Organizational Background
Health systems around the world face similar difficulties, such as an aging population; the increase in demand for health services; new technologies and expensive services; all while experiencing increasing financial constraints. In this context, providing high quality services that meet patient expectations with minimal resources is a major challenge, and has led some healthcare organizations to explore Lean methodology – which focuses primarily on improving processes, reducing and eliminating waste (Kelendar et al., 2020).
The authors present the case of Kaizen practice as part of a Lean implementation strategy for a Non-Governmental Organization (NGO) – specifically, a Social Health Organization –, with contracts in the countryside of Rio de Janeiro, Brazil. Non-Governmental Social Health Organizations are nonprofit institutions of the third sector, responsible for managing Brazilian public Health System (SUS) institutions throughout the country, in partnership with municipal and state health departments. Despite being characterized as a private company, it is subjected to the same public compliance regulations, which in turn have implications on company directions and strategy when compared to purely private companies. They are guided by the needs of the population and not by capital.
The company in question operates at all levels of public health, managing primary care, secondary care, and tertiary care units. Primary care is guided by the Family Health Strategy and was designed to be a space for health promotion and prevention, operating mostly with scheduled appointments and not answering to emergencies. Secondary care, which is sometimes referred to as “hospital and community care”, can either be planned (elective) care such as medical treatment with specialties like physical therapy, or urgent and emergency care such as the treatment fractures (the facilities are called UPAs). Tertiary care refers to highly specialized treatment, for which hospitals are allocated.
Non-Governmental Social Health Organizations are funded by public resources according to Brazilian regulation. Human capital is based on the contract established with the municipalities, which in turn is supposed to be based on technical guidelines provided by the Ministry of Health. It is also important to note that this kind of contract is based on compliance requirements, and each contract lasts between 1 and 4 years.
The company operates in four different municipalities. For this case they will be referred to as A, B, C and D. Table 1 presents information about each of these municipalities.
Table 1. Detailing of each municipality where the company has operations in place
| Municipality A | Municipality B | Municipality C | Municipality D |
| Public units managed | 1 hospital
3 primary care units and its 16 subunits | 1 hospital
1 secondary care unit | 1 hospital
4 secondary care units (3 emergency care and 1 specialty unity)
18 primary care units | 2 secondary care units (2 emergency care) |
| Start of Lean implementation | October, 2018 | May, 2021 | February, 2020 | Contract 01: June, 2021 Contract 02: December, 2021 |
| Population (number of inhabitants) | 10,392 | 54,273 | 91,938 | 999,728 |
| Population density (inhabitants per km2) | 12.67 | 56.273 | 209.96 | 4,035.90 |
| Human Development Index (HDI) | 0.668 | 0.700 | 0.709 | 0.739 |
Source: IBGE.