sophisticated syntheses and analyses to inform policy more adequately and in a more timely manner.
Keeping the generative or soft capabilities alive will be a challenge for the network in view of its institutionalisation, demands for accountability and its need to comply with government procedures and regulations. So far, the network has managed to maintain flexibility and an informal dynamism and to balance these qualities with interdependence and fulfilment of system requirements, such as being transparent and accountable to stakeholders. Member institutions have similarly found mechanisms by which to cope with competition while maintaining intense and fruitful exchange of knowledge and information. Long-serving members are aware that these soft capabilities are dearly needed to keep the network running. As such, they will likely be nurtured in the implementation of the forthcoming strategy.
7.2 Balancing political and professional dynamics with system requirements
Motivation and group learning
It is revealing to look at the respective capability areas and their relevance to the emergence and running of the Observatório. But comparing, weighing and assessing the importance of the different types of capabilities at a given point in time tells us little about what enabled their simultaneous existence and execution. Or, put differently, what glue has held the network together over such an extended period? Our review points to two factors which, though not necessarily conclusive, help us to understand a good deal of the puzzle.
First is the motivation of the Observatório's advocates. Many of the network's current decision makers relate their professional and activist origins to a
period of political turmoil, transformation and creation of a new social system. They belong to a much bigger movement with an interest in staying integrated and progressing at the same time. Political factors united this movement. Activists sensed an opportunity to change their country for the better. This may seem idealistic or naïve, but it gave strong roots to the social and political changes that followed. Being a sub-group of this movement, the "health sector reform party", as the public health advocates still call themselves today, translated the broader vision into an aim for a better health system. As a result, health sector reform is now at the top of Brazil's political agenda.
But why has this not happened as strongly in other social sectors in Brazil? The answer may lie in the second possible factor acting as the glue holding the network together: the continuing exchanges and interactions among members. This pattern existed from the network's early days. Exchanges and joint action helped to bridge the gap between individual learning and the network's overall capacity for action. Interactions were regular and oriented within the loose structures provided by associations, platforms and smaller (working) groups. The process was not deliberately guided - it was rather facilitated and stimulated. Collisions, convergence, integration, friction and separations generated energy, leading to added value, or group learning.
Across different actor groups, this process encouraged exchange of ideas and, ultimately, the creation of mental models from which shared visions, ideas and values crossed existing boundaries and were loosely aligned in an expanded new way of thinking. This entire process originally took place on the basis of peer mechanisms, but later was informed and gradually supported by inputs from the outside.
Looking ahead
It will be important to maintain an adequate mix of the four types of capabilities in the future. Professional knowledge and technical capabilities will remain a cornerstone of the network. To maintain the requisite ownership, commitment and dynamism, the soft capabilities that shaped and determined the character of the emerging dynamics over time will require special attention. The network's momentum depends on it. The challenge now is to balance maintenance of these capabilities with the demands of the Brazilian government and of stakeholders outside of Brazil to enhance the internal and external capabilities. Compliance with accountability, transparency and procedural and international management standards is on the agenda, which seeks to do away with informalities and personalised relationships driving decision-making - though these are precisely the elements that contributed to the network's early vitality and success.
The forthcoming strategy might map a path for the future. If used effectively as a tool, it could set out an approach to integrate the useful, but keep at bay the demands and requirements that could potentially prove undermining.
8. Performance: achievements and challenges
The Observatório network emerged independently of the Ministry of Health. Projects arose fairly spontaneously through horizontal interactions and in
collaborative programmes involving a variety of government and non-government institutions within Brazil and in the region.
Over time, this "movement" filtered into government. A coalition of academic thinkers and researchers, health professionals, managers and
even consumers made the case for an equitable and universal health system. Alliances were formed and persistent advocacy - supported by a multiparty coalition of the left wing and the centre - helped to build political will for change. In the end, advocacy for an improved public health system resulted in a constitutional amendment increasing funding for health at all levels of government.
