Abstract

This paper discusses the historical construction of the Expanded Family Health Center (NASF, in Portuguese), based on the analysis of 17 documents edited by the Ministry of Health (MH) between 2005 and 2021. This is a qualitative study of documental review that seeks to understand how the regulations and official instructive manuals have been shaping the way NASF teams operate. It proposes to divide the NASF construction process into five periods: previous movements (2003 to 2007); support guidelines (2008 to 2011); the universalization of nasf (2012 to 2015); expansion of support (2016 to 2018); and the dismantling of NASF? (2019 to 2021). The results show changes in guidelines over the years of the team’s existence, especially in relation to the matrix support concept and its two dimensions: technical-pedagogical and clinical care. This study also demonstrates the effects of the Previne Brasil Program on the NASF, which resulted in the reduction of 379 teams in 2020 and 2021. Added to this scenario is the SARS-CoV-2 pandemic, which may be repositioning NASF interventions in the Brazilian Unified Health System (SUS, in Portuguese).

Key words:
Matrix support; Expanded Family Health Center; Primary health care; Qualitative research; COVID-19

Introduction

Due to the different experiences of the Family Health Program, which have been in place since 1994, the Ministry of Health (MH) has been gradually leading municipalities toward the adoption of this model¹1 Cecilio LCO, Reis AAC. Apontamentos sobre os desafios (ainda) atuais da atenção básica à saúde. Cad Saude Publica 2018; 34(8):e00056917.. The National Primary HealthCare policy (PNAB, in Portuguese) from 2006 has been advancing in the reorganization of health care within the Brazilian Unified Health System (SUS, in Portuguese), formalizing the traditional name of the Family Health Strategy (FHS). The consequent increase in the importance of Primary Care as the coordinator of health care, with the respective allocation of financing for this level of care, has forced municipalities to face the challenge of the reorganization of its healthcare networks. With the FHS, the teams have the task of guaranteeing health care to users in a different way. It is hoped that this, over time, will be implemented throughout the country to meet all needs, which requires the intervention of more professional categories beyond the FHS teams

The Expanded Family Health Center (NASF, in Portuguese) was created in 2008 as a Family Health Support Center, aimed at increasing the resolutive capacity of the FHS and expanding the care provided to users of the territories in question²2 Brasil. Ministério da Saúde (MS). Portaria no 154, de 24 de janeiro de 2008. Cria os Núcleos de Apoio à Saúde da Família - NASF. Diário Oficial da União 2008; 4 mar.. It is organized as a specialized back-up interdisciplinary team that operates by means of the matrix support methodology and of its two dimensions: technical-pedagogical and clinical-care. The refers to the methodology though which the support teams and the NASF have been constructing their interventions will engender different arrangements and configurations of the support function, with impacts on the production of health care.

Matrix support has proposed other means through which to organize work and clinical process management, which seeks to surpass rationales that produce a fragmented health carefocused on one single physician. It is intended to join NASF specialists from the support groups with users, aimed at increasing the capacity of analysis and intervention concerning the health problems within a given territory³3 Campos GWS. Um método para análise e cogestão de coletivos: a constituição do sujeito, a produção de valor de uso e a democracia em instituições: o método da roda. São Paulo: Hucitec; 2015..

Method

This study selected 17 regulations and publications written by the MH, edited in 2005 and 2021. These documents were accessed in the official websites of the federal government and were produced to regulate the public health policies of SUS throughout the first two decades of the twenty-first century. These contain the regulatory theoretical references and the referent guidelines to the NASF work processes and outlines, and defines how the professionals of this team should work.

Two objectives were the guiding principles of this documental analysis⁴4 Cellard AA. Análise documental. In: Poupart J, Deslauriers JP, Groulx LH, Laperrière A, Mayer R, Pires AP. A pesquisa qualitativa: enfoques epistemológicos e metodológicos. Petrópolis: Vozes; 2010. p. 295-316.^,55 Mattos RA, Baptista TWF, organizadores. Caminhos para análise das políticas de saúde. Porto Alegre: Rede UNIDA; 2015.: identify the NASF’s organizational proposal and their main changes throughout their implementation, as well as to reflect on the guidelines defined in these documents regarding the work process and the matrix support concept.

For the purpose of understanding, the period of analysis was divided according to Chart 1. These periods were produced and marked as the expression of sociohistorical time, and were driven by a wide range of interests that were often distinct and contradictory to SUS itself.

The initial period had the characteristics of core demands from different subjects, in addition to the first designs of the arrangement of the interdisciplinary team. In the second period, after the creation of the team, one can see an effort on the part of the MH to disclose and disseminate the matrix support and the other support devices, with the inclusion of the NASF in the first review of the PNAB. In the third movement, new organizational parameters were established and the work tools were improved, aimed at universalizing support. In the fourth period, it is possible to verify the increase in the number of NASF teams nationally, and the changes in how the team is managed. In the fifth and final period, other cost parameters are defined and a pandemic of catastrophic proportions ravages the country, imposing adaptations in NASF’s organization and work.

