The Information on Decision-making in Health: From Predictable to Unpredictable

Introduction

Information is considered a fundamental asset for the planning of management practices and health services (Brazil, 2009). It is the main element for establishing health decision-making based on evidence and knowledge about the health situation of the population, to improve public health and the efficiency of health services. An analysis of the health situation information that supports and guides decision-making is needed, especially by the recognition that access to information is asymmetrical among the various actors between different spheres of government directly or indirectly involved (Moraes et al., 2013).

The decisions made by health organisations are, for the most part, within the traditional hierarchical model of decision, with little participation, as occurs in public health administration. Decision-making is a constant action, implying a systematisation and production of continuous information to feedback decisions. For this reason, it is important to emphasise the articulation between the need for information, search, use and production, key elements of the studies on information users. It is considered, then, that health managers should be users of information before making decisions.

In the field of information science, one of the methodological approaches used among the study models centred on information users is the one proposed by Dervin (1983, 1999), the sense-making approach. The core of this is approach based on the trinomial ‘situation–gap–use’, consistent with the cognitive decision-making model, which considers the information to be a construction of the subject that takes place in an active, dynamic and intuitive way. Dervin proposes that by making use of information, the user can transpose the gaps that appear in his path, reduce uncertainties, inform and educate himself and make progress on the path of action (Ferreira, 1995). The search and use of information result from the perception of a knowledge gap that is translated into the need and demand for information for the development of the activities of the information user.

When applied to our study objectives, it is inferred that, to intervene on a given health problem, it is necessary to fill a gap in the understanding of its breadth and characteristics, which requires using information to support the decision. Therefore, the objective of this study is to identify the information needs, search behaviour and information sources used by health managers involved with the decision-making process in Rio de Janeiro and the Informatics Department of the National Health System.

In this work, the definition of ‘information’ proposed by Souza (2011) is adopted: Information is a set of ‘signs’ that, representing empirical knowledge, constitute practices and representations that take place in the agent who lives and interacts within the society. An affinity is established between information and the practice of social beings characterised by a series of interactions and relationships in order to produce their knowledge. This is established in its organisational context as a mediating and structuring flow. This flow refers to the sequence and succession of dynamically produced events that determine its connection or instability, related to information practices. These, in turn, are the actions in which the informational needs permeate the search and use of information that is understood in a context whose meanings are constructed in social interaction.

If each decision-making implies searching and choosing among so many possible others (Foreit et al., 2006; Santos, 2010; Silva et al., 2004), some questions arise: The choice and decision in health is an effect of a sense constructed from what kind of information? What influences or interferes the decision, the seeking behaviour of information or the value given to information, or both? What is the information flow until the decision?

The value given to information depends on cultural meanings that, at the same time, contribute to its creation. Information users operate throughout informational action, based on relationships, languages, marked by the social that is reciprocally constructed (Berti & Araújo, 2017). It is directly linked to the ability to support managers to achieve their goals in the organisations, helps organisations to develop tasks more efficiently and effectively, equipping managers with fundamentals to decide if it is necessary to invest in information, information systems and additional technology (Stair & Reynolds, 2015).

The type of information required is dependent on the level of decision-making involved and the structure of the situations they face. Decisions made at the operational management level tend to be more structured, those at the tactical level are semi-structured, and, at the strategic management level, more unstructured. Structured decisions involve situations in which procedures can be specified in advance, whereas in unstructured ones, it is difficult to plan decision processes.

Most decisions related to long-term strategies can be considered unstructured. Unstructured decisions are those in which there are no procedures or rules to guide decision-makers to the correct decision. In these types of decisions, many sources of information must be accessed and are generally based on experience. Therefore, information systems must be designed to produce a variety of information and products that meet the new needs of decision-makers across the organisation (O’Brien & Marakas, 2011).

Actors at the strategic management level can seek decision support in systems that provide them with summary reports, forecasts and summarised predictions. On the other hand, actors at the operational management level depend on the management of information systems to provide pre-specified internal reports, emphasising detailed comparisons of current and historical data that structure day-to-day operations (O’Brien & Marakas, 2011).

