Over the last decade state and municipal government have made substantial investments in the development and improvement of the Emergency Care Network in the city of Rio de Janeiro, with a strong emphasis on boosting regulatory mechanisms besides the expansion of Emergency Care Units4. The creation and reorganization of the Centrais de Regulação on municipal and state level, empowered with authority to decide over the allocation of resources was a central managerial decision. The number of managers and health professionals overseeing regulatory processes increased. Information technology was intensively used in order to facilitate and broaden the regulation of access to health care resources, like hospital beds and consultation with specialists. A transition from regulation based on personal relationships or contacts to a more institutionalized regulatory practice was firmly pursued, expecting to challenge the power hospitals have over their beds. Much effort was employed to eliminate redundant and parallel procedures, to centralize work and information flows, to curtail personal interferences, to enhance expertise and to advance a paradigm shift towards cooperation and integration.
From the interviews and datasets analyzed the hospital sector and the local health system segmentation stood out as major issues that undermine the effectiveness of regulatory mechanisms and forestall the development of integrated health care services.
Access to hospital beds emerged as a central issue for the adequate performance of the Emergency Care Network. In all interviews conducted this problem was highlighted as a major obstacle. Among the many problems elicited, an undersized hospital capacity, with an insufficient number of hospital beds, was the most pressing issue. However, undefinition or restrictions of the type of care provided by hospitals, low hospital performance and management problems, especially concerning human resources and infrastructure, were also pointed out as relevant aspects.
The biggest problem was the insufficient number of hospital beds, especially to fulfill the demand from the emergency departments. In the twelve-month period examined in this research, 24,564 requests were placed for hospital beds in Internal Medicine wards via SISREG. This number encompasses requests placed by municipal, state and federal health care facilities in the city of Rio de Janeiro. During the same period the CRMRJ was able to obtain a bed to only 3,239 of the requests placed for Internal Medicine wards, resulting in 86.8% of unanswered requests. For Intensive Care Unit beds the situation was even more dire, 8,310 requests were placed in SISREG, but only 936 requests obtained a bed via CRMRJ, leaving 88.7% of the requests unmet.
A national research that assessed the implementation of the UPA, indicated that access to hospital beds was the major constraint to these units’ performance. Difficulties to get patients admitted to hospitals were persistent and led to distortions of the work performed and of the care provided by these units17.
The network of public hospitals located in the city of Rio de Janeiro holds 1,305 hospital beds in Internal Medicine wards, considering only the General Hospitals administrated by the three governmental levels, including Teaching Hospitals. Of these, 726, 243 and 190 are under municipal, federal and state administration respectively. In Teaching Hospitals there are 146 additional beds labelled “Internal Medicine”. Another 685 hospital beds are intended for curative care for specific medical specialties, like: Dermatology, Gastroenterology, Hematology, Nephrology, Neurology, Oncology, Pneumology, Tuberculosis, Burns Units and Mental Health. Psychiatric beds and beds from Specialized Care Institutes and Hospitals were not included. Hospital beds in Surgery wards amounted to 2,214, further subdivided among surgical specialties (table 1).
In the city of Rio de Janeiro there is only 0.2 public Internal Medicine ward beds available per 1,000 inhabitants, according to data from table 1 and from the 2010 Census, which estimated a population size of 6,320,000 million for the city of Rio de Janeiro. It is important to highlight that this estimate does not consider the part of the population that uses private health care plans and insurances, which tend to use private hospital beds. This might overestimate the size of the population that actually demand public hospital beds. However, in emergency care situations, even these citizens with access to private medical care may come to use these beds. Conversely, Federal Hospitals and Teaching Hospital beds are expected to be available to citizens from others cities within the State of Rio de Janeiro, which could further decrease this estimate. Specialized Care Institutes and Hospitals were not considered, because access to its beds is being regulated through ambulatory care, by means of outpatient waiting lists.
