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Planning pathways in the transfer of Directly Observed Treatment of Tuberculosis 1

ABSTRACT Objective: to investigate the planning pathways in the transfer of Directly Observed Treatment of tuberculosis. Method: a qualitative study conducted using interviews and a semi-structured guide, administered to five subjects who were among the coordinators and managers of the tuberculosis control programs, and the secretary of health of a municipality in the south of Brazil. Situational Strategic Planning and Discourse Analysis of the French matrix were the theoretical and analytical references used, respectively. Results: three reflexive axes were identified: weaknesses in the process of planning the Directly Observed Treatment transfer, antagonism between planning and daily requirements and formulation of planning and execution. Lack of systematization regarding the planning and execution for transfer the Directly Observed Treatment policy, demonstrates the fragility and incipience of this activity, and the possibility of its non-existence. Conclusion: the urgent need for managers and coordinators to better appropriate the theoretical framework for changing public policies, and the related planning mechanisms, includes a proposal for reorganization and qualification of the diffusion process, both practical-operative and political-organization.

with a deficit by the municipal and state authorities regarding the linkage between demographic context, planning, and financing of programs designed to reduce costs generated by TB (9) .
Thus, the present study began with the following question: how has the planning for transferring the DOT policy been prepared, from the perspective of the TB program coordinators and managers in the different government levels (state and municipal)? The main study objective was to investigate the planning This study intends to be helpful as scientific evidence, as this remains a subject still little known in these domains, but especially for the reorganization of activities and services linked to the diffusion of DOT at different levels of government, as a reflexive and inductive instrument of process qualification, as complex as complementary, such as the planning and transfer of public policies.

Methods
This was qualitative research, which used the Consolidated Criteria for Reporting Qualitative Research (10) , a checklist for the qualified description of the elements and steps taken in research of this nature.
The principal author conducted the interviews. An initial appointment with the subjects of the research was held by telephone and e-mail, during which information on the process, the day and dates for the development of this activity was provided. The research objectives and interest on the topic were explained during the initial contact for the interview.
In the present study, discourse analysis was adopted as the theoretical-methodological reference for recognizing the produced senses. French discourse analysis works with the constitutive crossing of three domains, namely: linguistics -does not focus on the language as an abstract system, but as a manner of signifying meaning; Marxism, with historical and dialectical materialism -the subject affected by history and by ideology; and, psychoanalysis -which deals with the subject of the unconscious (11) .
The participants were intentionally selected, and included coordinators, managers of the TB control programs and the municipal health secretary of Porto Alegre, totaling five subjects. In addition to telephone contact and e-mail, they were addressed personally (face to face) at the time of the interview. All individuals agreed to participate in the study.
The interviews were held in the participants' respective places of work and, although some of these Data were analyzed following the three steps of DA.
The first, from the linguistic surface to the discursive object, consisted of repeated readings of the transcribed interviews, analyzing the discourse, and trying to identify indicators for interpretation, and denaturalizing the word of things (11) .
The second step, from the discursive object to the discursive process, consisted of identifying discursive sequences (DSs) and relating them to the different discursive formations that delineate the circulating senses in the fragments under analysis. Finally, the third step, the discursive process itself (ideological formation), consisted of the interpretation of discursive sequences, considering the existing conditions of production and the discursive formations in which the statements were anchored (11) as well as the mobilization of the subjects, including the French DA and the subject under study (transfer of public policy and planning), to support the interpretative arguments.
Among the five subjects interviewed, three DSs were selected for analysis because they were ideologically representative of the subject-positions assumed by the interviewees. It should be noted that, in DA, vertical exhaustiveness is the most relevant, in-depth exploration of the empirical object, to the detriment of horizontal saturation, which evidences completeness through its extension (11) . Consequently, the corpus of the research is not necessarily related to the number of selected DSs, and can consist of a single DS, as long as the established objective is met.
Thus, three main reflexive axes derived from the data analysis were found, namely: weaknesses in the process of planning the DOT transfer, the antagonism between planning and daily requirements, and formulation of planning and execution.
The research project was submitted to and approved by three research ethics committees, and included only subjects who agreed to participate by signing the Terms of Free and Informed Consent form, having at least six months of experience with DOT. Those on vacation or health leaves during the data collection period were excluded.
The limitations of the present study are those related to elements present in the work environment, identified during the interviews (interruptions by colleagues, telephone, overwork, pressed for time to accomplish tasks, as well as the spatial arrangement of tables and seats, typical of shared spaces), which might generate some type of inhibition and influence the participants' responses.