The objective of this article is to identify the information needs, sources, seeking behaviour and uses of information by health managers involved in decision-making in Rio de Janeiro, Brazil, and in the Department of Informatics of the National Health System (Datasus) of the Brazilian Ministry of Health.

Method

In Brazil, the administrative organisation divides the territory into three main spheres that are autonomous, despite being interconnected, following a hierarchy from the bottom, more local level, like the municipal sphere, passing through the state level up to the federal sphere, at the top of the hierarchy. Each sphere responds to the other but with an autonomous management process.

This work is an exploratory and comparative study, since it compares the municipal and state government spheres of the public health administration of Rio de Janeiro, Brazil, their similarities and divergences in the view of the object of investigation—‘health information for the decision-making process of health managers’. It also includes the federal sphere, which contains the institution that collects and processes information in Brazil—the Department of Informatics of the National Health System (Datasus). It uses a qualitative, analytical and descriptive approach, as it aims to obtain, dimension, outline and critically examine the information provided by the key participants. It contains the interpretation of the chosen research universe, for its understanding and explanation, by the encounter of objectivity with intersubjectivities.

Interviews were conducted with a total of nine key participants working as health managers, four from the municipal government level, three from the state level and two Datasus employees from the federal level. Each participant was assigned a code to maintain their anonymity. Therefore, their statements are coded along with the description of the study results. In addition to the information transcribed from the interviews and analysed using the Atlas.ti software, data were also collected based on the analysis of legislation and management documents, such as laws, ordinances, decrees, strategies or even action plans, all public domain documents. These were considered as a result of the research and addressed throughout the description and analysis of the results. The content of the interviews analysed with Atlas.ti is described in the Results section as an exemplified narrative, selecting a few citations from the participants. The field study focused on the interviews using a semi-structured script with key actors responsible for the management of the information from each sphere of government, as well as health authorities of the highest level in each municipal and state secretariat of health.

All interviews were carried out by accepting and signing an informed consent form after authorisation by the health secretary of each government sphere, as well as the director of Datasus, with the audio recordings authorised by each participant.

Results

The interviews analysis shows that, according to the study participants, health intervention strategies are subsidised by technical, scientific information and the appropriation of experiences from different sources.

Another issue is the flow of information. This flow is understood as the movement of information that occurs from its point of collection until it reaches its destination, which could be individual actors or administrative units (Jamil, 2001). In this traditional mathematical definition of transmission from sender to receiver, Barreto (1998) asserts that there is a concealment of the stages of information processing, storage and retrieval. For the author, electronic communication gave visibility to these concealments and the position of the receiver, increasing the interaction with the information and reducing the time for its reception and access, enabling movements through several different information contents. Thus, the flow becomes successive events that it is mediated between the collection and production of information, subsidising decision-making (Barreto, 1998).

Most participants in this study report that the information flow is bottom-up, from health local units at the municipal to the federal level. It is frequently associated with the flow of documents that feed the health information systems (HIS) and rarely refers to the exchange directed to the production of information according to its use in decision-making. The only mention that connects the information flow with decision-making comes from the interviewee of the highest hierarchy in the municipal entity. He is endowed with high decision-making power and highly technical academic training, with information production activities intended for presentation at periodic meetings held with actors down a level in the hierarchy:

It is necessary to tabulate the information or even define what information will we have [...] but then, these more macro decisions, we define at the undersecretaries’ meetings, decide with the collegiate what information we will generate, bringing this information for a next meeting. In that meeting we define if the information was sufficient or not and if it is possible to set up an implementation plan for that decision. And then we do the planning at the next meeting, which can unfold in other meetings or not. And later, a review meeting, always making a strategic line. So, the whole meeting follows this process here. We build a strategic line for everything.