On national level the scenario is equally one of scarcity. In 2014, there were 2.19 hospital beds per 1,000 inhabitants including all hospital beds from public and private hospitals. When considering only public hospital beds this number falls to 1.56 hospital beds per 1,000 inhabitants. Both numbers are way below the average of 3.5-4.0 hospital beds per 1,000 inhabitants found among OCDE countries35. When examining only the hospital beds properly served with an adequate number of health care professionals and compatible medical technology and physical resources, which grossly correlates to hospital size, the hospital bed gap grows deeper, falling from 1.56 to 0.7 hospital beds per 1,000 inhabitants in SUS35.
Intensive care unit beds depict an even more critical situation in the municipality of Rio de Janeiro, with 0.07 public ICU beds per 1,000 inhabitants. In 2014, there were 12,680 Adult ICU beds available to SUS, among public, philanthropic and private providers35. Considering that, in 2014, the Brazilian population was of 202,768,562 million inhabitants36, on national level there was as little as 0.06 public Adult ICU beds per 1,000 inhabitants. Internationally, around 0.20 to 0.25 intensive care beds per 1,000 inhabitants is considered acceptable37. In Europe, in 2011, there was on average 0.11 ICU beds per 1000 inhabitants38.
In a research that sought to define the number of public Adult ICU beds required to meet the existing demand, an analysis restricted to the ICU beds regulated by CER-RJ identified that, to guarantee a stable system and a maximum waiting time of 6 hours to reach an ICU bed, the existing number of ICU beds should be doubled, if maintained the average length of stay in intensive care units39.
A specific example of this scenario of insufficiency is the acute myocardium infarction (AMI) care pathway. In several situations it is necessary to perform primary or rescue coronary angiography. Interviews reported that access to this intervention is restricted to specific cases and frequently take various days to occur. Specialized Care Institutes and Hospitals in which this intervention can occur, perform the procedure, but do not admit these patients to a hospital bed for immediate follow-up. Therefore, patients that succeed in undergoing coronary angiography have to return to the UPA or CER, and are later discharged from these same pre-hospital units. If in the one hand this arrangement has somewhat increased access coronary angiography, which has an important impact in decreasing AMI morbimortality, on the other hand there are problems in providing post-procedure care in pre-hospital setting, that is in UPA and CER, for these units are neither trained or fit to do so, since they lack the resources and knowledge do deal with potential complications.
A research conducted in the city of São Paulo demonstrated that the organization of a specific pathway to provide health services for AMI patients had a significant impact on disease morbimortality40. Thus, the arrangements established fore AMI care in the city of Rio de Janeiro as outlined above are unsuitable for the serious public health care issue that this disease represents. Even if the provision of coronary angiography in a pre-hospital setting is acknowledged as an increase in access to health care, its availability is unpredictable and its performance conditions are far from adequate. Proper management of AMI cases, because of its high prevalence and high morbidity and mortality, requires integration between different levels of the health care system. The absence of such integration considerably contributes to increase morbidity and mortality40.
The health facilities that more frequently granted CRMRJ access to their hospital beds during the period of this research are listed in table 2. Pediatric, psychiatric and OB-GYN beds were not included. The top five hospitals that made their hospital beds available to CRMRJ accounted for 75,5% of all the requests that were met. It is noteworthy that these hospitals did not have emergency departments. Municipal hospitals with emergency departments made hospital beds available in varying degrees, from 2 beds yielded by MH13 to 225 beds yielded by MH6. Federal administration made available only 53 beds to CRMRJ in 1 year. Among the Teaching Hospitals, only TH3 made 12 beds available. It is noteworthy that a pre-hospital unit, has ICU beds registered in the National Registry, that were made available to CRMRJ.
Brazil has an obsolete hospital system, in which predominate general purpose hospitals, of small and medium size, that provides acute, elective and long-term care, indistinctly. Patients with different health needs are all counting on an indisputably small hospital capacity of 1.56 beds per 1,000 inhabitants offered by SUS35.