The formation and partial institutionalisation of the Observatório were in sync with these wider changes in the Brazilian health sector. Having grown organically at first, the network was formalised by the presidential directive that gave the Observatório its legal status. This status enabled it to coordinate its own activities with the policies and programmes of the Ministry of Health and to take charge of the knowledge network that proved so crucial in strengthening the sector as a whole.
As such, the Observatório itself is an expression of performance. Its very existence demonstrates that the mix of capabilities described earlier resulted in valuable outputs: seminars, publications, associations, and the like. These spurred demand for more quality products and helped the actors of the Observatório develop their core business and a niche from which they could add value to the public health discourse. The network's outputs also contributed to higher level outcomes, such as formal recognition and status, secure funding for research over a longer period of time and - most importantly - the use of network knowledge and results to improve policymaking in public health.
There are indications that '[a]dvancements in the Brazilian health sector have been made possible as a result of solid health services research, which has brought together researchers, health service professionals, and politically organised groups' (Elias and Cohn 2003: 47). The Observatório network has
certainly contributed to this advancement. Its policy work and academic research in the areas of the history of human resources in health, training, management, the labour market and employment are well known and referred to by the Ministry of Health (see Annex 3 for a list of Observatório publications). Thus, there are also signs that Observatório outputs are used at the ministerial level, though overall evidence that the results are effectively and systematically applied in policy dialogue and formulation remains thin.
To date, indications of the effectiveness of the network are mostly indirect, though a few examples of sound, fact-based policymaking can be mentioned:
• inventorisation of human resources management practices at the local level;
• re-distribution of physicians and nurses to underserved areas (a telephone survey led to a last-minute policy correction that saved public money and allowed for a better coverage of underserved areas in the country);
• better knowledge of the dynamics of the physician's labour market in São Paulo State.
Unfortunately, as pointed out at various international meetings, Brazil like many other countries does not systematically use secondary data about trends in human resources. Capabilities to distil targeted conclusions from research are scarce and mechanisms to systematically absorb and transform analyses for policy discourse are weak. The Ministry of Health shares this concern and has in fact put improved data utilisation on its agenda.
To enhance the quality of the network's outputs, organisers stress the potential benefits of the Internet. According to PAHO's national advisor on human resources, this technology can enhance the articulation of ideas and exchanges. If used effectively, virtual spaces can provide cost-effective venues for deepening knowledge and understanding of approaches, and enhanced dialogue can enable actors to better contribute to the formulation of public policies (Paranaguá de Santana 2004).
Concerns about effectiveness have stimulated debate about current and future challenges, as at a recent network-related workshop in Belo Horizonte, Brazil.20 Stakeholders at this workshop wanted to see the network evolve beyond the publication of research findings, communication among members and organisation of financing opportunities. Nor do these actors perceive occasional meetings or dissemination of information through the Internet as sufficient. Rather, they would like the network to develop into a mechanism which facilitates intense communication between researchers through ongoing dialogue, interaction and joint work.
The need for the network to improve the quality of its work was also raised during the workshop. While the growth in membership in recent years has produced a critical mass of knowledge and given visibility to the theme of human resources in health, there is a need to introduce mechanisms to monitor and evaluate the outputs of the network. Stakeholders might see this as a means to strengthen the links between research and policy while advancing fundamental knowledge.
A third demand, closely linked to monitoring and evaluation, is to introduce competitiveness into network operations and to recognise excellence. Passos Nogueira (2005) suggests revisiting the network's current tendency towards egalitarianism in order for it to maintain its social relevance.
Finally, there was a demand for the network to incorporate the public in debates on public health policy. This would require more interactive processes, supported by the Internet (Famer Rocha 2005).