What were the problems that were stated in the previous meeting, what is the information that we need to solve that problem, be it theoretical or epidemiological or financial... financial is very... very polemic, it constantly appears. It is difficult to make a decision that has no financial impact. This happens all the time, and then there is an unfolding agenda with other meetings for implementation or, sometimes, even to generate information. (AM-4 / 1:1223–1224–1225)

It is important to highlight the previous report considering that one of the specific objectives of this study is to identify the processes and flows to relate the production to the use of information. This means the existence of the practice at the municipal level, although its institutionalisation seems to be limited in the public administration, since there is no mention of this type by the other federal entities. It is assumed, therefore, that the flow of documents, the distribution of death certificates or birth certificates, is an established practice in all federated entities, unlike the use-production information binomial.

The activities involved in producing this information for use in the decision-making process are centred on the choice and tabulation of data from the main HIS in order to organise them for presentation. It is indicated as a systematic collaborative activity, facilitated by the development and use of information systems, and interfaces with the national HIS databases, with data also chosen in a participatory way. This choice involves other actors, leaders who work in the detection of a health problem or in the implementation of health actions in response to it, demonstrating an organised and coordinated flow of information according to clearly defined objectives.

The information flows (see Figure 1) at the municipal level are pre-established and vary according to the condition or priority of the data to be collected. This collection also involves investigations on the behaviour of the event or health problem and cases that need clarification. In general, there are forms standardised by the Brazilian Ministry of Health (MH) and these have been agreed upon between the federated entities. These forms, whether from the Mortality Information System (MIS), the Notifiable Diseases Information System (NDIS) or Birth Information System (BIS), are sent to the state departments and later to the local ones, which, in turn, distribute them to local health units. The differential found is the existence, by the studied municipal entity, of pre-established investigation protocols, classified by type of disease condition, whose discussion occurs periodically.

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Figure 1.

Source: Souza (2018).

There is an intense concern with the collection of information, mainly to feed the HIS fulfilling the deadlines designated by the MH ordinances, since the transfer of resources is conditioned to the regularity of the information flow. Examples are the MIS and NDIS in which the flow is regulated by Ordinance No. 201, of 3 November 2010 (Brazil, 2010), to provide the resources of the Health Surveillance and Promotion Component of the Health Surveillance Department. Thus, producing information systematically is a secondary priority when compared to the collection of data, given the need to maintain the existing resources and workforce through the regular payment granted. In this scenario, it seems to be difficult to organise inputs and human resources to produce information and have a constant and real-time analysis of the health situation.

This flow of information is added to the stages of the informational work process (see Table 1) established routinely through compliance with instructions, ordinances and regulations originated vertically from the federal sphere.

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Table 1.

Stages of the Informational Work Process.

Stages	Federative Entities
	Local Health Unit	Municipal Secretariat of Health	State Secretariat of Health	Ministry of Health
Stage 1	Perform data collection	Aggregates municipal data	Aggregates state data	Aggregates national data
Stage 2	Identifies what is not standardised in data collection	Establish protocols and customise collection	In some cases, they stipulate data to be collected	Determines data to be collected
Stage 3	Review data collection	Analyse and review data	Guides and analyses data collection	Feedback to states and municipalities
Stage 4	–	Feedback to local health unit teams	Feedback to municipalities	Aggregates national information

Source: Souza (2018).

In the stages summarised in Table 1, the state and municipal departments can add or customise their own forms to cover other variables that are relevant locally, if they collect all the data contained in the national form. Data collection is carried out by professionals from health units who are more sensitive to detecting situations beyond what is included in the forms, as well as having the power to decide to refer cases within the Health Care Network. Data collected by the health units are sent to the Municipal Department of Health, whose main function is to analyse and review the data and, if necessary, return those that are incomplete. It is also the Department of Health’s responsibility to evaluate the municipality’s health situation using the dataset to take measures applicable in each scenario.

The municipalities send their data to the State Department of Health, which scans the variables within the databases to identify possible informational errors and, when necessary, returns them to the municipalities to make the necessary adjustments. The state has an important role in facilitating the transfer and communication of cases attended by a municipality other than that of residence, using the referral and counter-referral mechanism. With the dataset, the state secretary of health identifies regions with possible outbreaks, as well as regions with better health conditions, which can help guide and support the municipalities.