Among the hospitals in the municipality of Rio de Janeiro, there is a similar situation. Frequently the same hospital offers emergency care, elective surgical procedures and ambulatory care simultaneously. These hospitals constantly face the challenge to reconcile the tasks of an acute care hospital with the modus operandi and structure of a specialized hospital. In this situation, the same hospital bed is requested by an overcrowded emergency department and also by the long waiting list to elective admission, mostly to perform surgical procedures.
In 2012, the city administration created the CER in order to address overcrowding in the emergency departments of municipal hospitals. These units became responsible for all medical emergencies while the emergency departments of their neighbor acute hospitals focused on accident and trauma emergencies. These units were constructed in separate buildings and had their own health care staff, which represented an expansion of human and physical resources for emergency care.
A selection of 10 diagnostic and therapeutic resources available in public hospitals in the city of Rio de Janeiro is displayed in table 3. The number of Internal Medicine ward, Surgery ward and ICU beds and the existence of emergency departments is also presented for each hospital. Since all facilities possessed electrocardiogram devices and X-Ray equipment to perform simple radiographs these were not included. This table shows that a higher availability of medical technology is found precisely in hospitals that have a larger bed capacity and also emergency departments.
Comparing data from the tables 2 and 3 it is striking that, among the five hospitals that more frequently made beds available to CRMRJ, only 2 have a high availability of medical technology: MH5 and MH15. Both count on a reasonable array of medical technology, but neither have a CT Scan in their premises. The remaining 3 hospitals of the top 5 rely on very little medical technology. MH3 and MH10 offer only Doppler Ultrasound aside from X-Ray and EKG equipment. A similar circumstance is found in other hospitals: under state administration, SH1 and SH3 count on the same type of devices as MH3 and MH10. At municipal level, MH14 adds an Echocardiogram device to the previous set of equipment. In this scenario of low medical technology availability, these hospitals have a limited capacity to provide curative care, thus narrowing the range of health problems and disease severity they can care for.
Most municipal hospitals count on a good array of medical technology including CT scans, but many of them preferably admit to their beds patients waiting in their own emergency departments. The same happens with the two state hospitals that have emergency departments, SH2 and SH4.
While the hospital beds needed are expected to provide care to a large variety of health issues and problems, it is not unusual to find hospital beds whose availability is restricted to certain types of diseases. In some cases, this results from the restricted availability of medical technology as referred to before, but in other cases, especially in Teaching and Federal hospital, chief of services, without acknowledging the population health needs, decide alone the scope of care their service is providing.
In addition to the difficulties outlined thus far, a few hospitals exhibit a mismatch between their prevailing type of hospital beds, mostly surgical beds, and their predominant workload, mostly clinical emergencies, which often results in emergency department overcrowding.
A study on the definition of the functional typology of Federal Hospitals in the city of Rio de Janeiro observed that this process is barely rational and systemic and that change is largely driven by the urge to solve problems instead of deriving from planned action to render the hospital more efficient and integrated to the network of health care services. Each hospital incorporates technology and seeks to answer to health needs independently, ascribing their behavior to an allegedly disorganization of the local health system that hampers the possibility of mutual adjustment in order to reach integrated care. The discourses of resistance to change perceived in these hospitals demonstrate that the power dimension within these organizations needs to be considered in order to shape strategies to revise the functional typology of these hospitals41.
Another study also corroborates the existence of difficulties for the integration of hospitals in the RUE, evidencing that this process requires the definition of pacts and care flows, adequate functioning of other health services in the network, especially Primary Care Services, efficient regulation of access to services, and engagement of hospital managers and professionals42.
Regarding hospitals’ performance, a heterogeneous dynamic has been observed with significant variations in the average length of stay and hospital bed occupancy rate. Table 4 presents the total number of hospital beds and hospital admissions, the total number of Internal Medicine beds and hospital admissions due to clinical diagnosis. The table also shows the average length of stay and the hospital bed occupancy rate.
