The paper discusses the National Humanization Policy - HumanizaSUS (PNH), the Ministry of Health, from the narratives of his supporters and how understand their task in the Brazilian National Health System (SUS). It presents some doctoral research results, cartographic perspective, in which the narratives of the supporters of the different instances of SUS were intertwined. It is considered that a network is produced and heated by many anonymous, SUS workers, some of whom are also nicknamed supporters that maintains health as a dimension of citizenship from anyone, despite the complex national scene.
National Humanization Policy; Institutional support; Brazilian National Health System
The Política Nacional de Humanização - HumanizaSUS (PNH – National Humanization Policy) was created by Brazil’s Ministry of Health in 2003, based on the recognition of innovative and concrete experiences that compose a “SUSccSUS = Sistema Único de Saúde (Brazil’s National Health care System).[†] that succeeds”. For more than a decade, the PNH has fostered changes in care and management by inviting the subjects involved to reflect on and intervene in the daily routine of the Brazilian public health.
HumanizaSUS has produced movements within the SUS. Although this policy was triggered by the federal management, it has not been limited to the group of consultants who were hired to work in it. Many supporters contribute to heat the network that sustains health as a dimension of citizenship, despite many challenges. Who the supporters are and how they understand their task in the SUS are our guiding questions.
This article is part of the doctoral dissertation "A Política Nacional de Humanização na produção de inflexões no modelo hegemônico de cuidar e gerir no SUS: habitar um paradoxo" (The National Humanization Policy in the production of inflections in the hegemonic model of providing care and managing in the SUS: inhabiting a paradox), submitted to the Psychology Postgraduate Program of Universidade Estadual Paulista (UNESP), Assis campus. For this discussion, we were supported by thinkers of the Philosophy of Difference and of Collective Health, mainly those aligned with HumanizaSUS. They helped us in this enterprise because they see signs of captures and of forms of resistance, without regretting the present.
Navigating across narratives and events
In this cartography, we were interested in the encounters, stories andordinary work situations, as well as in the things we found strange, in the questionings and struggles that were produced throughout our trajectory in the HumanizaSUS. The cartography is configured as an experimentation that searches for other modes of narrating, researching and creating. It is an exercise of meeting the “[…] challenge of making science without a determined form and with no anticipated truths that overcode and imprison the potentialities of the very encounter”22. Fonseca TMG, Kirst P. Cartografias e devires: a construção do presente. Porto Alegre: Ed. UFGRS; 2003.(p. 10).
We problematized HumanizaSUS based on our trajectory with and in the PNH, mainly our experience as a consultant with the Ministry of Health from 2010 to 2013,and on the dialog with diverse workers of the SUS and in favor of the SUS – the many supporters that will be introduced below.
The study was approved by the Research Ethics Committee of UNESP/Assis, opinion no. 175,85. It was also authorized by the members and by the National Coordination of the HumanizaSUS Policy. The subjects involved in the study signed a consent document. One copy of this document is filed with us.
We view narratives as facets of reality, precious moments that open spaces so that analyses, challenges, anxieties, findings and interventions in the current state of affairs cangain strength and expression. Transformations are processes that are always put to the test, without a full stop. We agree with Blanchot33. Blanchot M. O livro por vir. São Paulo: Martins Fontes; 2005., who argues that “[...] the narrative is nota report on the event; rather, it is the event itself, the access to this event, the place where it is summoned to happen” (p. 8). It was an invitation so that we could “rejuvenate and age at once”, an event to Deleuze and Guattari44. Deleuze G, Guattari F. O que é a filosofia? Rio de Janeiro: Ed. 34; 1992..
Two opposed dimensions – subject and object –meet each other in the narratives and compose the same movement. When we read documents, listen to the supporters and problematize practices, we confirm that the production of the social world and desire, as Guattari55. Guattari F. Revolução molecular. Rio de Janeiro: Brasiliense; 1981. teaches us, is not in opposed poles, as modern rationality insists. The production of health, subjects and of the world are inseparable quantities. By viewing them as undergoing constant mutation, they inaugurate issues when the supporters think and narrate about themselves in the world.
