Abstract

This paper examines post-graduation professional training and qualification courses in the fields of public health and primary healthcare. Its aim is to reflect on the construction and methodological proposal of two courses given by ENSP/Fiocruz in partnership with the Municipality of Rio de Janeiro, over the years 2010 to 2014: The Professional Master’s Degree in Primary Healthcare (MPAPS), and Specialization in Public Health. Methodology: Systematization of academic documents of the courses, with preparation of emerging analytical categories (theoretical management-interface history, field of pedagogy). Results/discussion: Two classes of the MPAPS course (n=24 students per group) and five of the Specialization course (average 30 per group) were held in the period, with approval rates at the 90%–80% level, with curriculum structure adjusted to the local situation. As challenges that were implemented, we highlight: 1) On the epistemological level: development of competencies for professional training that would produce results coherent with health, as social/cultural production; 2) from the learning point of view: preparation of dynamics that give value to the students, their social-cultural context and experiences; 3) work environments and relationships, bringing their structured analysis into the learning environment.

Health education; Public health; Primary healthcare; Professional training

Introduction

Brazil has been achieving success in its policies of structuring its Unified Health System (SUS – Sistema Único de Saúde) since the 1990s. In this process a highlight has been the expansion and increasing qualification of Primary Healthcare, the main focus model of which is the Family Health Strategy (ESF – Estratégia de Saúde da Família)¹1. Brasil. Ministério da Saúde (MS). Política Nacional de Atenção Básica. Brasília: MS; 2012., and the shaping of the Healthcare Networks (RASs – Redes de Atenção à Saúde). In spite of these advances, process on decentralization is still slow, fragmented and with obstacles to integral care for the population’s health²2. Souza LEPF, Viana ALD’A. Gestão do SUS: descentralização, regionalização e participação social. In: Paim JS, Almeida Filho N, organizadores. Saúde Coletiva: teoria e prática. Rio de Janeiro: Editora Medbook; 2014. p. 261-270.; and expansion of the ESF is happening at unequal speeds and with very numerous challenges in the major urban centers³3. Giovanella L, Mendonça MHM. Atenção Primária à Saúde. In: Giovanella L, Escorel S, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Políticas e Sistema de Saúde no Brasil. Rio de Janeiro: Fiocruz; 2012. p. 575-626.. The municipality of Rio de Janeiro created strong motivation for change of the care model, and there was an exponential increase in the coverage of Family Health in the period between 2009 and 2014 (5% to 40%), through a new management model with the Social Health Organizations (OSSs)⁴4. Organização Pan-americana da Saúde (OPAS). Reforma da Atenção Primária à Saúde na cidade do Rio de Janeiro – avaliação dos três anos de Clínicas da Família. Pesquisa avaliativa sobre aspectos de implantação, estrutura, processo e resultados das Clínicas da Família na cidade do Rio de Janeiro. Porto Alegre: OPAS; 2013. Série Técnica Inovação na Gestão.. Another highlights in the period were the construction of new Family Clinics (Clínicas da Família), structural improvements in the physical areas, greater provision of inputs and contracting of professionals, expansion of the portfolio of basic services, and attribution of greater value to monitoring and assessment of the performance indicators of primary healthcare.

However, a study of evaluation of primary healthcare in the city showed that in spite of the progress in coverage and access to the services, challenges persist in the quality and degree of qualification of the healthcare provided⁴4. Organização Pan-americana da Saúde (OPAS). Reforma da Atenção Primária à Saúde na cidade do Rio de Janeiro – avaliação dos três anos de Clínicas da Família. Pesquisa avaliativa sobre aspectos de implantação, estrutura, processo e resultados das Clínicas da Família na cidade do Rio de Janeiro. Porto Alegre: OPAS; 2013. Série Técnica Inovação na Gestão.. To deal with these questions, it was necessary to build new practices and redefine the role of the network’s employees and managers. According to Gil⁵5. Gil CRR. Formação de recursos humanos em saúde da família: paradoxos e perspectivas. Cad Saude Publica 2005; 21(2):490-498., another line of action was just as important as discussion about training of human resources for the SUS: finding alternative ways to deal with the situation of the employees that already work in the system, needing to find ways to meet the complexity of the practices in the health services.The transformational context of primary healthcare in the city of Rio was a motivator for development of new competencies for workthat would enter into a dialog with the field of public health, integrated with the subjects of health promotion, prevention, care itself and care vigilance.