A survey was conducted to determine the number of NASF teams registered in the System of the National Health Facility Registry (SCNES, in Portuguese) - a historical series conducted from 2008 to 2021 - with the intention of numerically illustrating the repercussions of the analyzed documents, if they favor the implementation of new teams or if they represent a reduction in these.

Chart 2 presents 17 analyzed documents, as well as the subsequent results. The second column lists the main incorporations, changes, and alterations identified in the regulations and publications, movements that shaped the NASF work process.

Results

1^st period: 2003 to 2007 - previous movements

In the construction of a public policy, aspects of technical order share space with ideological and corporate interests form professional categories, often generating a clash between power and knowledge⁵5 Mattos RA, Baptista TWF, organizadores. Caminhos para análise das políticas de saúde. Porto Alegre: Rede UNIDA; 2015.. NASF can be understood as an organizational arrangement that arose due to this power play, city hall requesting financial incentives and the professional boards seeking greater insertion in SUS⁶6 Almeida ER. A gênese dos Núcleos de Apoio à Saúde da Família [tese]. Salvador: Universidade Federal da Bahia; 2016..

Another factor that contributes to the construction of SUS policies are the successful municipal experiences, which are projected as good practices. In the process of the creation of NASF, it is possible to identify some pioneering incentives in key municipalities, such as Betim/MG; Brumadinho/MG; Campinas/SP; Camaragibe/PE; Contagem/MG; Florianópolis/SC; Niterói/RJ; Santos/SP; and Sobral/CE⁶6 Almeida ER. A gênese dos Núcleos de Apoio à Saúde da Família [tese]. Salvador: Universidade Federal da Bahia; 2016.^,77 Gutiérrez AC. Núcleo de Apoio a` Saúde da Família do Território Escola Manguinhos: análise sob a perspectiva do apoio matricial [tese]. Campinas: Universidade Estadual de Campinas; 2014..

In 2003, the MH began the initial discussions concerning the Full Health Center, a project for the inclusion of an interdisciplinary team in Primary Care. The studies did not advance. However, in 2005, the proposal began to take shape as the Total Family Health Care Center (NAISF, in Portuguese)⁸8 Brasil. Ministério da Saúde (MS). Portaria no 1.065, de 4 de julho de 2005. Cria os Núcleos de Atenção Integral na Saúde da Família, com a finalidade de ampliar a integralidade e a resolubilidade da Atenção a` Saúde. Diário Oficial da União 2005; 4 jul.. Suggested with the purpose of expanding the resolutive capacity of the FHS, promoting comprehensive health care and actions of health promotion, the decree to create the NAISF was revoked two days after publication, with the justification of the non-definition of the financial contributions allocated to the municipalities⁶6 Almeida ER. A gênese dos Núcleos de Apoio à Saúde da Família [tese]. Salvador: Universidade Federal da Bahia; 2016.. Despite its short lifespan, it is possible to find articles that mention the implementation of some types of NAISF⁹9 Véras MMS, Quinderé PHD, Ferreira LP, Aragão JMGA, Coelho MAAA. Sistema de Informação dos Núcleos de Atenção Integral na Saúde da Família - SINAI. Saude Soci 2007; 16(1):165-171.^,1010 Oliveira CO, Rocha RM, Cutulo LRA. Algumas palavras sobre o Nasf: relatando uma experiência acadêmica. Rev Bras Educ Med 2012; 36(4):574-580..

The proposal for interdisciplinary support was brought back in 2007, with the debates being led by a working group proposed by the MH. After intense discussions, the control group understood that the said team model and specialized back-up, focused on the support function and on thematrix support would enable a broader scope of care⁶6 Almeida ER. A gênese dos Núcleos de Apoio à Saúde da Família [tese]. Salvador: Universidade Federal da Bahia; 2016.. In the following year,Decree 154/2008 was published, which created the NASF²2 Brasil. Ministério da Saúde (MS). Portaria no 154, de 24 de janeiro de 2008. Cria os Núcleos de Apoio à Saúde da Família - NASF. Diário Oficial da União 2008; 4 mar..

2^nd period: 2008 to 2011 - support guidelines

With the creation of the NASF, the MH was able to create the NASF according to its main interests; to define the values to be allocated to the municipalities for the implementation and maintenance of the teams; to make it possible to expand the scope of the intervention in the Basic Health Units (BHU), through the co-management³3 Campos GWS. Um método para análise e cogestão de coletivos: a constituição do sujeito, a produção de valor de uso e a democracia em instituições: o método da roda. São Paulo: Hucitec; 2015. and interaction of the interdisciplinary team with the FHS professionals; and to enable the expansion of the work market for 13 professional units in the health area.