After review by the state, the data are sent to the MH and become part of the national database, from where the national health situation is studied and stratified by region, pointing the priorities and main health problems. There are systems in which the submission is direct, and the reviews are carried out subsequently by each federated entity.

The data are collected through identified sources of information, which can be divided into six types:

Information from HIS: it is administrative or directed to a specific condition, which may be national or local. The most cited are the nationally based HIS, the MIS, the BIS, the NDIS and the Central Regulation System (RCS);

Regarding the demands for information by health managers, these can be of a predictable or unpredictable nature. The demand of a predictable nature is that which comes from flows forecast in the public administration, that is, information necessary to compose planning, execution and audit instruments. The government’s management and planning instruments used in all spheres of government are health plans made at the beginning of each government term where the objectives and goals of that government for the next four years are outlined. For its elaboration, it is necessary to know the health situation in order to guide the priorities. In addition, information in the form of indicators and indices capable of measuring planned actions is needed.

To achieve the objectives and goals set out in the health plans, management instruments are elaborated annually: the Budget Guidelines Law (BGL) and the Annual Budget Law (ABL), both as instruments that regulate the allocation of resources for the execution of health actions. To assess the use of the resources provided for in the BGL and ABL, the Annual Management Reports are prepared, which is another crucial moment to look at the health indicators and contracted, targets and evaluate the management performance. Although this annual evaluation is foreseen, it is important to monitor these indicators throughout the year, in order to make possible adjustments to the actions and even data processing.

For the interviewees, search for information is referred to as accessing national databases, whose strict approximation occurs with the classification of Wilson (1999) on seeking behaviour in information systems. However, there were no significant differences in the behaviour of the interviewees, who are the users of information, between an information-seeking behaviour and an information system-seeking behaviour. It is also relevant to clarify that this was not an in-depth topic in the interviews.

The information-seeking behaviour of the study participants at the municipal and state levels is centred on the collection of epidemiological information for decision-making in the main national HIS (DIS, BIS and NDIS). Then, this decision needs to be made, and the data are tabulated and transformed into information. Three types of situations occur: (i) data to be tabulated, (ii) information produced is reviewed and (iii) information is produced not only from data tabulation but also with in-depth investigation of the topic, including the search of scientific information.

When the information professional refers to tabulating some information demanded by managers, it is understood, for this study, as the action of producing information. In this scenario, the actor will operate in a logic of building new information, by understanding the identified problem and analysing the context of the situation.

This is reflected in the speech of the study participant at the municipal sphere, when he mentions that he also uses databases from previous years to contextualise and enrich the information produced. Even if the information already exists through regular production, it is reviewed before dissemination.

For the state level, the search, use and production of information are concurrent processes. An example given by the state information professional that involves the three processes in practice is set out below.

...some occasional demand, depends, for example: circumscribing by age group, reviewing the existing information concerning pregnancy in adolescence. So, we do the research to identify which age groups we want to target, to understand adolescence.... (AE-1/1:1079)

In the state case, the beginning of the information search process is usually thematic. In the previous example, the manager’s knowledge gap is to understand the health situation of adolescents. There is a search in the main national databases about existing information; this information is updated and used to produce specific information capable of bridging the gap raised.

Several actors at the municipal or state level are endowed with autonomous and proactive behaviours in the search for information, whether the health authority of the highest health hierarchy or state information professional. The latter aims to search for epidemiological information already produced weekly by the Municipal Secretary of Health.

Framed within the demands of predictable information, there are also those arising from audits and inspections carried out by the control bodies, which are the Courts of Accounts and the Public Ministry. The judicial and police sectors are also cited as one of the most frequent information seekers. In this case, the demands may not have a clear periodicity, but there is an agreed protocol and response so that they happen within the predicted situations, so much so that in the Informatics Department of the National Health System there was a ‘special investigations’ task group.