Another particularity of the city of Rio was the creation, in 2011, of the Residency Program in Family and Community Medicine (SMSRJ: Programa de Residência em Medicina de Família e Comunidade), a medical specialty for which historically it had been difficult, at a national level, to fill the vacancies offered. The doctors in primary healthcare of the municipal network are also required to be able to act as preceptors of some 100 new residents, with specific competencies for this teaching practice, which takes place in the work environment⁶6. Autonomo FROM, Hortale VA, Santos GB, Botti SHO. A Preceptoria na Formação Médica e Multiprofissional com Ênfase na Atenção Primária – Análise das Publicações Brasileiras. Rev Brasileira de Educação Médica 2015; 39(2):316-327..

Although the SUS is considered to be the largest employer in healthcare in Brazil, training of professionals is much more directed to the traditional market demands, and much less to the needs of changes in this system and integration of teaching with service⁷7. DalPoz MR. A crise da força de trabalho em saúde. Cad Saude Publica 2013; 29(10):1924-1926.^,88. Dussault G, Dubois CA. Human resources for health policies: a critical component in health policies. Hum Resour Health 2003; 1(1). [acessado 2015 set 18]. Disponível em: http://www.human-resources-health.com/content/1/1/1
http://www.human-resources-health.com/co... . According to the authors, the crisis of the workforce in health is aggravated by the effects of globalization; of the demographic and epidemiological transition characterized by the aging of the population; changes in the patterns of health and illness, and consequent change in the ways of using the services.

The change of behavior and expectations of the users, who today are much more demanding on the qualities of health professionals, and of inclusion and diffusion of the use of new technologies, are other conditions to be considered⁷7. DalPoz MR. A crise da força de trabalho em saúde. Cad Saude Publica 2013; 29(10):1924-1926.^,88. Dussault G, Dubois CA. Human resources for health policies: a critical component in health policies. Hum Resour Health 2003; 1(1). [acessado 2015 set 18]. Disponível em: http://www.human-resources-health.com/content/1/1/1
http://www.human-resources-health.com/co... . Professional education in health for the 21^st century should, thus, be understood as part of an inter-related group of organizations that implement the various functions of an educational system.The training of health professionals creates a need for learning as the nucleus of a transformative education, molded by adaptation of competencies, which can be planned for specific, local, contexts, considering the power of the global flows of information and knowledge⁹9. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, Fineberg H, Garcia P, Ke Y, Kelley P, Kistnasamy B, Meleis A, Naylor D, Pablos-Mendez A, Reddy S, Scrimshaw S, Sepulveda J, Serwadda D, Zurayk H. Health professionals for a new century: transforming education to strengthen health system in an interpendent world. Lancet 2010; 376:1923-1958..

Aiming to train professionals with protagonist qualities, and competencies to deal with the challenges of healthcare in the municipality of Rio, the Sergio Arouca National Public Health School (ENSP: Escola Nacional de Saúde Pública Sergio Arouca), a unit of Fiocruz/Rio with a long history of training of human resources for the SUS, formed a partnership with the Municipal Health Department (SMS) of Rio to develop courses that were considered to be strategic.

The mechanisms of institutional cooperation took place through the TEIAS initiative (Integrated Healthcare Territory of the Manguinhos School), having as its basis a co-operation contract signed in December 2009¹⁰10. Casanova AO, Teixeira MB, Engstrom EM. O apoio institucional como pilar na cogestão da atenção primária à saúde: a experiência do Programa Teias - Escola Manguinhos no Rio de Janeiro, Brasil. Cien Saude Colet 2014; 19(11):4417-4426.. One highlight result of this cooperation was the offer of some courses for training, among these, in the strict sensu environment, for a Professional Master’s Degree in Primary Healthcare (MPAPS), with emphasis on the Family Health Strategy, and in lato senso, the Specialization Course in Public Health. It should be pointed out that the target public of these courses was health professionals with higher education, employed by the state or contracted under the employment laws by the social health organizations, all workers with employment linked to the SMS–RJ.

