Introduction

The adverse impact of poverty continues to be a determining factor in maternity and child development; it is a predictor of children’s developmental achievement and can be mitigated with early interventions whose intensity and time of exposure vary according to the degree of vulnerability [1,2]. Chile, has the challenge in terms of child protection of reducing inequality, which implies a commitment and ethical imperative, it is also one of the 17 Sustainable Development Goals to which Chile is adhered, and taking on this challenge requires understanding the causes and consequences of inequality on people’s lives [3]. Social protection must be safeguarded from the early stages of life, since, once these inequalities are established, they materialize and it is very difficult to reverse them [4], In this scenario, the Comprehensive Childhood Protection System Chile Crece Contigo (ChCC) law was created, aimed at all children from gestation to 9 years old, in this context there are some challenges such as strengthening the impact evaluation system of policies and programs that directly and indirectly affect the welfare of children and their families [5].

On the other hand, the implementation processes of public social protection policies require taking into account various factors that may condition their success or failure [6,7] , it should be noted that the management and development of integrating policies face challenges in the organizational capacity of state institutions [8,9], among them, we can point out the economic context, the institutional environment of change, the adequacy of intersectoral policy agendas, the generation of coordination programs, the formulation of intersectoral communication and information channels, and, one of the most relevant factors, the capacity and modality of leadership (flexible and integrative or rigid and hierarchical) used in the process [10,11].

The implementation of the ChCC System involves applying a management model that considers three ministries; Health, Education and Social Development, in terms of the responsibility of the actors, the national level comprising an inter-ministerial technical committee, responsible for planning, implementation and evaluation of work plans, providing technical support [12], at the regional level, made up of inter-ministerial coordinators, responsible for resource management, support and technical assistance at the Health Service level, the latter made up of hospital coordinators (maternity, pediatrics) and primary care, responsible for executing supervision of the applicability of the program’s regulations [12].

It is in this context that the present study has been carried out, which allows to know the perceptions from the perspective of the responsible actors, in relation to the management process in the implementation of the social protection policy for vulnerable children. The objective of this study was to understand the perceptions of governmental, administrative and technical actors at the national, regional and Health Service levels regarding the management process in the implementation of the ChCC system.

Method

Type of study a descriptive interpretative qualitative design was used, which assumes a naturalistic orientation of the research, studying the phenomena in their natural and unaltered state [13], allowing to understand the perceptions of those who experience the study phenomenon, in relation to the management process in the implementation of the policy. Population: the participants corresponded to key informants (voluntary and expert subjects) [14], based on criteria to ensure that those with experience in the study phenomenon, the criteria corresponding to clinical leaders and governmental managers responsible for decision making during the implementation management of the CHCC system at the national, regional and health service level of the Ministries of Social Development, Health and Education, recruited in governmental units and clinics, with a total of 10 participants, according to Table 1. The sampling was purposive of maximum variation to ensure a diverse group in terms of skill level, professional experience and policy implementation [15], determined by discursive saturation of the data [16], participants corresponded to a total of 10. Data collection: The method of approach was through an email invitation, data were collected through individual qualitative interviews lasting 45 to 60 min. in a private and agreed place, data collection was done through individual qualitative semi-structured in-depth interview [17], with open-ended, flexible questions, recorded on an MP4 device. The questions were: How do you perceive the experience, in relation to the management process during the implementation of the ChCC system? What challenges do you perceive during the experience related to the management process in the implementation of the ChCC system? And what benefits do you perceive in relation to the ChCC system? Nominal code (E) was used for the identification of the speeches, all participants voluntarily signed informed consent, and it was carried out in Santiago, Chile, between November 2014 and March 2015.

Data analysis

Consisted of a thematic analysis [18], which identifies a theme, captures something important about the data in relation to the research question, and represents a meaning in the whole. To become familiar with the discourses the transcripts were reread several times and notes were selected before coding by combining codes related in a meaningful way to create categories.

Consisted of a thematic analysis [18], which identifies a theme, captures something important about the data in relation to the research question, and represents a meaning in the whole. To become familiar with the discourses the transcripts were reread several times and notes were selected before coding by combining codes related in a meaningful way to create categories.

Results

The findings in the speeches studied revealed the category Capacities and leadership in management, highlighting the fundamental role played by the actors responsible for decision making during the implementation of the CHCC system at the different levels of action; they acted responsibly and used negotiation, communication and organization skills, mainly in the initial requirement. The need arises to apply competencies related to leadership capacity and modality (flexible and integrating, rigid and hierarchical) mainly in the process of redistributing human and economic resources, in articulating communication and information channels, in generating programs for coordinating integrated agendas and inter-sectoral institutional exchange instances, and in team building.