International standards recommend a hospital bed occupancy rate between 75 and 85% 35,37,43. In table 4 it is noteworthy that few hospitals meet this pattern. Most of the hospitals that have emergency departments operate with occupancy rates way above: MH2 92%, MH8 173%, MH9 112%, MH11 127%, MH13 169%, MH16 103%, MH17 106%, FH2 93% and FH5 86%. Occupancy rates higher than 85% increase risk to patients and in acute care hospitals rates higher than 90% denote a bed shortage crisis35. Conversely, most hospitals that do not have emergency departments exhibit occupancy rates below 75%, which suggests underuse of beds and resources. Teaching hospitals and Federal hospitals without emergency departments display predominantly this pattern.
The average length of stay is long for most hospitals, a previously known problem. Considering all the hospitals listed in the table 4, the average length of stay is of 8 days, consistent with the OECD average in 201544. However, when examining hospital admission due to clinical diagnosis separately the average LOS increases by 4 days, reaching 12.6 days. Calculating the average length of stay of hospitalizations due to clinical diagnosis for each administrative level, the results are the following: 9.5 days for municipal hospitals, 7.75 days for municipal hospitals, 15.4 days for federal hospitals, and 12.5 days for teaching hospitals. Considering only the hospitals that have emergency services (7 municipal, 2 state and 3 federal) this average drops to 10.5 days.
The hospital sector performance was considered problematic and represented an additional element to accentuate the shortage of beds according to some UPA coordinators who also worked or had worked in the hospital sector. Long average lengths of stay are explained by several limitations of hospital operation.
Among them we have: reduced operation at night and on weekends, primarily due to reduced availability of consulting physicians and diagnostic services. The availability of diagnostic services may actually be a critical issue for hospital efficiency. A study that sought to analyze the reasons for delayed hospital discharge of patients in internal medicine wards of teaching hospitals identified as one of the main reasons for this problem the long delays to perform diagnostic tests or to release tests reports45. Other factors related to delayed hospital discharged included: a more time-consuming decision-making process due to longer discussion over clinical case in teaching hospitals as well as difficulties in obtaining specialists opinion on cases45. However, the most common scenario is the absence of a daily ward routine performed by a single consultant. Instead, the care plan is devised each day by physicians and health teams working shifts, who may be unexperienced or unqualified, resulting in longer lengths of stay, misdiagnosis and ineffective treatment.
Besides all the hardships previously outlined, existing hospital beds can become unfit for admission due to physicians and nurse shortages or else due to neglected maintenance: infrastructure in need of repair and damaged equipment.
Within the municipal administration, it is already acknowledged that, in a scenario of chronic scarcity and prolonged financial constraints, the improvement of working processes is fundamental to increase access to existing resources. In this sense, the reduction of the average length of stay is one of the goals to be implemented, through optimization of health care provision.
The emergence of NIR promoted the expansion of the regulatory culture that succeed, little by little, in confronting hospitals' self-centered behavior in relation to becoming part of the health care network. It also contributed in making hospitals recognize their performance and efficiency problems. The progressive organization of the network and the growth of the regulatory culture forced hospitals and their teams to start perceiving themselves as a part of the system, having to share responsibilities.
The idea that chiefs of services have unquestionable control over admission to the wards under their responsibility is still appreciated by many, which lead hospitals to neglect their expected and potential role in an integrated health services network when organizing its operation.
Despite have being drafted in norms form many years now, only recently NIRs have been enacted in the city of Rio de Janeiro. Thus, these committees still have little power to oversee access to hospitals’ resources. Support from the board of directors is critical for the NIR to perform its tasks. The extent to which they succeed in attending requests placed by CRMRJ, for hospital beds and diagnostic tests, depends on how hospitals perceive themselves within the network and how high-level managers from Health Department understand the importance of regulatory mechanism and the role of the hospital for accomplishing the goal of an integrated health system. Often even with the support of the board of directors, NIRs persist requiring authorization from chiefs of services to grant CRMRJ access to hospital beds.
In the process of building and structuring SUS, hospital sector was continually neglected. The elevated investment costs required to improve hospital sector, coupled with the process of expansion of outpatient care, underpinned by an overcritical discourse to the hospital-centered model, culminated in a problematic scenario in which the Brazilian hospital sector is predominantly small in size and inefficient in the provision of care37.