Aiming to contribute to discussion of training of professionals for the health system, including the fields of public health and primary healthcare, the aim of this article is to reflect on the construction and methodological proposal of the courses in the period 2010-2014, and to provide some deeper reflections on the historical-management context, and training/qualification in the field of public health/primary healthcare.These are the concerns that inspired us in this experiment.

Methodology

This is an exploratory study, presenting and discussing an experience ofprofessional health training, from the point of view of the coordinators of the MPAPS and Public Health Specialization courses, held in the period 2011 to 2015, at ENSP/Fiocruz, in the city of Rio de Janeiro.

The aim of the first part, describing the experience, was to systematize teaching and administrative documents relating to the courses, for the two classes of the MPAPS and all five classes of the Specialization Course. These can be summarized as: Documents about the initial project of conception and about the operational development of the courses, such as tenders or announcements of public competition for selection of the students; the minutes of selection; academic records (specific for each group); and the curriculum structure of the courses, expressed in the summary documents of the disciplines or modules, and in the case of the MPAPS, in the pedagogic material prepared for the student. Also used as a source of data for description were the assessments made by the students at the end of each discipline/module, and the reports produced by the coordinators and teachers of the courses, which were sent at each term of the period studied to a Technical Assessment Commission, made up of managers of the Rio de Janeiro SMS.

It should be noted that the authors of this paper, researchers of ENSP/Fiocruz, worked on the coordination of the courses in the period studied, having access to the documents and materials referred to. These experiences contributed to the considerations discussed here, and are in the second, more analytical part of the paper. What follows below, thus, is a description of the construction and methodology of each course, its specificities and objectives, providing elements of the context of the education/training process. Following this description, subject categories emerging from the systemization of the documents were constructed: The historic-management context of the courses, and its interface with the fields of public health and primary healthcare, and with the field of pedagogy.

In discussion of them, an effort was made to highlight the points of meeting and points of divergence experienced in the two courses, and also the challenges for professional training/qualification in public health and primary healthcare, considering the contributions to the local context, where significant transformations in the model of management and healthcare were implemented in the period.

Results and discussion

Construction and methodology of the courses

In construction of the curriculum of the MPAPS,the political-teaching project was prepared in a participative manner, with employees’ learning and qualification needs identified and planned collectively, and in a dialog with the local health context. For this, workshops were held coordinated by teachers of ENSP/Fiocruz, involving health professionals and managers of SMS Rio, and also teachers with recognized experience in academic institutions, such as the Federal University of Rio de Janeiroand the State University of Campinas. Taking as inspiration the proposal for a course of the Brazilian NorthwestFamily Health Training Network (2009), the curriculum was modified to adapt to conditions and professional practice in the municipality of Rio de Janeiro¹¹11. Brasil. Ministério da Saúde (MS). Fundação Oswaldo Cruz. Escola Nacional de Saúde Pública Sergio Arouca. Curso de Mestrado Profissional em Atenção Primária à Saúde com ênfase na Estratégia de Saúde da Família. Organizadores: Engstrom EM, Teixeira CP, Moreira COF. Orientações para o curso. Rio de Janeiro: Fiocruz; 2013..

The objective of the MPAPS was to systematize and produce technical and scientific knowledge that would expand competencies for work in primary healthcare, contributing to the strengthening of the SUS. The subjects that comprise the curriculum were related to the knowledge, skills and attitudes necessary to achieve the competencies expected for primary healthcare professionals.The curriculum structure was formed in seven subject modules, which correspond to the major areas of competence (Table 1).

The competencies constructed were directed towards: i) developing actions in promotion of health; ii) understanding and activity in the integral primary healthcare model; iii) management of the clinical practice; iv) use of information and communication in health; v) planning and evaluation in health; and vi) competencies for the work of education in health, especially as preceptor and in the exercise of the methodologies of teaching and learning; vii) production of knowledge or research methodologies¹¹11. Brasil. Ministério da Saúde (MS). Fundação Oswaldo Cruz. Escola Nacional de Saúde Pública Sergio Arouca. Curso de Mestrado Profissional em Atenção Primária à Saúde com ênfase na Estratégia de Saúde da Família. Organizadores: Engstrom EM, Teixeira CP, Moreira COF. Orientações para o curso. Rio de Janeiro: Fiocruz; 2013..