Even though it was derived from the Paidéia theory set forth by Gastão Wagner de Sousa Campos, the key concept of the matrix support, which defines the means of interaction between a support group - NASF - and the reference teams - FHS - is not mentioned in Decree 154. It is believed that this fact may well have been the authors’ strategy to diminish the resistance to the proposal in this format, which had resulted from the prior discussions concerning the NAISF. At this time, two groups politically disputed the goals of the team to be created - as a support team (matrix) or as a group of specialists to provide direct care to the users⁶6 Almeida ER. A gênese dos Núcleos de Apoio à Saúde da Família [tese]. Salvador: Universidade Federal da Bahia; 2016.. Despite the omission of the concept, continued education and clinical care for specific cases appeared as actions to be carried out by the NASF, joining the two forces in the same proposal.

As of the expansion of the number of NASFs, the MH began the qualification process of the professionals’ work processes. The increase in the scale of the teams in the National Health Facility Registry (CNES) shed light on the need to discuss how these practices had been developed, in part due to the difficulty of operating within the logic of the matrix support¹¹11 Melo EA, Miranda L, Silva AM, Limeira RMN. Dez anos dos Núcleos de Apoio à Saúde da Família (Nasf): problematizando alguns desafios. Saude Debate 2018; 42(1):328-340..

In 2009, the Basic Care Notebook (BCN), number 27 - NASF guidelines was launched. The BCN 27 was presented with the expectation that the publication can truly strengthen Primary Health Care (PHC) in Brazil, by increasing the knowledge of the teams that work in this area, be they FHS teams, NASF teams, or general management teams¹²12 Brasil. Ministério da Saúde (MS). Secretaria de Atenção a` Saúde, Departamento de Atenção Básica, Núcleos de Apoio à Saúde da Família. Cadernos de Atenção Básica, número 27. Brasília: MS; 2009. (p. 8). The text seeks to mark the action primarily in a perspective of shared and interdisciplinary work, making it explicit that the individual approach conducted directly with the users should occur only in extremely necessary situations (p. 8), seeking to move away from the outpatient model that the inclusion of FHS specialists might suggest.

The BCN 27 points to integrality as the main guideline of the team, as it is of full care provided to users and collectives that it is possible to plan a less fragmented care, anchored in the specific needs of each territory. In addition, it presents and discusses the agreement concerning support functions, the matrix support, the expanded clinic, the single therapy project, and the health project in the territory, defined as necessary technological tools for the organization and development of actions.

In the previous chapters, the publication presented the nine strategic areas of NASF action, with reflections regarding the context of these areas in the national scenario, the policies in place, and their main challenges. Debated were the means of the formulation and agreement on collaborative work within the FHS, integration strategies, and other means through which to insert specialties within BHUs.

In 2010, the country registered an increase in the number of crack users. The “crack epidemic”, as it was called by the media, forced the MH to institute diverse measures to tackle the problem¹³13 Nappo SA, Sanchez ZM, Ribeiro LA. Is there a crack epidemic among students in Brazil?: comments on media and public health issues. Cad Saude Publica 2012, 28(9):1643-1649.. One of these was the creation of another modality of the NASF - NASF 3 - geared toward full care in mental health, focused on crack, alcohol, and other drug users in municipalities with less than 20,000 inhabitants¹⁴14 Brasil. Ministério da Saúde (MS). Portaria no 2.843, de 20 de setembro de 2010. Cria, no âmbito do Sistema Único de Saúde - SUS, os Núcleos de Apoio à Saúde da Família - Modalidade 3 - NASF 3, com prioridade para a atenção integral para usuários de crack, álcool e outras drogas. Diário Oficial da União 2010; 20 set.. The typology was revoked in the first revision of the PNAB in 2011¹⁵15 Brasil. Ministério da Saúde (MS). Portaria no 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica. Diário Oficial da União 2011; 21 out., with the teams being converted into NASF 2. The NASF 3 returned in 2012, with a different arrangement.

The PNAB of 2011incorporated important changes that were being implemented in SUS, as is the case of NASF. The text included the matrix support concept, which appears in four key moments, not necessarily associated with the NASF practice. On the first occasion, the text was based on permanent education and the processes of institutional support, as in one of the “provisions for support and horizontal cooperation”¹⁵15 Brasil. Ministério da Saúde (MS). Portaria no 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica. Diário Oficial da União 2011; 21 out. (p. 7). After, the text mentioned the item about the formulation of the workload of the FHS professionals, who can use part of the work shift with permanent education activities and the matrix support. Regarding the attributions of the NASF, the supporter should work by sharing knowledge and health practices, through actions of the matrix support, together with associated teams. Moreover, upon ascribing some functions to the public health official - category recently inserted in the team - the matrix support concept is cited for the 4^th time in the PNAB. The text indicates that these professionals “can reinforce the institutional support and/or the matrix support, so long as these are exclusive to them”¹⁵15 Brasil. Ministério da Saúde (MS). Portaria no 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica. Diário Oficial da União 2011; 21 out. (p. 16).