The supporters and their task in the SUS and in favor of the SUS
In favor of the right to high-quality health for any individual and reaffirming the principles of the Brazilian Constitution, the HumanizaSUS Policy has accumulated experiences, partners and productions since its creation, in 2003. The PNH has produced experimentations in the SUS, indicating inflections in the direction that seemed to be the only possible one. These events promote differences in the subjects, practices and health services, as we will illustrate through the supporters’ narratives.
“No one knows the entire SUS”, as I learned with Nelson Santos in a lesson he taught more than a decade ago, when I was attending a postgraduate course in Mental Health offered by UNICAMP, in the city of Campinas (state of São Paulo). This idea, coming from one of the formulators of the SUS and great defender of the Brazilian universal healthcare, emphasizes the complexity derived from the many nuances of the ongoing experience in the country. The SUS is a collective production, and its countless hindrances and riches can only be understood when studied by many of us.
We started from Santos’ proposal and we dare state that it can be applied to the PNH and to other policies that aggregate subjects by producing networks and agencies in the SUS. These common subjects who produce collective experiences, bet on the public dimension, and struggle for high-quality health as a right already indicate an event.
HumanizaSUS is more than the sum of the Technical Nucleus and of the National Coordination, both located in Brasília (the capital city of Brazil), as well as of the regional consultants hired by the Ministry of Health. This benchmark, which values anonymity instead of ownerships and authorships, is not something trivial. Many times, we participated in hot discussions that disputed the meaning of humanization and the forms of implementing it.
The statement “for us in the PNH...”brings at least three non-antagonistic positions: sometimes, it marked the consultants’ position as official representatives of the Ministry of Health; sometimes, the place of authority that was added to an authoritative bias, guaranteeing the primacy of the meaning of humanization; and, sometimes, it defined a large “anonymous army"66. Santos NR. Posfácio. In: L’ Abbate S. Direito à Saúde: discursos e práticas na construção do SUS. São Paulo: Hucitec; 2010. p. 281-83., whose ethical affinities keep them together in the struggle for changes in the SUS and in favor of the SUS.
A result of the reform movements in the field of health, HumanizaSUS is produced by its many supporters. “Supporter” is the term that is commonly used to indicate the subjects who exercise the function of institutional support, viewed as a device and method, in the Policy’s experimentations. Even among the supporters, there are different understandings of how this function is performed.
On a razor’s edge, we have, on the one hand, HumanizaSUS as a composition, marked by the inclusion of different forms of thinking about and operating the support, a Policy that bets on the production of a common dimension and on singular practices that respond to the problems and challenges of the daily routine of the SUS. On the other hand, we observed that there are signs of standardization, in an attempt to produce greater alignment, and this may cause inflexibility in the modes of supporting. Thus, we highlight “[…] the ‘risk’ that is always present in a policy – that is expected to be collective, contingent and procedural – of functioning coopted by the State forces."77. Vasconcelos MFF, Martins CP, Machado DO. Apoio institucional como fio condutor do Plano de Qualificação das Maternidades: oferta da PNH em defesa da vida de mulheres e crianças brasileiras. Interface (Botucatu). 2014; 18(1):997-1011.(p. 204).
In the federal management, there are the consultants, a group hired by the Ministry of Health that, among other tasks, support humanization actions in the territories to which they are reference. In addition, there are subjects who identify with the PNH and are the many partners of the Policy. Furthermore, the term “supporter”is used to designate the people who attended education courses fostered by the partnership among the federation’s entities.
One of the problematic issues for the Policy is whether the education and intervention processes, mainly the courses that educate supporters, which have been offered since 2006, are able to amplify the participants’ capacity for analysis and intervention88. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Política Nacional de Humanização. HumanizaSUS: documento base para gestores e trabalhadores do SUS. Brasília (DF): MS; 2010..“Do we educate supporters?” is one of the recurrent questions that mobilize the PNH members.