Some other subjects, such as organization of Healthcare Networks and their integration with primary healthcare, care for vulnerable groups, violence, and mental health, were indicated in the workshops (and by the students, during the development of each class) as being of importance in the local health system, perhaps similar to other large urban centers and were incorporated into the curriculum as ‘Special Topics’.

One of the characteristics of the course was adoption of new methodologies of training for the services, assuming as a premise that it is possible to learn from experience, since we are capable of understanding the meanings of what we live through. The students were instigated to reflect on their practices, seeking theories and questions that would help them to understand and provoke changes in the working context. Thus the curriculum, as well as the subjects of the course conclusion dissertations, were associated with work in the local health system.

With the qualification credential structure approved by the Public Health Post-Graduate Program of ENSP/Fiocruz, two classes were then offered (First Class: 2011-2013; Second Class: 2013-2015). The academic offering was similar in both classes: 150 university graduate professionals took part in the selection process, competing for the total of 24 places in each class. There was approval and classified in an English language examination, specific knowledge in Primary Healthcare, and an interview. The composition of the classes was multi-professional, even though approximately half of the students were basic healthcare doctors, who operated as preceptors for doctors in residency. Of the universe of students, the approval rate was 90% for the first class and 85%, for the second. The total number of teaching hours in the Master’s course was 1,470 hours, the class having a duration of 24 months. All the modules were obligatory, and given in person (one day per week, on Fridays).

Considering that in the education of adults, experience is the central engine of the processes of learning and development of new knowledge, skills and attitudes, the active methodologies were implemented through: Tutorial groups, seminars, dramatizations, skills training, practices in services/community, directed study, team project, and dialog-based expositions.

The Specialization Course in Public Health for graduate level workers in primary healthcare of the municipality of Rio took as the basis for its formulation the curriculum of an identical course, offered regularly on free demand by ENSP. However, the possibility of training specialists in public health who were employees of the municipal health network was a rare opportunity to reflect on the city’s conditions of health and healthcare, and to indicate/construct some possibilities of changes.

Thus, some subjects and methodological approaches were incorporated in the teaching matrix of the initial course, based on a workshop held between teachers of the institution and the managers of healthcare of the municipality. This workshop generated indications for adaptation of the curriculum on two levels: i) that people qualifying at the end of the course should be critical-reflective, and potential leaders in their territory; and ii) that the problems that arise in the day-to-day services should be fully set out and reflected upon in the light of the social and cultural contexts, generating potentially strategic ways of dealing with them. A total of 757 health professionals who had worked in the function for at least a year in the municipality were inscribed to compete for the 175 places offered (35 per class). It is worth noting that 85% of the concluding pupils defended their monographs, in the first four classes; those of the fifth class are still in the conclusion phase.

A teaching innovation was incorporated in the course as from the fourth class, with the creation of a device that aimed to articulate the processes of teaching-learning in health practices (acts of care). Certain issues worked on in the classroom over the period of the modules were discussed in the context of the services between students who worked in that region and the other workers of the area, mediated by a lecturer/supervisor of ENSP.

We should note here that when we refer to ‘teaching innovation’, we refer to the capacity of the courses to articulate in the ambit of their teaching processes the following two dimensions: a) an interaction between elements of the critical theories of education, understood as the capacity of the teaching process to structure an analysis of the spaces and actors that interact in the production of care in a critical manner, with elements of post-critical theories, assuming language as a central factor, that is to say, to understand that we consist of discourses, we produce discourses about ourselves and about others, and we act on them and we are affected by them; b) considering the idea of a device as a network of relationships that can be established between heterogeneous elements, such as institutions, discourses, laws, administrative measures and scientific enunciations, a reflexive map is produced, in the ambit of the health services, that articulates the discourses of the actors of the territory in an interaction with the concepts produced in the course, and contained in the discursive practices of the students.