National studies on the implementation of prehospital care in Brazil that analyzed the SAMU and the UPA pointed out serious issues concerning lack of support from hospitals and emergency departments, in terms of access to diagnostic tests and hospital admission, that significantly impacted the mission and performance of these facilities to deliver prehospital emergency care17,18.
In the case of Rio de Janeiro, as mentioned, there is an obsolete and fragmented hospital network, with serious management problems within its hospitals. In spite of the managerial technologies incorporated, especially with regard to regulation of access to care, the hospital network remained largely unchanged before the expansion of access to health care was made possible by improvements in the structuring of the RUE. MH6 was inaugurated in March 2013, at the time with 120 beds, and can be cited as one of the few changes undergone by the hospital sector in the city of Rio de Janeiro. Another was the ICU bed expansion that ensued, with 33 new beds with the creation of a specific CER in the South Zone of the city in August 2012 and 38 new beds at MH2 in August 2015, from 30 to 68. Despite these measures, scarcity is still the dominant condition.
Over the last 10 years state health policy has strongly focused on the expansion of the Emergency Care Network, with the creation of numerous UPA. Nonetheless, the creation of Brain Institute, Children's Hospital and Orthopedics Hospital express investments in the provision of inpatient and outpatient Specialized Care. In addition, a foundation to manage human resources for health care was created to overcome legal constraints to employ public servants, which allowed an increase in the number of health professionals, mainly in Specialized State Institutes for Endocrinology and Cardiology.
The public hospital, notably in the example of Rio de Janeiro, continues to be a locus of technological concentration, whose importance has not declined with the incorporation of technological advances in outpatient care, since access to medical technology in an outpatient setting is still very fragile in the municipality. Outpatient access to diagnostic tests, specialists’ referrals and pharmaceuticals is insufficient and incompatible with the trend of progressive reduction of hospital beds observed in Brazil35.
Other factors render the inadequacy of the hospital sector and the gaps in the provision of care in the system as a whole even more acute. Population ageing constitutes a major challenge for health systems, which in Brazil’s case is greatly accentuated by a situation of significant social vulnerability, derived from profound socioeconomic inequalities.
The hospital network of the city of Rio de Janeiro, considered all the 30 hospitals, of table 1, is comprised predominantly of large and medium sized hospitals. There are 14 large-size hospitals (more than 150 beds), of which 6 have emergency departments, and 12 medium-size hospitals (between 50 and 150 beds), 5 with emergency departments. The predominance of large-size hospitals in the network is a positive characteristic, especially when observed that these hospitals cluster most of the medical technology, medical specialists and pharmaceuticals available in SUS. However, this favorable aspect is overshadowed by the significant number of such hospitals that provide emergency care. These hospitals face the challenge of reconciling the demand arising from overcrowded emergency departments and the requests of access to hospital beds and diagnostic tests placed by primary care services, prehospital services and small-size hospitals, via CRMRJ or CER-RJ. This dilemma remains unsolved and hinders the integration of these hospitals with the network health services. One of the managers interviewed in this study calls for an urgent remodeling of the hospital sector in order to better organize care, obtain the best performance from the existing hospitals and accommodating the emerging and growing demand for long-term care.
Hospital sector is complex and expensive. Costs to invest and remodel are high, as well as to maintain and improve. The recent successful development of RUE made explicit the need to expand the size of the hospital sector. However, increase of hospital services capacity could be attained through improvements in hospital performance and operation, which in face of prolonged financial constraints, might be the only path available to strengthen hospital sector within SUS.
Health System Segmentation
In addition to the analysis of the hospital sector presented thus far, the segmentation of the local health care system and the overlapping of services stand out as issues that further aggravates the situation.