In terms of performance, one should also look at the interaction between the Ministry of Health and PAHO with regard to the support they have provided to the Observatório. Over time, PAHO has provided a constant and reliable source of assistance. This was particularly important at times when the Ministry of Health was unable to extend support because of the unavailability of qualified staff in the government, for political reasons, or because of lack of funding. Figure 3 shows PAHO support over time. Interviewees confirmed that PAHO as an outside actor performed consistently and helped to support the movement's growth even in difficult periods.
Figure 3: PAHO support over time
9. Reflecting on networks and networking
9.1 Drivers of networking in Brazil
Networking and creation of formal networks is common in Brazil. A careful look reveals some distinct features which may indicate why networks emerge so robustly in this country. From a social and historical perspective - the viewpoint of such recent writers as Olivieri (2003) and Chaves et al. (no date) - we see that almost all of today's networks have their origins in the social movements of the 1960s. Though some Brazilian social movements date back to the 1930s, the fight against dictatorship seems to have been particularly formative in shaping a common ground and broad consensus for building up citizenship. In the struggle to create democratic, participatory and decentralised structures in their society, more formal arrangements emerged, such as the Brazilian Association of NGOs (1991) and the Brazilian Forum of NGOs and Social Movements (1992).
In Brazil, the concept of networking is closely related to a social movement based on the principles of democracy, participation and decentralisation - the belief that problems can be solved through compromise and cooperation rather than confrontation. This has led to some innovative practices in terms of the relationship between civil society and government, such as "participatory budgeting", which contests patterns of inequality and the clientelism and patronage still present in the country (Menezes 2003). Networks are therefore not only a manifestation of the will of a social movement and of civil society. They also express new forms of relations between civil society and the state (Chaves et al. no date).
Many sources mention Brazil's unique social and historical context. But there might yet be other explanations for the Brazilian success in networking. The size of the country, for example, poses huge challenges to connecting and organising in a systemic way. Over such great distances, comprehensive stand-alone arrangements are difficult to set up and maintain, whereas decentralised initiatives based on a common idea are relatively easier to orient and execute. Another explanation could be derived from Brazil's cultural identity, with its distinct mixture of southern European and West African influences. These are clearly hypotheses that go beyond the scope of this paper. But in the context of networking, research on them seems worth pursuing.
9.2 Are networks replicable?
The Observatório is an exponent of Brazil's community of networks and networking activities. Our review has shown how the Observatório unfolded and how it developed as part of a wider social movement. It is one piece of a jigsaw puzzle, a piece that has found its place within the wider framework of reshaping society. The network would not have emerged as it did without the contextual factors that shaped it.
From this perspective, a network arguably cannot be replicated or designed. But there are certain design elements that can be observed in the context of change processes. Clearly, the more ownership there is of a process, the larger the probability that these elements will be brought to bear. In other words, the more external push and pull, the less likely sustainability and success will be.
In the case of the Observatório, the combination of a repressive environment and a maturing civil society set the scene and propelled the network's emergence. In this same context, a number of design elements helped to fuel the experience. Today, seven elements are still proving their value in the network's day-to-day operations:
• emphasis on horizontal interactions and exchanges, as opposed to a vertical hierarchy;
• information sharing to link the partners at the various levels, whereby free sharing, access to knowledge and information and openness prevail;
• deconcentration and decentralised decision-making based on the principles of participation, equality and sharing of responsibilities;
• action in accordance with commitment, dedication and motivation, not in response to command and discipline;
• delegation of authority to those best placed at a given point in time, and autonomy and space for network members to explore, unfold and create;
• strategic investment and use of technology to facilitate equal and rapid interaction;
• continuous nurturing, clarification and reconfirmation of objectives - either informally, or through more structured processes leading to strategies and work plans.
The Observatório also illustrates the value of constructing a matrix of experiences and focal areas to orient the work programme and the admission of new members.
The architects of the Observatório realised that while networks are useful, they can also pose problems. For instance, the governance structures of an institution working on its own are considerably simpler than those where multiple parties must be heard and consensus reached before a decision is taken. Brazil's sheer size, its ongoing decentralisation process and the spread of technical and professional expertise across the country helped to propel the decision to implement the network. Perhaps these characteristics explain why other Latin American countries have not taken up the Observatório idea as readily as Brazil, particularly the smaller countries.