From this perspective, the territories of the services were taken to be a space of construction/production of knowledge.The purpose was to forge a greater integration between the processes of teaching and those of caring and managing in the field of health.This activity had two objectives: i) to construct a method of accompanying the processes of teaching-learning in the territory; ii) to make possible expansion of access of the course to other professionals of the network, through discussion of the ambit of the services.

Similarly, reflections were expanded on subjects which were to be translated into concrete realities in the day-to-day work, but which, because of their transdisciplinary nature, are usually neglected in curricula of training in the field of health. Thus, multi-or inter-culturality, gender and sexuality, drugs and violence gained spaces of reflection, especially as mediators that articulate practices of education in the field of health.

Reflections on the management history context

Training – acquisition of skills and practice – in the field of public health and primary healthcare should be understood in the light of the issues brought up by the reform of the Brazilian health system, which aimed to ensure universal provision of integral health, oriented by the amplified concept of health forged in the Federal Constitution of 1988. Specialists in public health, since the proposal for Health Reform was constituted, have been seeking to exercise influence in the conflicts surrounding the giving of a new direction to the reform in the health system¹²12. Pego RA, Almeida C.Teoría y práctica de las reformas en los sistemas de salud: los casos de Brasil y México. Cad Saude Publica 2002; 18(4):971-989..

However, the lack of consensus on what public health is and what strategies should be used to guarantee upholding of these principles has led to an intense debate in the area of public health. This debate takes place in a context of crisis of the contemporary institutions of society, expressed among other aspects by a dispute between market, State, and society as providers and/or regulators of public health.

At the same time, the complexity of the epidemiological situation, marked by a triple burden of illnesses and polarization between non-transmissible chronic illnesses, violence, and infectious diseases, is also an important element to be considered, to the extent that it is related to determinants that are multifactorial. In the case of the municipality of Rio de Janeiro, the differentiated distribution of risk factors between the various population groups has unequal impact on the way in which these groups become ill and die, and also accentuates the historic inequalities, as described in the 2010-2013 Municipal Health Plan¹³13. Rio De Janeiro. Secretaria Municipal de Saúde e Defesa Civil. Plano Municipal de Saúde do Rio de Janeiro, 2010-2013. Rio de Janeiro, 2009. [acessado 2015 set 18]. Disponível em: http://www.rio.rj.gov.br/dlstatic/10112/3700816/4130215/PLANOMUNICIPALDESAUDE20102013.pdf
http://www.rio.rj.gov.br/dlstatic/10112/... .

Historically, the field of education/qualification in public health is made up of a group of basic disciplines (Planning, epidemiology and the Social Sciences) and by complementary disciplines, such as Statistics, Demographics, etc.¹⁴14. Paim JS, Almeida Filho N, organizadores. Saúde Coletiva: Teoria e Prática. Rio de Janeiro: Medbook; 2014.. However, the complexity of the issues that are placed before the health system points to the limit of the disciplinary structure in training processes for explanation of the reality, since although each one of these fields has a privileged lens from which to look at the complex of health-illness-care, none of them is capable of comprehending all the angles that surround the object¹⁵15. Almeida Filho N. Intersetorialidade, transdisciplinaridade e saúde coletiva: atualizando um debate em aberto. RAP 2000; 34(6):11-34.. The effect of this perception is to channel an effort at construction of new knowledge, theoretical and practical.In this context, other approaches and objects have been incorporated into the field.

This debate also enters into a dialog with the discussions held by the Pan-American Health Organization in the search for construction of new paradigms to respond to questions that arise from the crisis of public health. An important aspect in this discussion is the recognition that public health is not a medical specialty, and a greater intersection with the human and social sciences is important¹⁶16. Paim JS. O objeto e a prática da Saúde coletiva: o campo demanda um novo profissional? In: Paim JS.Desafios para a saúde coletiva no século XXI. Salvador: EDUFBA; 2006. p. 99-116..

These discussions have brought into the area of training and qualification the need to reflect on the characteristics of construction of knowledge and practices in this field. Bourdieu’s¹⁷17. Bourdier P. O poder simbólico. Porto, Rio de Janeiro: Difel, Bertrand Brasil; 1989. concepts of the field of science and the field of practicality, understood as spaces of interaction of different social forces, have been used by academic writers for better comprehension of the field of Public Health.