The decisions, mainly from a financial nature, we take the numbers we have in the contracts, with the numbers of the state court of auditors, crossing the information so that we have a financial situation within the real and what is plausible with the law. (AE-1/1: 1249)

There is an understanding by the state manager that the response to the information demands of the Public Ministry deals with the production of information to support the decision. This view comes with the necessity to consult documents, financial contracts, reports and produce a response to the problem presented. This reflects a controversy between the comparison of information produced systematically to support the daily decision regarding health care and assistance and those demands that incur problems with administration of contracts and resources. In view of constant inspection by regulatory agencies or even the press, it is difficult to achieve the balance between responding within the requested deadlines and carrying out the work of processing and using information. It requires an intense organisation of the information work process, as well as the capacity for integration of the team to share tasks that are performed by other professionals.

Demands affect the work process and are time-consuming, being reported as bulky and growing. This increase in quantity was related to the period after the institution of the Access to Information Law, which increases the transparency of the public administration process, giving access to information, and, therefore, allows greater control by the Public Ministry and civil society.

They ask the trivial, because while they ask us, they send it to the municipality, the state and the federal government. When there is an epidemic, for example, the case of Dengue, it is very common for them to send it to the national Dengue control program [...], to find out if the municipality is complying with the guidelines... if it has a national manual, even worse, because they look at the manual. The state has a state directive, a roadmap... (Do they look to see if it is suitable for the location?) Yes, they do. Is the plan adequate to the model that the ministry establishes or that you have established? (AE-2/1: 1133–1134)

The unpredictable information demands are generally external to the health sector, coming from the media, the population and the academy. These are expected to occur, but it is not possible to predict how, when or the purpose of the request. Each management sphere organises and standardises a way for these actors or institutions to request information, even though the procedures used are diverse. Some can directly access the manager to request information, while others can go directly to the communication sector by entering the most common flow. Some look for technicians through e-mails and phone calls, as well as the media may first have access to a fact that information professionals and managers themselves are unaware of.

After the demand, actions are taken to understand the request and identify to which department in health secretary these data will be solicited. There are specific sites that provide some treated data, as well as indicators and indices that have already been calculated periodically. When there is some information that requires further investigation and new data collection or work in databases, studies are carried out and elaborated as needed. If regular monitoring is necessary, then a planning process is established to initiate a new data collection and processing routine in order to systematically enable the production of this type of information.

An example of this situation is the need to respond to unforeseen external demands for information from the press. In the municipal sphere, it occurs almost daily, and the manager of the highest hierarchy sets aside 30 minutes every day to respond. In federal, municipal and state entities, the information professional works together with the manager to support the decision. The information is discussed and shared in order to present adequate content to compose the reply to the demand. The government reiterates the concern of avoiding data and information misinterpretations from the non-specialised press, which often occurs.

Frequently cited cases are communicable diseases or those that affect famous people. Given that HIS are built around anonymised information about the individuals, it is not trivial to find a case with the name as a requirement. It requires effort and time from information professionals in the epidemiological surveillance sector, interfering with the progress of daily work. Furthermore, if there is an immediate concern about the possibility of outbreaks or epidemics, investigating the state sphere increases the impact on other activities:

… most of the time it is from the point of view of the state health system, we first search the national database systems, we see, at least, how this information is presented, or if it is already sufficient. Even if from the state point of view, but if it is something that may be registered in the national systems, we also seek this information, even to have a basis, in case the superintendence, the sub-secretaries, and our own units do not have this information available, for example, for communication advisory. (AE-1/1: 1237)

In the municipal entity, all study participants reported openness to participation and broad listening from leaders. The most frequent information needs for decision-making are requested by the health authorities of the highest hierarchy, being of an unpredictable nature, directed to information professionals, sometimes from the mayor.

Still in the municipal sphere, using data whose origin is the opinion of users expressed in ombudsman’s offices often occurs in the sector of control of transmissible and non-communicable diseases. Faced with an immense volume of information from Primary Care, there is a need to integrate informational processes to provide adequate responses in a timely manner. For this reason, the efforts of information professionals linked to information technology and managers with specific information demands were joined to create an interface capable of automating such processes, increasing access to information for decision-making.