The Observatório was never seen as an alternative to other institutional arrangements. For many state functions, networks can offer no substitute. The aim was rather for the network to complement processes ongoing within the government and society. Networking was an added mechanism for interactions that cross the boundaries between state and civil society. Networking was also viewed as a means to upgrade research and services related to human resources in health. This feature of being additive and complementary to existing structures is common among networks and corresponds to other successful networking experiences both in Brazil and elsewhere (Whitaker 1993).
In the case of the Observatório, individuals and organisations bought into the network idea because it enabled them to advance their own cause and translate their ideas into action. Simply said, it delivered added value. Participants understood the power of interaction in generating synergies and that an arrangement such as that being proposed in the Observatório could strengthen all of its members. The results would benefit their own work and the sector as a whole.
What role did external support play in shaping the network? The stronger workstations would probably have found their own way to pursue their interest in human resources in health. But the Observatório facilitated their progress, allowing them to expend more energy on content matters instead of the search for complementary funds and institutional support. Though the stronger workstations would survive if the Observatório disappeared today, the weaker network members, in many cases the smaller and younger ones, would probably cease to exist. However, past experience in nurturing new members which have now become stronger suggests much potential for the future.
10. Conclusions
This case study set out to investigate the interrelationships between networking and capacity development. Particularly interesting for the overall ECDPM study on Capacity, Change and Performance was the question of what types of capabilities are needed to initiate networking and to make networks function over a long period of time. A second key question was how capacities which were created in the context of networks can lead to performance.
Concerning the first question, it is clear that many capabilities emerged. They developed incrementally over the years. Some were growing some thirty to forty years before the network obtained its legal status. Experience helped to connect, shape, organise and nurture them. This was not an orchestrated process, but the accompaniment and facilitation of PAHO was nonetheless critical. A mix of technical, internal, external and so-called "soft", or generative capabilities emerged which supported the unfolding and sustenance of the network. But there are differences between these capabilities in terms of their importance and use over time.
The technical and professional capabilities of the network members and their motivation to make the theme of human resources key in reform of the public health sector served as a cornerstone in creation of the network. Building and nurturing these capabilities proved vital in the network's infancy and remains so today. The focus on content helped network members maintain intellectual independence while shaping the sense of autonomy that characterises current interactions among the workstations.
During the initial years a number of soft capabilities catalysed the technical and professional capabilities. These soft capabilities included flexibility, creativity, pragmatism, inventiveness and entrepreneurial spirit. They provided the only way for the network to find its way in the prevailing context of political repression and dearth of government support for policy, research and services on human resources in health. Informality in procedures became the initiative's only choice. This working culture has remained in evidence through the years, especially in the network's decentralised structure, the frequent interactions among members, the consensual decision procedures and the regular exchange and rotation of professionals among jobs in government, workstations and sometimes the international scene.
This dynamic process resulted in group learning and formulation of shared ideas that reinforced the technical and professional capabilities mentioned above. Moreover, it informed a common thinking about the enhancement of internal and external capabilities which became important in the mid-1990s. The network developed an internal approach of facilitation and stimulation which was implemented by the Ministry of Health in cooperation with a well-informed PAHO office in Brasilia. The network's strategic partner over the years - PAHO headquarters in Washington, DC - provided stabilising support.
The late 1990s saw the enhancement of internal capabilities transformed into a degree of formalisation, institutionalisation (the Observatório becoming legally recognised) and secure funding. Network architects, furthermore, immediately recognised the potential strategic importance of the Internet, and quickly introduced this tool to enhance the quality of the network's interactions, both internally and externally with other networks. Today, exchanges with other networks within Brazil and internationally are more intense than in the past, which has significantly boosted the network's productivity and its profile.