Other changes are related to the formulation and work shifts of the centers. New professional categories were included - totaling 19 professions - which became part of both of the NASF typologies. In addition to having new specialties available to them, the municipalities had the freedom to define their arrangement through the choice of the manager. They also established the minimum work shift for the teams and the reduction in the number of associated teams.

Much like the BCN 27, the PNAB reinforced the collective and educational character of the NASF actions. In one excerpt where the activities to be developed are pointed out, the “collaborative care or not” is cited, avoiding the use of the expression “individual care”. Once again, the commitment is that of not “outpatienting” the conduct of the specialists, providing a type of action geared toward the pedagogical dimension of the matrix support.

3^rd period: 2012 to 2015 - universalization of NASF

In 2012, two decrees were edited with effects concerning the NASF. The 1^st updated the variable Basic Healthcare package (PAB, in Portuguese), giving a 1/3 increase in pay for the NASF 2 teams, but maintaining the same values for the NASF 1 team¹⁶16 Brasil. Ministério da Saúde (MS). Portaria no 978, de 16 de maio de 2012. Define valores de financiamento do Piso da Atenção Básica variável para as Equipes de Saúde da Família, Equipes de Saúde Bucal e aos Núcleos de Apoio a` Saúde da Família, instituídos pela Política Nacional de Atenção Básica. Diário Oficial da União 2012; 16 maio.. The 2<sup>nd</sup> redefined the parameters of the connection of the two modalities of already existing teams and recreated the NASF 3, this time with no connection to the questions linked to drug use and drug abuse<sup>17</sup>17 Brasil. Ministério da Saúde (MS). Portaria no 3.124, de 28 de dezembro de 2012. Redefine os parâmetros de vinculação dos Núcleos de Apoio a` Saúde da Família (NASF) Modalidades 1 e 2 às Equipes Saúde da Família e/ou Equipes de Atenção Básica para populações específicas, cria a Modalidade NASF 3, e da´ outras providencias. Diário Oficial da União 2012; 28 dez..

As in the other modalities, the NASF 3 can contain any one of the 19 professional categories established in the last version of the PNAB. However, it should accompany one or two teams, which enables a closer relationship than in other arrangements, “configuring as an expanded team”¹⁷17 Brasil. Ministério da Saúde (MS). Portaria no 3.124, de 28 de dezembro de 2012. Redefine os parâmetros de vinculação dos Núcleos de Apoio a` Saúde da Família (NASF) Modalidades 1 e 2 às Equipes Saúde da Família e/ou Equipes de Atenção Básica para populações específicas, cria a Modalidade NASF 3, e da´ outras providencias. Diário Oficial da União 2012; 28 dez. (p. 3). For the already existing modalities, the decree led to the reduction in the number associated teams: NASF 1, from five to nine teams, and NASF 2, from three to four teams. This reduction was an important movement of the MH in the sense of qualifying the support provided by the NASF, which began to dedicate itself to the follow-up of less teams and users. In addition, the creation of the NASF 3 enabled the universalization of the support to all Brazilian municipalities with FHS or BHU teams for specific populations, regardless of its territorial or populational extension.

In the first semester of 2013, the MH published two decrees on the same day. One increased the valued transferred to NASF 2 by 50%, in addition to allocating the rest to the NASF 3. The other defined the incentive of the 2^nd cycle of evaluation of the National Program for Access and Quality Improvement in Primary Care (PMAQ-AB)¹⁹19 Brasil. Ministério da Saúde (MS). Portaria no 562, de 04 de abril de 2013. Define o valor mensal integral do incentivo financeiro do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB), denominado como Componente de Qualidade do Piso de Atenção Básica Variável (PAB Variável). Diário Oficial da União 2013; 4 abr.. This cycle allowed for the adherence of all of the teams to Primary Care and the performance, for the first time, linked to the evaluative processes of the NASF teams throughout the country²⁰20 Brocardo D, Andrade CLT, Fausto MCR, Lima SML. Núcleo de Apoio à Saúde da Família (NASF): panorama nacional a partir de dados do PMAQ. Saude Debate 2018; 42(Esp. 1):130-144.^,2121 Lima RSA, Nascimento JA, Ribeiro KSQS, Sampaio J. O apoio matricial no trabalho das equipes dos Núcleos de Apoio à Saúde da Família: análise a partir dos indicadores do 2º ciclo do Programa Nacional de Melhoria do Acesso e da Qualidade. Cad Saude Colet 2019; 27(1):25-31..