There is a support movement in the SUS that cannot be reduced to the policies of the federal management. This methodology, recognized in Collective Health as “[…] one of the most important innovations […] aligned with the defense of rights and with democratic participation in the SUS"99. Passos E, Barros E, Nunes G, Teixeira R, Paula T. Apresentação. Interface (Botucatu). 2014; 18(1):805-6. (p. 805), has been gaining strength, influencing the sanitary movement1010. Campos GWS. Apoio matricial e institucional em Saúde: Liane Righi entrevista Gastão Wagner de Souza Campos. Interface (Botucatu). 2014; 18(1):1145-50. and being configured as a field of experimentation, marked by theoretical-methodological convergences and divergences.
Although this is not exclusive to the PNH, we would like to highlight that the HumanizaSUS experience of promoting decentralized actions in states and municipalities based on support relations is a benchmark in the federal management. The "[...] PNH is the only policy of the Ministry of Health that has maintained action, discourse and a theoretical formulation about Institutional Support from 2003 up to the current days."1111. Pereira Júnior N. O apoio institucional no SUS: os dilemas da integração interfederativa e da cogestão [dissertação]. Campinas (SP): Universidade Estadual de Campinas; 2013. (p. 74).
We found, in the supporters’ narratives, diverse positions about how to exercise this function. Rather than formulating a simplistic answer to the question posed by the PNH and mentioned above, we are interested in monitoring and finding evidence that there are workers in the SUS and in favor of the SUS –and many of them also call themselves supporters - who understand their action as reported by the narrative below:
“Being a supporter means always be learning something new, because the supporter isn’t ‘the guy’, but a person who stimulates inclusion, group work, being together… I just can’t be afraid of trying, nor of making mistakes! If I make a mistake, I do it again in a different way, I apologize, I ask for help, I transform…”. (emphasis given by the supporter).
It is in this learn-by-doing in a job, which implies daring, asking for help, making mistakes, apologizing, betting on inclusion and on the construction of collective spaces, that HumanizaSUS, as well as its supporters, have been producing themselves during a little more than a decade.
Support is considered a devicedd According to Foucault and Deleuze, a device is a network whose compositionis heterogeneous, a set of lines of different natures that configure a machine that makes one see and speak (lines of visibility and enunciation) articulated with the dimensions of power and creation (lines of strength and subjectivation).[‡] and the method of the PNH, a mode of operating in the daily routine of the SUS that implies taking it as something that it is not a priori; rather, it is produced in the relationship among people, institutions, knowledge, powers, practices and other elements. Therefore, the goal of supporting a group is to operate among the working processes that compose the daily routine of the service, making diverse agencies and analyzing verticalities and authoritarianisms in the provision of healthcare for the collective creation of coping.
Supporter and group gradually construct, based on a given reality and on local challenges, spaces to share the finding of strange things, which can produce inflections in the hegemonic forms of providing care and managing in the field of health. This is a bet on the daily exercise of democracy, on the creation of subjects and not on their deletion, on a permanent negotiation in the construction of health as the common good1313. Martins CP, Luzio CA. Experimentações no apoio a partir das apostas da Política Nacional de Humanização – HumanizaSUS. Interface (Botucatu). 2014; 18(1):1099-106..
Thus, the PNH has made an inflection inside the other health policies, aiming at the integrality of the practices and trying to overcome the fragmentation of care, being marked by the inseparability between care and management. It has even produced detours in the traditional modes of policymaking and in the vertical and uniform programs of the federal management that have been determining the actions taken in every corner of the country.
We are aware that “[...] no detour is definitive”44. Deleuze G, Guattari F. O que é a filosofia? Rio de Janeiro: Ed. 34; 1992. (p. 116), but this inflection, throughout more than a decade, has configured a scenario composed of many subjects, partnerships and productions. The several managements of the HumanizaSUS Policy have created, with the Ministry of Health, strategies to produce movements in the interior of the machine and also in diverse points of the network, in an attempt to contribute to the effective implementation of the constitutional principles.