Results and Discussion
In the reflective axis, weaknesses in the process course of TB control strategy, in which a supervised treatment is one of the components, has also been significantly influenced by scientific, technical data, as well as transnational financial resources (12) .
However, although there are indications of a starting point (problem) and of the agents involved in the process, as will be discussed later, lack of clarity and details regarding the planning step of the DOT The feasibility of training, as a possible element for the transferal process, seems directly correlated to the existence of resources, which is aggravated by the fact that TB still appears as a neglected disease, without the structural and organizational quality necessary for control and treatment in many health services (14) . In fact, the development of human resources for TB control was so important that it was considered as an element of a strategic plan, in 2006-2010, for Africa, America, Southeast Asia and Western Pacific regions (15) .

The results of a study conducted in Divinópolis,
Minas Gerais, demonstrated that the local TB control program had as difficulties: a fragile planning process, lack of a standard model for the diffusion of information and data, lack of a training program and trained professionals, who in turn, demonstrated lack of knowledge in diverse areas such as surveillance, TB diagnosis, and accomplishing the DOT (16) . In Cabedelo, Paraíba, other factors emerged as barriers in the management and performance of primary care services in relation to TB treatment, such as: the fragmentation of professional practice, lack of systematization in home care, and focus of the professional qualification (17) .
Hesitations represented by the murmurs, hum and well, cannot specify what actually motivated the subject.
The problems and objectives no longer have fixed seats and the substantive opportunity becomes polysemic: to obtain financial resources, to promote the qualification of professionals, and to improve patient compliance and DOT implementation. Nothing, or very little about the plan for policy transfer, was observed.
Thus, the marked lack of systematization of planning on execution of the DOT transferal demonstrates not only the fragility of this activity, but also the possibility of its non-existence. Commonly, planned actions are not always performed, and routinely demand as "putting out fires", that not only distort and make the practice of planning unfeasible, but, above all, reinforce a less thoughtful and well-founded management practice (18) .
The importance of planning for TB control is scientifically proven. The National Tuberculosis Control Program in Brazil, seeks to improve the qualification of processes such as planning, monitoring, evaluation of control actions, prevention, care, diagnosis, epidemiological surveillance, etc. (16) A study conducted in the Tak province, Thailand, demonstrated that planning, was one of the main elements for disease control in that setting, along with effective sharing of data and information, and improvement in the diagnosis process and care, among others things (19) . system still overlaps the managers' rating scale. They, in turn, need to plan actions that consider the real needs of the population, with proposals for change that consolidate the various health services offered (20) .
The tension of this sentence extends to the practical operational field of planning, in which unfortunately incorporates the limitation of the activity itself and, perhaps, even the passivity of the subject for reverting the situation. We know the importance of a periodic evaluation of a plan, which is a unique opportunity to qualify the process, to guide the decision-making, and to adapt the resources to achieve the goals. As observed, there is still a long distance between wanting (we would like) and doing it (unfortunately).
In this DS, we again noticed that the planning that instruments. The fact is that it is not enough to have theoretically perfect public policies, which become ineffective due to the lack of qualification of the diffusion process, practical-operative and political-organizational.
As it is still a serious public health problem, an even more cautious look at the process of transferring policies aimed at controlling TB is required, and the planning of this stage is a operational foundation. Such an understanding is inclusive and should be broadened to other sectors and health policies at the diverse government levels, which qualifies the present experience as the first one of many others that may follow.