After having defined the new parameters, the MH once again began to qualify the work process, and in 2014, it published the BCN 39 - NASF - Volume 1: Tools for management and daily routines. If in the BCN 27 the objective was to debate the support guidelines, this second volume presented the “how to do”. Its having been launched five years after the implementation of the NASF allowed for the accumulation of experiences necessary to draft the technical material that would dialogue with the practice and that could reflect on the main overlappings in the operationalization of the matrix support²²22 Brasil. Ministério da Saúde (MS). Secretaria de Atenção a` Saúde, Departamento de Atenção Básica. Núcleo de Apoio à Saúde da Família. Cadernos de Atenção Básica, número 39. Brasília: MS; 2014..

The publication of part of the actions that comprised the agenda of the professionals to contemplate the matrix support, reflecting on the necessary infrastructure and condition for these activities to take place. The structuring elements of the interventions were defined as follows: the meeting of the matrix support; the meeting of the NASF team; the shared and specific individual care; the shared and specific home care; the shared and specific collective activity; and the creation of support materials, routines, protocols, among other actions of permanent education.

The BCN 39 also debates other tools and word strategies, such as work in groups, the genogram, and the ecomap. These are all part of the menu of activities that the technicians can make use of, but these should not be limiting or restrictive in relation to the other possibilities and paths that may arise, such as work by means of addressed demands and with offers from supporters, based on singular situations.

The publication lists some challenges for shared work, such as the lack of training to work under the logic of the matrix support, the multiplicity of demands that are addressed to the supporters, and the lack of knowledge about the different possibilities of NASF actions. It points out suggestions to tackle these questions, be it through meetings and rounds of conversation to reflect on the daily challenges, or as of the direct intervention of the managers to mediate conflicts and impasses.

4^th period: 2016 to 2018 - expansion of support

In 2015, an outbreak of cases of newborn children with microcephaly and other genetic malformations attributed to the Zika virus were identified, especially in the Northeast region. Faced the sanitary emergency, the MH authorized Brazilian municipalities to implement NASF teams²³23 Brasil. Ministério da Saúde (MS). Portaria no 1.171, de 16 de junho de 2016. Credencia Municípios a receberem incentivos referentes aos Núcleos de Apoio a` Saúde da Família (NASF). Diário Oficial da União 2016; 16 jun.. The decree required that each team had at least one physical therapist and recommended that it also include an occupational therapist, a phonologist, or a psychologist, relevant professionals in the area of rehabilitation. With these strategies, the decree sought to instrumentalize the FHS to carry out actions of early stimulation and psychosocial support to the families undergoing follow-up.

To subsidize the work of the teams, the MH published the “Early Stimulation in Primary Care” in 2016. The guide affirms that it is up to the NASF to follow-up on family and children, as it is “very important that it also offer, in addition to shared care, specific individual care, according to the agreed therapeutic project”²⁴24 Brasil. Ministério da Saúde (MS). Secretaria de Atenção a` Saúde, Departamento de Atenção Básica. A estimulação precoce na Atenção Básica: guia para abordagem do desenvolvimento neuropsicomotor pelas equipes de Atenção Básica, Saúde da Família e Núcleo de Apoio a` Saúde da Família (NASF), no contexto da síndrome congênita por Zika. Brasília: MS; 2016. (p. 16-17). The manual illustrates the clinical dimension of health care within the matrix support, which can be understood as a change in the direction regarding the action of the NASF up to that moment. In the final considerations, the publication reiterates the guidelines, signaling the importance of the individual approach in early stimulation, and points out that this type of direct action would not contradict the precepts of the matrix support. In the second semester of 2017, the last review of the PNAB was published. One update accompanied many criticisms, both in relation to the process of construction without social participation, as well as the changes approved and their possible impacts on the weakening of SUS and the privatization of primary care²⁶26 Almeida ER, Sousa ANA, Brandão CC, Carvalho FFB, Tavares G, Silva KC. Política Nacional de Atenção Básica no Brasil: uma análise do processo de revisão (2015-2017). Rev Panam Salud Publica 2018; 42:e180.^,2727 Giovanella L, Franco CM, Almeida PF. Política Nacional de Atenção Básica: para onde vamos? Cien Saude Colet 2020; 25(4):1475-1481..

Regarding the NASF, the text contains important changes. The team takes on the name of Expanded Family Health and Basic Health Center (NASF-AB). The concept of “support” was removed, and the adjective “expanded” was added. With the change, the NASF-AB began to provide support to all teams, including the more recently created Primary Health team, a model concurrent with the Family Health.