According to Luz¹⁸18. Luz MT. Complexidade do Campo da Saúde Coletiva: multidisciplinaridade, interdisciplinaridade e transdisciplinaridade de saberes e práticas: analise sócio-histórica de uma trajetória paradigmática. Rev Saúde e Sociedade 2009; 8(2):304-311., the use of this concept is important in public health because it makes it possible to uncover the hierarchical distribution of the contents and the actors who, over time, construct these discursive practices. Analyzing the development of public health in the last two centuries, the author observes that there has been a change from a polidisciplinary model of public health to a semi-open discursive structure, which has made possible incorporation of viewpoints from disciplines arising from different scientific fields.This phenomenon, allied to the complexity in the practices and forms of social intervention, in the author’s view, breaks with the idea of a mono disciplinary paradigm, bringing, as she understands it, a greater discursive wealth to the area.

Almeida Filho¹⁵15. Almeida Filho N. Intersetorialidade, transdisciplinaridade e saúde coletiva: atualizando um debate em aberto. RAP 2000; 34(6):11-34. sees public health as comprising three fields: i) a disciplinary field – where the emphasis is on the construction of the process of scientific output/knowledge – expressed principally by epidemiology; ii) a technological field, understood to mean historic and social spaces of application of technology, formed by planning and management in health; and finally iii) a field of social practices, understood to mean structured or semi-structured spaces where the communal or professional praxis take place, expressed by promotion of health.

The construction of these paradigms, as Almeida Filho and Paim¹⁴14. Paim JS, Almeida Filho N, organizadores. Saúde Coletiva: Teoria e Prática. Rio de Janeiro: Medbook; 2014. remind us, is realized by historical subjects in their scientific and practical communities, within a wider social and political context, where the inflections in the field of knowledge are subordinated to the field of practice.

Based on these reflections, an effort has been made to structure the analysis of problems of day-to-day routine of the health practices of the professionals in the courses that have been designed and held. In general, the post-graduate students in public health/Primary Healthcare have a superficial contact with the subjects of the area during their graduation. At the same time, they have the day-to-day experience produced in the daily work of the health services, marked by different positions that they occupy in the health services, in management or care, or further, marked by their profession, due to the multi-professional nature of this field. In our experience, the possibility of these life experiences producing reflections with potential to produce ruptures and re-elaborations of practices depended on the degree of the student’s prior theoretical input, on the form in which he took hold of the tools and types of knowledge shared over the length of the course and/or because of the place that he occupied in the hierarchical scale of the agents that produced the practices and the care in the field of health.

In this sense, the requirements of training and qualification demanded a dual role from the courses: to introduce the students to the discursive practices of the areas; and, at the same time, to offer tools that made it possible for them to construct a view on the collective, in a critical, reflexive manner and with autonomy to operate in the local health system, taking, as a starting point, the areas of concern and reflections that these professionals brought from professional practice in the day-to-day work of their services.

Reflections on the area of teaching

The idea of taking work as an educational principle is not exactly new in the field of health. This place has been presenting itself in lines of expression such as “new teaching methodologies”, “new competencies for work”, “new areas of knowledge produced in the work”. This group of expressions converges to the idea that the work and the subjects involved in its production are central to an educative practice that is capable of producing changes in the subjects and in the practices of health.

In general these conceptions, in the context of training in public health, are inscribed in curricular models, understood here, as in the comment by Moreira¹⁹19. Moreira AFB. Currículo, utopia e pós-modernidade. In: Moreira AFB, organizador. Currículo: questões atuais. Campinas: Editora Papirus; 2008. p. 9-21., as a “significant instrument used by various societies both to develop the processes of conservation, transformation and renewal of historically accumulated knowledge”, and also to “socialize” human beings according to values that are taken to be desirable. Thus, when situating the work and its subjects in the center of the curricular structures, it is presupposed that these are capable of mobilizing various senses of an accumulated knowledge in societies, and also incorporation of subjectivities that are adequate to the values expected by that society.

These different meanings of knowledge, in turn, by taking the work as center of the processes of learning, presuppose the idea that the analysis of the work by the subjects involved in its production leads knowledge, historically accumulated, to processes of renovation and transformation.This process would be capable of modifying the work itself, being a conductor at the same time of change in the practices of health and in the role of the actors of the work in the production process, thus culminating in transformation of the material conditions of the work.