Turning to the second question, how capacities created in the context of networks can lead to performance, the case shows that motivation and group learning play key roles in this transformation. Motivation took two forms: professional and political. Vibrant professional interest in investigating the relevance of planning, management and training in human resources for health was blended with political ideals and the conviction that society needed to be fundamentally changed. The pattern of continuous interaction and exchange facilitated sharing and group learning. These twin motivations catalysed the shaping and assembling of the complex capabilities puzzle into a performing network, or - following the terminology from section 2 - into overall capacity.
The case of the Observatório shows that informal networking can evolve into networks with more formal structures delivering outputs and outcomes and potentially impacting on the well-being of society. Yet we should recognise that the Observatório's capacity development process is far from complete. There are demands and challenges to be addressed, such as the recent political turmoil caused by accusations of bribery within the Lula government.
There are also demands from within the network for intensification of the exchange in terms of content and relevance for policymaking, and for the introduction of monitoring and evaluation to ensure the quality and relevance of the network's outputs. With the institutionalisation and the provision of substantial resources, the 'hour of truth' has arrived, as one network member put it. Funders and the public have expectations for improved outcomes now that the government has fully subscribed to the idea of a formal network contributing to and informing public policy and services. If not, the network risks losing its legitimacy, together with that of the "health alliance" which helped to put it in place.
It seems clear that the future development of the Brazilian Observatório will rely on the dynamics of endogenous processes. Outside actors are welcome to assist, but they must take care not to tear the fabric of the network, which was woven through an inimitable interaction of internal forces and external assistance. Much will depend on the internal steering process of the movement in the near future. In the meantime, network members are vigorously carrying forward the strategic planning exercise in a process which bodes well for the future.
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Annex 1: Brazil key facts
Annex 2: Case study methodology
The WHO and the UK Department for International Development (DfID) suggested that the ECDPM look at the Observatório experience as part of our overall study on Capacity, Change and Performance. We made first contacts with the network and the Ministry of Health during a visit to Brazil in March 2004. At that time, we held discussions and briefings with Paulo Seixas, Coordinator of the Observatório workstation at the State Secretariat of Health in São Paulo, Pedro Miguel dos Santos Neto, Director at the Ministry of Health in Brasilia and José Paranaguá Santana, Advisor for Human Resources at PAHO-Brasilia. Lively exchanges on the scope of the research led to the Observatório secretariat's appointment of Francisco Eduardo de Campos as a resource person to work with Volker Hauck (of ECDPM) to document the Brazilian experience.
Several meetings followed in São Paulo, Rio de Janeiro and Brasilia in June and July 2004. At these gatherings, the PAHO advisor discussed the purpose of the study with stakeholders of the network and solicited their collaboration. Complementary literature and visits to some of the institutes provided a feel for the latest developments. In consultation with the secretariat, a number of Observatório workstations were selected at which to conduct interviews. The aim was to produce a representative sample of the different types of members, in terms of range of experience, national or regional focus and thematic specialisations. Because the research was seen as a learning experience for the network as well, an extensive bibliography reflecting the products of the different workstations was prepared and later published on the Observatório website (see Annex 3).
Field interviews were conducted by Francisco de Campos of the Federal University of Minas Gerais, Volker Hauck and Paulo Seixas who joined the team as a resource person. The three visited Rio de Janeiro (UERJ and Poli/FIOCRZ), Natal (UFRN), Recife (AM/Fiocruz), Brasilia (UnB) and Belo Horizonte (UFMG) in late August 2004. In Brasilia the team conducted additional interviews with representatives of the Ministry of Health and PAHO-Brasilia. Interviews were recorded for future reference. Volker Hauck conducted complementary interviews at COC/FIOCRUZ in Rio de Janeiro during the first week of September 2004.