In yet another careful reading, one can see that in addition to the change of the noun “support”, the matrix support concept is also removed from the Primary Health policy. Nonetheless, at the same time in which it is omitted as a concept, the principles of the matrix support are affirmed in the three specific competencies defined in the law. In item “a”, co-management appears through collaborative planning together with follow-up teams. Item “b” points to the expansion of the clinic and is able to synthesize the purpose of the action of the support team together with the reference team in order to contribute to the increase in the capacity of analysis and intervention and, consequently, to produce greater coefficients of autonomy. Item “c” lists the different possibilities and types of action, such as case discussions, individual care, the collaborative construction of therapeutic projects, permanent education, and the discussion of the work process, types of intervention that are directly linked to the two dimensions of the matrix support - clinical care and pedagogical.

5^th period: 2019 to 2021 - the dismantling of the NASF?

The four previous periods can be characterized as those in which the core aim was the institutionalization of a policy. All of the claims, clashes, and achievements were fruits of a long process of worker, user, and manager disputes, which materialized into the consolidation of the NASF. The 5^th and final period, marked by another position taken by the MH in relation to the team, coupled with the thousands of deaths caused by the SARS-CoV-2 pandemic, brings some uncertainties, which explain the reason for the subtitle in the form of a pessimistic question.

The Previne Brasil Program²⁸28 Brasil. Ministério da Saúde (MS). Portaria no 2.979, de 12 de novembro de 2019. Institui o Programa Previne Brasil. Diário Oficial da União 2019; 13 nov., edited in November 2019, established the new model of financing the cost for the PHC, a mixture comprised of weighted capitation, payment per performance, and incentives for strategic actions. The payment per performance is measured through the defined indicators in a specific decree, and for the years of 2021 and 2022, the interdisciplinary actions in the scope of PHC, among others, would be monitored²⁹29 Brasil. Ministério da Saúde (MS). Portaria no 3.222, de 1 de dezembro de 2019. Dispõe sobre os indicadores do pagamento por desempenho, no âmbito do Programa Previne Brasil. Diário Oficial da União 2019; 1 dez..

Regarding the incentives to strategic actions, the program does not include the NASF, which, in practice, extinguishes discretionary financing. In addition, it revokes diverse regulations, among which are Section II of the Consolidation Decree 2/GM/MS, from September 28, 2017, which defined NASF association parameters, such as workloads of the professionals and teams, and the minimum and maximum number of associated teams.

In response to the criticisms, the MH edited the Technical Note 03/2020³⁰30 Associação Brasileira de Saúde Coletiva (Abrasco). Em defesa da atenção primária e do direito universal a` saúde: pela revogação da Portaria nº 2979/19 do Ministério da Saúde [Internet]. [acessado 2021 jan 20]. Disponível em: https://www.abrasco.org.br/site/wp-content/uploads/2019/11/Nota_em_defesa_atencao_primaria_21_novembro_2019-1.pdf
https://www.abrasco.org.br/site/wp-conte... ^,3131 Brasil. Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Nota Técnica no 03/2020. [acessado 2021 ago 15]. Disponível em: https://www.conasems.org.br/wp-content/uploads/2020/01/NT-NASF-AB-e-Previne-Brasil.pdf
https://www.conasems.org.br/wp-content/u... , in which it assumed the extinction of the parameters of conformation and financing. It also informed that, according to that set forth in Decree 3.222/19, interdisciplinary team arrangements can be financed through the payment per performance in 2021, as interdisciplinary actions in the scope of PHC. The note indicates that the specialists can be registered together with the FHS team of the PHC team, becoming a fixed and organic member of these collectives.

The final regulation is Decree 37/2021, edited to substitute Decree 99/2020, which redefined the types of PHC teams in the SCNES, including team 72 - Expanded Family Health and Primary Care Center Team (NASF teams-AP)³²32 Brasil. Ministério da Saúde (MS). Portaria no 99, de 7 de fevereiro de 2020. Redefine registro das Equipes de Atenção Primária e Saúde Mental no Cadastro Nacional de Estabelecimentos de Saúde (CNES). Diário Oficial da União 2020; 7 fev.^,3333 Brasil. Ministério da Saúde (MS). Portaria no 37, de 18 de janeiro de 2021. Redefine registro das Equipes de Atenção Primária e Saúde Mental no Cadastro Nacional de Estabelecimentos de Saúde (CNES). Diário Oficial da União 2021; 18 jan.. Code72 joins the three NASF modalities, defines another name for the nucleus, and again allows new NASF teams to be registered in the CNES, which had been forbidden by Previne Brasil. As of the month of May 2020, the municipalities began their migration to the new code, a process that is still ongoing.

Reflection of the policies concerning the number of teams registered in Brazil

The data from Table 1 were grouped according to the five construction periods of this study. They enable the visualization of the historical-political construction of the team, showing the effects of the policies adopted by the MH since the implementation of the NASF, whether by leading to the creation of more centers - with the creation of NASF 3 - or by producing a reduction in the number of teams, as can be seen in the final period. The months of December of each year were used as the reference.

