Discricionariedade e atuação dos Burocratas de Nível de Rua nos serviços de saúde municipais

Abstract

In the scenery of bureaucratic systems, there are public policies and their different actors involved in the various phases of the process of elaboration, implementation, and evaluation. In the implementation phase we find street level bureaucrats, civil servants who are in direct contact with the user providing services and benefits. These professionals make decisions exercising their discretion. The way in which decision-making takes place influences the implementation process and, consequently, the citizen's life. In this dissertation, we aim to learn how the street-level bureaucrat, active in the PPI-SUS Integrated and Covenanted Programming, in the Department of Health in Nepomuceno-MG, exercises his discretion and also analyze the importance of the street-level bureaucrat's role in the implementation of public policies. For this analysis, we chose the expanded analysis model that proposes the correspondence of structural, individual and relational dimensions. The obedience to formal rules, the defined position in the organizational hierarchy, encompass convictions, institutional perspectives, styles, routines, customs, and conduct directives that are materialized and socially consented. When performing the tasks, the bureaucrat carries beliefs and styles of action to the individual level that, even in the observance of rules, are intertwined with individual structure and perspective. The institution, in order to exercise control over individual attitudes and guarantee institutional preferences, elaborates both incentives and punishments. Bureaucrats operate in an environment where external aspects derived from rewards and/or sanctions are not exclusive to decision-making, with singular aspects such as pleasure in the exercise of functions, autonomy, reputation, cooperation, which instigate the balance between rationality and intangibles dimensions entangled in the larger and more chained system of relationships. Mutual communication, exchange of information, actions in agreement to public bodies, building partnerships with local entities, and movements, comprise a set of relational factors present in the act of decision. The interrelationship of the three dimensions enables a new look at the implementation of public policies, extrapolating the rigid boundaries arising from these dimensions. Interviews were carried out with street level bureaucrats, working at the PPI-SUS at the Health Department of Nepomuceno and the respective content analysis. As a result, street-level bureaucrats know the conditions and regulations for decision-making, exercising, however, limited discretion, especially due to the insufficiency of vacancies, close ties in the internal environment, affective bonds with employees from other units and service providers, the user's interference in the indication of medical emergency and the inadequacy of the physical structure that does not take into account the necessary privacy of both the employee and the user. The action limitation is also related to the auditor physician and the unit manager. At the end, we make recommendations to assist and improve the performance of street level bureaucrats and contribute to the efficiency and effectiveness of public management.