The interviews were based on questionnaires developed in line with the conceptual framework of the overall study on Capacity, Change and Performance (see inside cover). In writing up this study, the authors made use of initial results of this larger study, as documented in the Interim Report.23
Annex 3: Selected publications of the Observatório
Background
• Observatório de Recursos Humanos em Saúde nas Américas - 1999-2004: lições aprendidas e expectativas para o futuro. Unidade de Desenvolvimento de Recursos Humanos, OPAS/OMS.
• História, saúde e recursos humanos:análises e perspectivas. Gilberto Hochman, Paula Xavier dos Santos e Fernando Pires-Alves.
Development
• Residência médica: prioridades do Sistema Único de Saúde que determinam a distribuição de vagas. Adriana Rosa Linhares Carro, Aniara Nascimento Corrêa Araújo, Nosor Orlando de Oliveira Filho and Paulo Henrique D`Ângelo Seixas.
• Educação profissional em saúde: uma análise a partir do censo escolar 2002. Júlio César França Lima, Luciane Velasque, Mônica Vieira, Renata Reis, Rita Elisabeth da Rocha Sório and Valdemar de Almeida Rodrigues.
• Tendências do sistema educativo no Brasil: medicina, enfermagem e odontologia. Ana Luiza Stiebler Vieira, Ana Claudia Pinheiro Garcia, Antenor Amâncio Filho, Célia Regina Pierantoni, Clarice Aparecida Ferraz, Eliane dos Santos Oliveira, Janete Rodrigues da Silva Nakao, Sérgio Pacheco de Oliveira, Silvana Martins Mishima, Tania França and Thereza Christina Varella.
• Rede de recursos humanos em saúde: os nós constituintes da integralidade em saúde. Maria Ysabel Barros Bellini, Décio Ignácio Angnes e Suzane de Mendonça e Silva.
Labour market and jobs in health
• Precarização do trabalho de nível técnico em saúde no Nordeste: um enfoque nos auxiliares e nos técnicos de enfermagem. João Bosco Feitosa dos Santos, José de Freitas Uchoa and José Meneleu Neto.
• Médico e o mercado de trabalho em saúde no Brasil: revendo conceitos e mudanças. Rômulo Maciel Filho and Célia Regina Pierantoni.
• Configurações do mercado de trabalho dos assalariados em saúde no Brasil. Sábado Nicolau Girardi, Cristiana Leite Carvalho, João Batista Girardi Jr. and Jackson Freire Araújo.
• Precarização do trabalho do agente comunitário de saúde: um desafio para a gestão do SUS. Janete Lima de Castro, Rosana Lúcia Alves de Vilar and Vicente de Paula Fernandes.
• Limites críticos das noções de precariedade e desprecarização do trabalho na administração pública. Roberto Passos Nogueira,1 Solange Baraldi and Valdemar de Almeida Rodrigues.
Management
• Assistência domiciliar - instrumento para potencializar processos de trabalho na assistência e na formação. Maria José Bistafa Pereira, Silvana Martins Mishima, Cinira Magali Fortuna, Silvia Matumoto, Rafaela Azenha Teixeira, Clarice Aparecida Ferraz, Janete Rodrigues da Silva Nakao, Marcia Regina Antonietto da Costa Melo and Maria Luiza Anselmi.
• Recursos humanos e gestão do trabalho em saúde: da teoria para a prática. Célia Regina Pierantoni, Thereza Christina Varella and Tania França.