The numbers show a small growth in the four first years, during a period in which the NASF work proposal was still being presented. The publication of the CNB 27, the courses offered by the MH, and the inclusion of the team in the 1^st review of the PNAB of 2011, defined the guidelines for the matrix support and affirmed the NASF as an important Primary Care policy introduced by the MH.

The teams present a more expressive increase as of 2012, the year in which a wide range of relevant decrees were approved, such as Decree 3.124, which changed the NASF 1 and 2 association parameters, and recreated NASF 3; there was a new definition of team financing values in 2012 and 2013; a new BCN was edited in 2014, advancing in the discussion about the challenges and power of the NASF modes of operation.

The onset of the Zika virus and the publication of the PNAB of 2017, which in addition to the change in the name, brought about the expansion of the reach to all PHC teams and maintained the paths of growth and the consolidation of the interdisciplinarity, as of the specific NASF arrangement.

The scenario of expansion and gamble of the MH was interrupted in 2020, after having reached it highest number ever in January 2020, with 5,904 NASFs. The beginning of the fall in the number of teams registered in the SCNES happened together with the changes implemented by Previne Brasil and the arrival of COVID-19 in the country.

To analyze the reflections of the two years in place of the new model of financing of PHC, Table 2 and Graph 1 show the monthly variations of the number of NASF teams in 2020 and 2021.

It is possible to observe the gradual reduction in the registration as of February 2020, with oscillations in some months. The biggest drop was seen in May 2020, with the beginning of the migration to the new code - NASF-AP, with 111 teams unregistered. In December 2021, there were 5,525 NASF teams in the SCNES. Considering the two years of operation of the Previne Brasil, 379 NASF teams lost their accreditation.

It is important to highlight that Table 2, in addition to the validity of the new model of financing, reflects, as of March 2020, the effects of the COVID-19 pandemic. Measuring the influence of the pandemic and the economic questions that such a scenario involves, such as the reduction in the investments and need for the reallocation of financial resources to other sectors, produces a scenario of a differentiated analysis of other periods.

The supplementary material of this article is available from: https://doi.org/10.48331/scielodata.8PCFOH

Discussion

Through the results in the first four periods, it is possible to observe the construction and strengthening of the interdisciplinary arrangement proposed by the NASF. This process began in the expansion of the number of implemented teams, engendering the increase in the scope of the primary care interventions and contributing with the integrality of care provided to the users and the collective groups.

Since the publication of Decree 154 in 2008 until the last review of the PNAB, it was observed that the NASF was expanded to more health professionals; the parameters of association were reduced, bringing supporter and the supported closer together; all municipalities were able to implement their teams with financial backing from the MH, which also was also gradually increased; the managers gained higher degrees of autonomy so that they could shape the teams according to their demands, so long as they observed some key criteria of parameterization.

The BCN 27 guidelines, the first guiding document of the NASF, sought to establish a work directed toward technical-pedagogical actions, providing a new means of interdisciplinary collaboration. However, the resistance of some supporters in attending to care demands may have contributed to a list of questions criticizing the teams³⁴34 Klein AP, d'Oliveira AFPL. O "cabo de força" da assistência: concepção e prática de psicólogos sobre o Apoio Matricial no Núcleo de Apoio à Saúde da Família. Cad Saude Publica 2017; 33(1):e00158815.^,3535 Tesser CD. Núcleos de Apoio à Saúde da Família, seus potenciais e entraves: uma interpretação a partir da atenção primária à saúde. Interface 2016; 21(62): 565-578..

The BCN 39 was able to advance in relation to the tension between the individual care and the matrix support. In the entire text, the individual approaches are placed as one of the support dimensions, always connected to a shared care plan, without the use of provisos such as “only in extremely necessary situations”, as seen in BCN 27. It is understood that the justification for the use of these expressions was meant to establish a mode of operation that was different from the NASF, especially as regards the traditional forms of referrals. Such movements were guided by pedagogical actions, based on the sharing of knowledge and of permanent education, strategies used to produce the expansion of knowledge and the autonomy of the professionals that participate in them.

In the manual of Early Stimulation in Primary Care, the clinical care dimension becomes a protagonist in the interventions, ever-increasingly demonstrating that clinical actions geared directly to the user are not only part of the scope of actions, but they are also essential and complementary to the matrix support.

Considering the new configurations of the NASF teams-AP, where the manager has total freedom to define the arrangements and formulations, it is understood that these changes can bring risks to the continuity of this interdisciplinary team model, be it related to the criteria to be used in more flexible formulations, or even through the termination of discretionary financing³⁶36 Massuda A. Mudanças no financiamento da Atenção Primária à Saúde no Sistema de Saúde Brasileiro: avanço ou retrocesso? Cien Saude Colet 2020; 25(4):1181-1188.^,3737 Morosini MVGC, Fonseca AF, Baptista TWF. Previne Brasil, Agência de Desenvolvimento da Atenção Primária e Carteira de Serviços: radicalização da política de privatização da atenção básica? Cad Saude Publica 2020; 36(9):e00040220..