This point of view instigates us to a reflection on the meanings of the relationship between theory and practice. By overcoming the relationship between knowledge and technique in education (application of techniques arising from scientific and specialized knowledge), the theory/practice relationship inscribes a reflexive and critical meaning into the educational processes, while at the same time pointing to education as a place of critical subjects which, “armed with different reflexive strategies, commit themselves, with greater or lesser success, to educational practices conceived, the majority of times, from a political perspective”²⁰20. Larrosa J. Notas sobre a experiência e o saber da experiência. Rev Brasileira de Educação 2009; 9..

At the same time, Larrosa²⁰20. Larrosa J. Notas sobre a experiência e o saber da experiência. Rev Brasileira de Educação 2009; 9. further highlights the need to go beyond the division that took over education between so-called technical people and so-called critical people, that is to say, of an education as applied science or as policy praxis, proposing reflection on another binomial, which he names ‘meaning/experience’²⁰20. Larrosa J. Notas sobre a experiência e o saber da experiência. Rev Brasileira de Educação 2009; 9.^,2121. Larrosa J. Experiência e alteridade em educação. Rev Reflexão e Ação, Santa Cruz do Sul 2011; 19(2):4-27.. This is not the place to go more deeply into this reflection which is outside the scope of this paper, but to note that in the field of education there is a strong tension and collision between its various theoretical currents, where the place of critical theories of education, as an inspiration for work as an educational principle and basis for analyzing the theory/practice relationship, is not, in today’s world, the only possible strategy for thinking about the relationships between the subjects of work and their processes of production of knowledge.

We can situate this reflection on two communicating planes: a) the field of knowledge, that is to say the plane of the truths that will be placed in movement in the educational processes; b) the ways in which these truths are made to circulate, or that methodological strategies guide the processes of teaching-learning. On the first plane, we must ask what are the best knowledges or truths and why it is these, and not others, that should nourish the processes of training/learning. The second plane refers to the idea of how such truths are structured and activated during the processes of teaching/learning.

The first plane of analysis remits us to the criteria that define our choices. Silva²²22. Silva TT. Documentos de Identidade: uma introdução às teorias do currículo. Belo Horizonte: Autêntica Editora; 2011. highlights that these choices point to the type of “human being” that is desired in each society, in each social space or in each work environment. He affirms, also, that these choices involve responses to questions such as: what type of people it is desired to develop (critical, reflexive, analytical); for what society; with what rationalities; and what subjectivities should be emphasized. To answer them, it is necessary to take a position on complex questions about human nature, about the nature of learning or about the nature of knowledge, of culture and of society²²22. Silva TT. Documentos de Identidade: uma introdução às teorias do currículo. Belo Horizonte: Autêntica Editora; 2011..

We can, here, talk of a challenge to training in public health and, specifically the training for professionals who are situated in the center of the processes of reorganization of primary care in the municipality of Rio de Janeiro, which should bring together three strategic elements: 1) adopt strategic methodologies that place the work in the center of the processes of learning, that is to say, the work is the teaching element that structures the production of knowledge; 2) consider the items of knowledge that are most related to the processes of production of autonomy, that is to say, that the choice of items of knowledge should consider their capacity to produce social emancipation; and 3) consider that the process of production of the differences in society involvessubjective relations in the ambit of training/teaching, which implies considering reflections on what has been socio-culturally allocated as a deviation, abnormality or marginal practice or effect.In this aspect, the curriculum should include elements of race/ethnicity, gender and sexuality and comprehension that the truths on these questions are discursive productions.

In our experience, we have clarity that the realization of these courses was not a simple challenge, in that we proposed to bring together elements that are based on different theories of curricula, such as comprehension of the role of ideology and of social classes in the production of the subjects and their views on society, expressing the kernel of the critical theories.In the same way, comprehension of the role of the discourses in the shaping of the truths and the incorporation of inter/multi-culturality are aspects to be considered as a matrix of a curriculum process, expressing the post-critical theories of the curricula.This conjugation of critical and post-critical elements, anchored on processes of learning that consider the worker in his multiple inscriptions in the productive process, far from constituting a practice of coupling the role of teaching together with the ideas of maximization of production, comprise formation of a space where “not everything is socializable, and even less so, controllable, when we are talking about the teaching/training of human beings”²³23. Arroyo MG. As relações sociais na escola e a formação do trabalhador. In: Ferretti CJ, Silva Junior JR, Oliveira MRNS. Trabalho, formação e currículo: para onde vai a escola? São Paulo: Xamã; 1999. p. 13-41..