I believe that the social protection system Chile Crece should be above the political administration on duty, it should be a State policy, because now it has to be adjusted to each government and that delays progress and harms children (E2).

At the beginning, in the health area a lot of work was done, everyone assumed their role, but we have to continue to maintain it over time, it is a law and we have to comply with it, we had to resort to all management resources, because people are used to their routine, besides, there is always a lack of resources (E3).

It was a tremendously demanding job, especially in the implementation stage, which implied modifying work schemes, yields, concentrations, a whole change had to be made, but on the other hand, we know that changes in health require time and resources (E1).

Likewise, it was observed that the national level is the one that provides the guidelines decreed by law that must be complied with at all levels of action, in this sense the speeches revealed that they are satisfied with the implementation process, but they also recognize weaknesses identified, mainly in the installation of the integrated network work model.

My feeling is that it has been and will be a real contribution to the development of vulnerable children; we will see the impact in the future. It is already installed, we accomplished the commitment, it is a developed country policy, I hope the population appreciates it (E7).

At the beginning we called all the actors at regional levels, professionals of this unit and mayors, ministerial secretaries of health, education, social development, the whole network, but over time we recognize that there is some lack of coordination, I do not know why it is so difficult to work with the health area (E1).

Our weakness is the lack of integrated work, since some health areas work isolated and it is difficult for them to integrate into the network, they are very structured (E2).

With respect to the category Critical knots in the implementation of the management model, the analysis shows that the interviewees faced decisions and challenges of building a unified network, aligning teams in order to internalize the essence of the ChCC system, which is integrated networking. In the speech, mainly from the regional level, there are difficulties in the implementation of actions for coordination, communication and articulation with intersectoral and assistance networks, in addition, the speeches point out that there is a management culture with routine rules established by each institution, and they are aware of the existence of possible resistance to the innovation promoted by the new management model. In addition, the interviewees feel that the main interest of the ministerial authorities is to accomplish the implementation and report the required progress.

So each of the health services has a person in charge of ensuring that the actions are executed, my vision is that there is a clear organizational structure, they just have to apply it to their daily routine, but sometimes there are people who resist change, we are clear that in health, changes are long term (E4).

At the beginning we worked very closely with those in charge, but as time went by we were left alone, there was a lot of rotation of new people with no experience, but we still accomplished everything with a lot of sacrifice of time and lack of resources, there was a lot of lack of coordination and poor communication between the levels of action, and the computer system failed (E8).

We have found that in the management of the levels there is a great deficit in the integration of the network, in education, health and municipality, each one works on its own, isolated, we have not been able to improve this area which is very important for the operation of the Chile Crece system (E9).

I think that intersectoriality and networking is scattered, it does not work between hospitals with primary care etc. (E10).

Some did not like the change, they feel that there is more work, they are used to doing the same thing for years...the routine (E9).

There is also recognition of another critical node, described in the subcategory Invisibility of contractual conditions, revealed in the discourse of the Health Service level, which recognizes that the continuity of the system is related to the commitment, experience and permanence of the trained human capital. However, there are feelings of frustration, abandonment and hopelessness because they do not feel listened to or considered in decision making, especially due to the contractual conditions of personnel without the right to social security benefits, a situation that leads to high personnel turnover and overload in the teams due to the permanent training of new people, which may also affect continuity of care and intersectoral work, the actor consider that the contractual factor is a priority that must be evaluated by the authorities.

The system has not ensured the positions, it only ensures resources to pay fees, we have had a high turnover of people, they feel that the contracts are precarious, so there is a risk in the effectiveness of the actions, they are upset (E6).

I hope this will improve mainly in the contracts, the staff is eager to do things well, but they are looking for better and stable expectations and this has affected the system Chile Crece at least here in the hospital (E9).

As a coordinator, I feel that I am permanently training and coaching people, there is no continuity, it also overloads the teams; they do not even last six months and they leave, because of the contractual conditions, it is exhausting (E9).

Another category unveiled was Vision of the social benefits of the policy, in the speeches.

It was observed the social vulnerability of the people they serve and the value of the social context that surrounds them, feelings related to hope, trust, commitment and clarity about the meaning and relevance of the public policy were revealed. They consider that their continuity is necessary with an integrated management It was observed awareness of the benefits and conviction that it will be a contribution for future generations of vulnerable population.