Furthermore, some questions need to be asked: How can high-quality follow-up be offered without minimal parameterization? In the case of professionals being registered directly as members of the FHS team or of the PHC team, would this not be returning to the model prior to the Family Health Strategy, in the molds of outpatient or health centers? What actions of matrix support would these professionals be able to sustain in their daily routines, or do they intend to centralize the interventions only in direct care?

By contrast, the strengthening of the clinical care dimension at the expense of the pedagogical dimension can weaken the processes of clinical reformulation and management, which NASF’s mode of operation proposed. The omission of the matrix support concept from the PNAB, the removal of the substantial support of the name of the team, and the termination of discretionary financing incentives suggest an intentional maneuver and coordination toward its dismantling. To achieve more democratic, autonomous, and participative spaces within SUS, the matrix support has lost ground in the health policies of the Bolsonaro government.

Final considerations

This study concludes that in its first two years in place, the Previne Brasil Program promoted the dismantling of the NASF, with the reduction of 379 teams, representing a setback to the approximate number of NASF teams that were registered in February 2018. It is believed that the decrees that have been issued since 2019, such as those that modified the means of financing primary care and that changed the registration of the SCNES teams sought, among other purposes, to substitute the NASF for other types of interdisciplinary teams. It is important to note that one of the indicators of the payment per performance, set forth in Decree 3.222/2019are the interdisciplinary actions of the PHC. While the NASF loses funding and the teams are discontinued, other arrangements are encouraged by the MH.

Few active teams have a direct impact on the number of professionals in activity, reducing the capacity of SUS actions when faced with accumulated scenario of millions of people infected by COVID-19, in addition to producing the non-care for those people undergoing follow-up by NASF teams that have lost their accreditation. In the context of a long-lasting pandemic, with the large number of diseases and sequelae resulting from the disease³⁸38 Miranda DAP, Gomes SVC, Filgueiras PS, Corsini CA, Almeida NBF, Silva RA, Medeiros MIVARC, Vilela RVR, Fernandes GR, Grenfell RFQ. Long COVID-19 syndrome: a 14-months longitudinal study during the two first epidemic peaks in Southeast Brazil. Trans R Soc Trop Med Hyg 2022; trac030., Primary Care will need to create mechanisms of identification and clinical care for these cases³⁹39 Ruiz D. Pós-Covid-19 e a importância da ESF para o cuidado e reabilitação [Internet]. [acessado 2022 maio 10]. Disponível em: http://link.abrasco.org.br/accounts/118857/messages/803?email=mauriciomattos@gmail.com&c=1629033523&contact_id=55830&envelope_id=658
http://link.abrasco.org.br/accounts/1188... , many of which will demand interventions from different professional centers, renewing the potential of teamwork. In this light, the NASF represents the strategic arrangement for the multifactorial approach to these diseases - together with the PHC teams - given that the participation of specialists from the social services, physical therapy, nutrition, psychology, phonology, among other categories that can participate in the team, expand the capacity of health units to respond to the new and traditional demands from the many territories within the country.

Regarding the termination of discretionary funding, such initiatives as the Primary Health Care Financing Program of the State of Rio de Janeiro (PREFAPS)⁴⁰40 Secretaria de Estado de Saúde. Resolução SES n° 1938 de 25 de novembro de 2019. Altera a resolução SES N° 1.846, de 9 de maio de 2019, que aprovou o Programa de Financiamento da Atenção Primária a` Saúde do Estado do Rio de Janeiro. Diário Oficial do Estado do Rio de Janeiro 2019; 25 nov., which included the NASF in the list of teams financed at the end of 2019, has been contributing in an attempt to maintain the centers, thereby strengthening the FHS teams in the pandemic scenario. In the PREFAPS, the NASF 1 and NASF 2 teams of the municipalities of the Fluminense region of Rio de Janeiro receive monthly financial incentives, referred to as sustainability in the component program. Another incentive - the expansion component - is paid in one single payment for newly implemented teams, functioning in the same molds adopted by the MH before Previne Brasil.

Since its creation in 2008, NASF’s mode of operation was constantly adapting to the prerogatives of SUS. If in the beginning it was primarily geared toward actions of the matrix support, it was observed that direct care was not contradictory to that set forth in the matrix support. The search for a balance between the two dimensions - pedagogical and clinical care - taking as the starting and ending points the needs from the users and collective groups, produces interventions geared toward expanded and shared clinics, as well as the co-management of health care. Being able to shape the diverse possibilities of intervention is the result of daily construction, conducted through the micro-policy of interdisciplinary work. To achieve this, both teams, supporters and the supported, need to be open to interaction and to new possibilities.

References

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History