This being so, our challenge was put, on three levels: 1) on a more epistemological plane, in which we asked what elements of knowledge were necessary to train and qualify a public health/primary healthcare professional capable of producing concepts that were coherent with those enunciated that inform health as a social and cultural production and not only as a biological event; 2) in a perspective of learning, it was a case of thinking through dynamics that in fact gave value to the subjects of learning, considering their social-cultural contexts and their experiences (here the word experience is seen from the point of view of Larrosa²¹21. Larrosa J. Experiência e alteridade em educação. Rev Reflexão e Ação, Santa Cruz do Sul 2011; 19(2):4-27. as a confluence of meanings such as alterity, reflexivity, subjectivity, transformation and passion); 3) inscribing the two previous levels in the environments and relationships of work, that is to say, configuring an invitation to the collectives of this space to analyze the work situations based on certain concepts previously reflected by the students in the formal environments of learning.

Final considerations

Professional training and qualification for the SUS has challenged both the training institutions, with their graduate and post-graduate programs, and also the health service, providing institutions in their projects to signify work spaces as spaces for learning.

The processes of reorganization and expansion of primary healthcare have added more elements of complexity. When one goes outside the walls of the health units and looks at the territories as living spaces, with their contradictions, their uncertainties and unpredictabilities, permeated with real histories of real subjects; when one establishes care pathways and singular therapeutic projects; when one re-orders the spaces of management of the work, then teaching and qualification is challenged to (re)signify its own choices and its own teaching processes.

In a context where the curriculum provides choices that shape answers to different challenges and which are anchored on the nature of knowledge, culture, society and the distinct ways of learning, to produce an interlocution between the group of items of knowledge that express ideas of social emancipation, critical-reflexive subjects and subjectivities that break the traditional social-culturally constructed binary viewpoints, and to aggregate methodological elements that place the realities of the work and its actors at the center of the production of knowledge in health, has not been, and will not be, a simple task.

Our trajectory was based on a participative and democratic construction between actors of academia and of the health services.Our choices took place at the interface between critical and post-critical theories in a context of recognition of the complexity of the field of collective health, recognizing its little-defined frontiers and its always procedural dynamic.

Thus, it was possible to consider experiences as devices for learning, added to the constitution of a network of knowledge that is inscribed in a transdisciplinary point of view.

The result of this experience has shown some zones of tension which will be challenges for the construction of future training processes. These are: i) work as a central category of the educational process evidenced a conflict between the different forms of the subjects’ inscription in the productive process; ii) the adoption of active methodologies of learning pointed to the permanent tension between disciplinary and inter-disciplinary practices in the interior of the training curricula; iii) reflection on interdisciplinary categories such as gender, sexuality, ethnicity and race is still strongly demarcated by disciplinary structures; iv) a critical angle of view (not criticism itself) applied to policies and relationships of work continues to be a challenge to be faced by health professionals, due to the difficulty of realization of reflexive distancing on the processes of work in which they are immersed.

In spite of these challenges, we believe we have achieved a pattern of training/education/qualification which, side by side with the necessary construction of new leaders inside the various territories of the municipality of Rio de Janeiro, is contributing to constitution of care practices which in fact take into account the singular and collective differences, and the various narratives, that write the life history of these populations.

It is important to point out that the short period of implementation of the teaching policy prevents a consistent evaluation of the results, and that these should be seen principally as monitoring of solutions and obstacles observed. Considering that any process of professional training must necessarily be accompanied by studies on those emerging from the course, this mode of assessment has been implemented by the coordinators of the courses, constituting a device that is capable of echoing the successes, shortcomings, lessons learned and practices successful, highlighting the innovations generated in and based on the processes of learning.

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