Discussion

In the health sector in Brazil, the flow of information goes through analytical and decision-making bodies and involves several actors, from their collection point next to the patients, collecting data about their health, illness or death until reaching epidemiological HIS or those about physical and financial resources, in the case of administrative HIS. In both cases, information crosses different levels, from the local sphere, through the municipal, state up to the federal (Cavalcante et al., 2011). The study by Cavalcante et al. (2011) corroborates the findings of this study, being the flow of information in health characterised as bottom-up.

Nevertheless, if not passing on financial resources involves a penalty, how will the computerised information structure be maintained or developed? It is advocated to search for a form of penalty other than financial, considering that one must assess beforehand where and what existing gaps prevented such compliance. Instead of acting as a coloniser and repressor, as Santos (2010) states, the state could help health establishments, municipalities and states to solve the present problems. The lack of typists or conducting training with actors that feed and foster the HIS to motivate them about the importance not only of the collected data but also of its flow need to be addressed by the state.

Few articles could be correlated to the results of this study. From the research, two cases related to Ghana and India were identified. Despite comparability limitations between countries, it is still interesting to point out similarities or differences.

There are similarities in the types of information sources that support decision-making. For instance, in Ghana, as in Brazil, epidemiological and administrative data are used in the health system, such as costs, quality of life and equity data (Hollingworth et al., 2020). Epidemiological data use the demographics, vital statistics and disease burden data collected including sample surveys, with demographic health data being surveyed every five years. However, clinical efficacy data are also collected for evidence-based decision-making from articles in newspapers that carry out peer review, while in Brazil the patient’s electronic health record is a source of clinical information. Sample surveys are used as primary sources of information on chronic non-communicable diseases. Both countries use the source of scientific information produced by the academy, and Ghana uses a secondary source for this type of analysis. Thus, there are similarities in the use of the same sources of information between Brazil and other countries that aim to achieve universal health care, as is the case of Ghana.

As diverse as the sources of information used in Brazil may be, the integrated use of these various types of sources to support the decision-making is still a challenge that competes with the dynamics of the functioning of the health departments. The operation in Rio de Janeiro serves as an example of how it occurs in the rest of Brazil, since they operate according to national rules and regulations, despite the states and municipalities having the autonomy to build their decision-making process. Furthermore, the demands for central information from the MH are the same for the different states and incur in a routine of collecting and sending information that is part of the work process of health managers in the lower levels of the hierarchy in the secretaries of health.

Producing information regularly to provide evidence for health decisions is also a challenge in Brazil due to the unpredictable demands for information that interfere with the daily work process, causing interruptions that can take days until such demands are answered. However, in India (Ka et al., 2020), there is an attempt to create a platform to monitor and produce information to support the decision-making with the construction of a pilot project. They recognise the importance of having a tool that integrates and allows monitoring, in real time, geospatial information from emerging and re-emerging threats, disasters and mass events.

In Brazil, such unpredictable demands come, for example, from the Public Ministry. This is an autonomous state agency which, despite interfering in the daily activities of the health management service, serves to inspect and protect health rights. The Public Ministry is constitutionally charged with protecting the legal order, the democratic regime of law and the social, collective and individual interests. In this way, it is inserted in the political, legal and social constitutional organisation to combat and effectively resolve the threat and injury to health. When defending the legal order, it indicates the best path for situations, allowing the application of legal effects resulting from threats to the protected public interest, ensuring that the constitutional regulations are enforced (Maggio, 2018).

Thus, health secretaries undergo inquiries that may be related to the implementation of public policies, services and health actions offered, as well as the conduct of managers in the execution of these. The priorities and collegiate decisions of the health councils that work in social control are also protected, to ensure that the health manager approves the decisions made.

Even so, the Public Ministry lost the confidence of the population, being overtaken, for example, by the press, which is another source of unpredictable demands imposed on health departments. It suffers criticism, such as failing to resolve the health problems, to which it is presented to, in a timely manner and with adequate extension. Maggio (2018) states that the performance slows down the functioning of the management and does not strive to obtain terms for adjusting conduct or resolving offences against health rights. In the case of the results of this study, the participants report that they often participate in surveys, but the recommendations for resolving the issues are not known to health managers.