We are clear that this is a law and it implies that we have to comply with it, I am happy for the poor children, it is a good social policy, we are committed to this, mainly with the poor children, we will see results in the future, but we have to comply with everything (E5).

I see a lot of positive projection and great benefits for poor children, the work of those in charge of management is a tremendous responsibility to generate change in the way we communicate as a network, because we are used to working each one in their own area, but we must recognize that there is a commitment to vulnerable children (E6).

Discussion

In the implementation of the protection system, the actors appealed to their repertory of knowledge and experience for management, facing the complexity of processes involving the implementation of changes and transformations, multiple obstacles and administrative barriers, including adaptability to new scenarios and financial restrictions (10). From the speeches, a certain difficulty arises to face the collective action of the work teams, where it is necessary to use a continuous participative approach in order to prevent situations of resistance and to face the culture of fragmentation in the teams [21], scenarios in agreement with the participants of the study that reveal that the traditional organizational culture of the teams involved is maintained.

On the other hand, the literature emphasizes that interinstitutional and intersectoral collaboration is the best practice to achieve effectiveness and efficiency of health resources, which can reduce fragmentation; however, there is little linkage between the health and social systems responsible for the care of the vulnerable population [22], coinciding with one of the critical knots in the implementation process due to the lack of integrated work described by the participants.

Another fact observed is related to the capacity and modality of leadership in implementation, according to studies on the challenges of human capital during processes of change, it is the effective and efficient leadership in decision making, what impacts in the use of available coordination channels and the multiplicity of roles [21]. In this sense, the managers responsible for the analyzed phenomenon applied their knowledge and professional leadership experiences. The evidence indicates that teams require the development of management and leadership competencies from management to operational actors in order to improve coordination, execution and communication, especially when implementing integrative public policies [23].

The speeches showed that health personnel perceive that authorities do not see their work conditions, which causes a permanent turnover. These data are consistent with evidence that points to the phenomenon of unfavorable working conditions that generate discomfort and many staff changes, so it is essential to seek an improvement in hiring conditions in order to generate quality care and an appropriate human capital management policy, which may be a key factor in the success of change processes [24,25]. The evidence reviewed present arguments on the weaknesses generated by the continuous turnover of personnel, which impacts on the institutional capacity to meet needs; the continuity of intersectoral agreements and effective coordination in interdisciplinary work teams (10), other studies relate the adequate working conditions of public health service personnel to guaranteeing quality in the provision of public health care [26].

From the perspective of the interviewees, commitment and confidence to produce a change were revealed, they understood the meanings of this new order of the social reality of the world of work, a positive vision of the benefits of implementing social protection policies for children was glimpsed, they shared the needs of the new scenario by accepting the integrative policy of equity and participation, author [27], highlights the usefulness of participatory approaches to achieve the union of team members, who interact in processes that lead to a change in health equity policies, this approach has proven successful in addressing longterm changes by achieving the commitment and empowerment of the teams. The participatory approach is recommended in the implementation of integrative programs because it seeks to create sustainable partnerships over time, due to the deep and critical knowledge of social and cultural behaviors [28].

Finally, in the speeches of the interviewees, they revealed their perceptions about the complexities involved in policy management at the responsible levels, in the literature the complexity and challenges in the implementation of integrative policies sustained in the interdisciplinary and intersectoral network is recognized, the actors assume the challenge of convening to develop adequate working environments and holistic understanding and participatory practices are required [29].

Conclusion

This study provides an understanding of the natural and unaltered state of the perception of the actors responsible for the management of the implementation of the public policy of social protection for children, establishing interaction between the different levels of action, it is concluded that it was a complex process of change, where they faced administrative and human capital barriers. There were challenges mainly in the management of integrated work with interdisciplinary and intersectoral networks at different levels of action, despite the fact that the essence of social protection policies is to be participatory and inclusive.

In the area of research and public health, this study provides evidence on the relevance of the management capacity of the actors when implementing social protection policies, mainly in coordination and communication, which are key actions of the network management model, the findings also highlight the importance of knowing the perception of the subjects involved in the management of social protection systems, in order to provide effective results in reducing inequalities for the unprotected.

Acknowledgement

This study was approved by the Scientific Ethics Committee of the Nursing Faculty of the Universidad Andrés Bello, number L1/CECENF/92.

Funding

Vice-rectory for Research and Doctorate UNAB, DI-422-13 / I.

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