In the city of Rio de Janeiro, this overlapping has its origins in the first half of the twentieth century, when the public health system was comprised of the municipal hospitals (Rio de Janeiro was the federal district at the time), open to all citizens, and of the Social Security Institutes for Medical Assistance that provided medical care only to those that were regularly employed. Later theses institutes were incorporated by the federal administration, being run by the federal government since then. Over time state administration also took over some hospitals when the city ceased to be the federal district.
Tense and conflictive federative relations between state and municipal administrations in the city of Rio de Janeiro is an old and well-known problem, mainly derived from both the presence of state and federal health facilities in the municipal territory and from the burden derived from providing emergency care to the population of bordering cities, without the regional political action expected from state administration46. Besides, the municipal administration continuous quest to establish direct relations with federal administration, overlooking state administration role and actions add to forestall the formation of an effective and integrated network of health services. The persistence of unresolved conflicts sustain a distancing of state and municipal administrations, which hinders policy debate and cooperation to develop an integrated health system46.
Despite the transfer of three general hospitals that provided emergency care, located in the West Zone of the city, from state to municipal administration, which resulted in the majority of emergency hospital services being managed by the municipal health department, attenuating services segmentation and enhancing integration, the phenomenon of conflictive and distant relations among the government levels remains largely unchanged. This produces important implications for the operation of the network, with little integration of regulatory mechanisms and significant overlap of health care provision. As a result, health care facilities struggle to deliver reasonable performance and patients are deprived of timely access to health care. Municipal and state health care facilities have little access to beds and resources from each other and federal hospitals still operate mostly independently from the health care network as whole.
The segmentation of the network is elicited in table 5. In the sample of ICU bed requests, from the 50 requests placed by state UPA through CRMRJ that were granted access to a hospital bed, 78% were beds in state hospitals, while only 8% were beds in municipal hospitals. From the 185 requests placed by either a municipal UPA or CER through CRMRJ that were granted access to a hospital bed, 91% were beds in municipal hospitals, while only 1.6% were beds in state hospitals. In the sample of Internal Medicine ward beds requests (table 5), from the 16 requests placed by state UPA that were granted access to a hospital bed, 43% were beds in state hospitals and another 43% were beds in municipal hospitals. From the 345 Internal Medicine ward beds requests placed by municipal UPA or CER that were granted access to a hospital bed, 95% were for municipal units. CRMRJ had no access to beds in state hospitals. It can be noticed that state UPA had access to both state and municipal hospitals, while municipal UPAs had access to only 3 state hospital beds.
The federal hospital system in the city of Rio de Janeiro, which harbors a large amount of the medical technology available in the local health system, does not operates with effective regulation of access to its beds and barely acknowledges its crucial role in the Emergency Care Network. Over the last few years, the federal hospital system has been continuously compelled to become integrated to the health care network. However, the federal administration has largely retained its autonomy in the management of its hospital beds. This autonomy of the federal hospitals in relation to the network is also seen in the interaction among the federal hospitals.
The development of networks requires the recognition of the interdependence of actors and organizations, since none of them has all the resources and skills necessary to solve the health problems of a population in its various life cycles32. This understanding about the development of networks converges with the concept of governance as the decision-making process and the process by which decisions are implemented or not. Conceived in this way, governance analysis should focus both on the actors involved in the decision-making and implementation process, and on the conditions and structures created for the effectuation of the decisions made33. The possibility to solve a coordination problem in face of conflict is contingent by the nature and / or existence of governance structures34. The health care facilities involved in shaping the RUE, UPA and CER more than hospitals, experience very acutely this interdependence on a daily basis and recognize the need for integration in order to offer better and broader access to care for patients. The mechanisms of cooperation and coordination put into practice in this network have aimed at improving the management of resources, so tragically scarce, although mostly within each administrative sphere. No systematic mechanisms for creating and maintaining common governance are being adopted. Actors and organizations persist working separately, far from pursuing coordination of their interdependence for a collective project.
A limitation of this study is that complementary and decisive subjects to the challenging task of developing Integrated Health Services like health care financing, human resources management model and physicians’ central role in the accomplishment of integration were only superficially examined.