To respond to unpredictable and external demands on the functioning of health secretaries, there is an informational behaviour that involves the search, use and management of information and its sources to meet the information needs (Martínez-Silveira, 2005). In this study, it implies (i) assessing and understanding informational needs, (ii) searching for existing health indexes and indicators or (iii) if there is no information, there is a search in the database and study work and information production. Few studies (Cavalcante et al., 2017; Lima et al., 2015) address the informational behaviour of public health managers in their daily work in the government sphere.

Therefore, this behaviour, when structured and standardised as part of the work activities, creating an informational culture within government management, may have a lesser impact on the functioning of the health management service. The structuring avoids the accumulation of functions and activities that fall on a single health manager. Still, it is an important activity of transparency of information about the health of the population, since most of the statistical demands come from the press to deepen the understanding of cases of communicable diseases, serious diseases in famous people, outbreaks or epidemics.

Like this study, Cavalcante et al. (2017) reveal that the information is likewise submitted to an analysis, but it deals with a contrast between the information collected and the supervisory practices of the actions of the Hiperdia network in Minas Gerais, Brazil. It is also reported that there is a bureaucratic determinism in the production of indicators, considering that some of them correspond to previously agreed management indicators, being, therefore, part of the daily information production of the service. These indicators are prioritised in the registration and dissemination process to meet the recommended goals (Cavalcante et al., 2017), which refers to the internal and predictable demands for information within the government management revealed here.

As part of the foreseeable demands, there is an action to produce information for use in public health management, for the formulation of health policies and for political, administrative, and financial purposes, among others. It is considered, then, that the health manager is also an information user in which the binomial production - use of information supports his decision-making, being the decision an action of the manager.

However, the production of information is standardised and systematic, especially with regard to information that will be sent to the MH. Little relevance, in general, is attributed to the use of information as a basic management principle, given the vast amount of information collected and existing in HIS and sample surveys. There is a disparity in the comparison of the municipal sphere with the state sphere of Rio de Janeiro. In the studied municipal sphere, technological resources are maximised, and software is built to produce information that supports decision-making. This differs from the state level where there is a greater volume of health information implying a greater management of its production.

In such a manner, each governmental management, with its autonomy in the internal functioning, can manage its resources to satisfy the informational needs of decision-making. It is essential to keep in mind that health information seeks to reflect the health/disease situation of a population and their living conditions. Even administrative information is strategic and of interest to health services to enable an analysis of the health reality. Thus, health information quantifies, qualifies and contextualises health problems and the need for health services and actions.

There is a divergence between the study by Lima et al. (2015) and the findings of this study. While the authors refer to an evolution in this sense in the state and federal spheres, here we present a development of the binomial production - use of information in the municipal sphere. Nevertheless, Rio de Janeiro is the second largest Brazilian metropolis and this may justify such a divergence in relation to smaller cities. It is a limitation of this study that it cannot compare the findings with those of other smaller cities, and, therefore, with limited human and financial resources for the establishment of a consolidated information culture and routine.

It is worth noting that the way in which information is processed between states and municipalities in the country has similarities to the regulations established by the federal government. As much as this study has interviewed managers from the municipality and state of Rio de Janeiro, the differences that may exist when compared to other cities possibly focus more on the work process and the binomial production - use of information for decision-making than on the flow of information and use of information sources. Thus, there are important similarities that enable this study to provide findings with national representativeness.

Conclusion

The municipal sphere is better structured to handle information than the state sphere, regarding both the treatment of information and the binomial production - use of information. The unpredictable information needs interfere with the health management work routine and impact the health managers’ decision-making in both spheres. Higher-level managers spend most of their time on decision-making processes focused on acute communicable diseases. Information is seldom used in this decision-making process, with the limitations of the HIS being pointed out as the main cause. The type of information most used is epidemiological, compatible with administrative and financial information, as well as scientific information. The production of information for decision-making needs to be systematised to support decisions, making a synthesis of the many sources of information available. Better coordination and integration of information processing techniques are recommended in order to qualify health decision-making.