Annex 4: People interviewed
Célia Regina Pierantoni, Coordinator, Observatório (UERJ), Rio de Janeiro
Júlio César França Lima, Director of the Human Resources, Observatório (Poli/FIOCRUZ), Rio de Janeiro
Janete Castro, Coordinator, Observatório (UFRN), Natal
Romulo Maciel, General Director (AM/FIOCRUZ), Recife
Eduardo Freese Carvalho, Director of Public Health Nucleus (AM/FIOCRUZ), Recife
Ricardo Tavares, Coordinator, Observatório (AM/FIOCRUZ), Recife
Roberto Passos Nogueira, Coordinator, Observatório (UnB), Brasilia
Waldemar Rodrigues, staff member, Observatório (UnB), Brasilia
Maria Luisa Jaegger, Secretary of Human Resources Management and Education, Ministry of Health, Brasilia
Maria Helena Machado, Director of Human Resources Planning, Ministry of Health, Brasilia
Pedro Miguel dos Santos Neto, Coordinator, Observatório Unit, Ministry of Health, Brasilia
José Paranaguá Santana, Advisor for Human Resources, PAHO-Brasilia
Paulo Seixas, Observatório Coordinator, State Secretariat of Health, São Paulo
José Roberto Ferreira, International Cooperation, Presidency of Fundacao Oswaldo Cruz (COC/ FIOCRUZ), Rio de Janeiro
Luiz Eduardo Fonseca, International Cooperation, Presidency of Fundacao Oswaldo Cruz (COC/ FIOCRUZ), Rio de Janeiro
Notes
1 Annex 1 presents key statistics on Brazil's demographics and economy.
2 The Learning Network on Capacity Development, a network of policy researchers and practitioners from development agencies, confirmed the importance of this topic at a recent meeting (see www.capacitywhoiswho.net).
3 Annex 2 presents a brief overview of the methodology of this research.
4 This thinking about capacity is discussed in Morgan et al. (2005).
5 We make a semantic distinction between capabilities and capacity, with the latter being a result of a combination of capabilities. This distinction allows a more focused operational discussion of the capacity issue. Because our current interest is in a network of organisations, this paper primarily looks at capabilities, though it refers to individual competencies where appropriate.
6 The World Health Report in 2006 will focus on human resources, arguing that solid knowledge of human resources problems and potentials enables better decision-making in health.
7 Centro Brasileiro de Estudos em Saude Coletiva, http://intranet.ensp.fiocruz.br/cebes/index.cfm
8 Associação Brasileira de Pós-graduação em Saúde Coletiva, http://www.abrasco.org.br
9 http://www.Observatório.nesc.ufrn.br/entrevista_02.htm
10 The working group on human resources in health still exists today. It continues to interact regularly with the Observatório's secretariat.
11 Plan Decenal de Salud para las Americas: informe final de la III Reunión Especial de Ministros de Salud de las Américas (Santiago, Chile, 2-9 October 1972).
12 In Portuguese, Rede Observatório de Recoursos Humanons em Saúde.
13 Portaria No. 26, Secretaria de Politicas de Saude publicada no Diário Oficial, 21 September 1999.
14 Portaria No. 1, Secretaria de Gestão do Trabalho e da Educação na Saúde, 11 March 2004.
15 http://www.opas.org.br/rh/redes.cfm?id_rede=11
16 When the network accommodated this requirement by forming a consortium, it was accused of acting as a cartel to win the bids. This led Observatório members to change their strategy. They subsequently first competed for clusters of projects and then organised the cooperation afterwards, regardless of who won the bid. They also invited institutions from outside the network to participate, depending on the specific needs of the project.
17 http://www.opas.org.br/rh/redes_a.cfm
18 According to Senge (1990), "mental models" are conceptual structures in the mind that drive cognitive processes of understanding. They influence people's actions because they mould people's appreciation of what they see. People can therefore be said to observe selectively. Mental models invisibly define our relationships with each other and with the world in which we find ourselves.
19 As early as the 1970s, PAHO had learned that technical assistance which leaned on strong foreign inputs was unlikely to work in the long term. Similarly, "twinning arrangements" which coupled institutes in North America with those in Brazil showed unsatisfactory results. PAHO then went a different path, favouring horizontal cooperation which stresses collaboration between equals rather than vertical relationships based on top-down advice from "seniors" to "juniors". This went somewhat against common thinking at the WHO at the time, though it was integrated more widely in the WHO over the years (from interview with José Roberto Ferreira).
20 Workshop 55, VI Congresso Nacional da Rede Unida (Belo Horizonte, Brazil, 2-5 July 2005).
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