Finding breaches to produce changes
One of the many deadlocks that we found concerned the term “humanization”. Although polysemic, polemic, grounded in the SUS and causinga broad debate in the field of Collective Health, humanization as proposed and defended by the PNH understands that there is not an ideal human, and refers to the “[…] always unfinished task of reinvention of our humanity."1414. Benevides R, Passos E. A humanização como dimensão pública das políticas de saúde. Cienc Saude Colet. 2005; 10(3):561-71. (p. 570).
The term “humanization” was already marked by the bias of goodness, favor and protectorship. The challenge was to make humanization be able to stammer, as Deleuze proposes1515. Deleuze G. Crítica e clínica. São Paulo: Ed. 34; 1997.. Inventing other uses and meanings, creating new problems and producing uncommon connections so that humanization contained the more than “[…] one thousand struggles waged on a daily basis by the users and workers of the SUS"1616. Benevides R. Mensagem para os 10 anos da PNH [Internet]. Brasília (DF); 2013 [acesso 28 Nov 2013]. Disponível em: http://www.redehumanizasus.net/67594-mensagem-de-regina-benevides-para-os-10-anos-da-pnh
In this play of forces, homogenizing and idealized discourses regarding the human dimension, as well as the State marked by charity and control mechanisms, are weakened. In 2003-2004, a new political moment enabled a breach, and one group, “the infiltrated”, betted that there were other ways of doing politics. These dimensions start composing the federal management concomitantly, affecting actors and disputing meanings, financing, and political-institutional and academic spaces.
In the conversation circles in which we participated and in the supporters’ narratives, the term “humanization” was understood as one of the supporters tells us: “[...] I used to think that, to humanize the SUS, it would be necessary to pat the users on their heads”. Many workers mentioned, in amazement, that they ignored the dimension of the changes proposed by the PNH: “[…] I remember that I talked to a colleague […] I told her that the person who is humanized is humanized, period. I’m overloaded and I can’t assume one more activity”.
In a daily routine full of tired and resigned subjects, the supporter explains that he and his colleagues were
“[...] used to bureaucratic, authoritarian and centralizing organizations that value the production of procedures and activities and forget to analyze the results and effects for the professionals. The professionals, who, in the majority of times, are overloaded, do not evaluate their working processes and do not interfere to change them. It becomes easier to transfer the problem to another person than to assume the responsibility for its resolution”.
The hindrances and challenges of the SUS, very well known by its actors, were taken as the point-of-departure for the PNH, which attempted tore-write the experiences, emphasizing the capacity for reinventing the clinic, the management and the traditional forms of working in the field of health. Thus, the tone of benevolence, festivity and of something superfluous that had marked the theme up to then was replaced – at least in the perspective of official documents and in many supporters’positions – by the radicalness of an invitation for the people involved to dare rethink their working processes, transforming them in order to struggle to guarantee users’ and workers’ rights.
One supporter tells us that
“[...] not always do we need great maneuvers, great investments (of course, in many situations, these are necessary); I’ve learnt that it’s not necessary to expect or search for great solutions, magical solutions; rather, we must search for partners, co-partnerships, and dialog, sharing problems and solutions”.
There is an event, signaled in the narratives, that is related to the construction of the common dimension. In times in which the capital is rooted in bodies and souls, the supporter above talks about changes in the working processes that do not have a monetary correspondent that reaches them. The health work that needs to be rethought in the collective spaces “[…] is not reduced to the application of a procedure: working is exercising a thought and it is also living."1717. Barros ME, Silva FH. O trabalho do cartógrafo do ponto de vista da atividade. In: Passos E, Kastrup V, Tedesco S, organizadores. Pistas do método da cartografia: a experiência da pesquisa e o plano comum. Porto Alegre: Sulina; 2014. p. 128-52. (p. 130).
Conversation circles: daily doses of democracy
The Policy invites subjects, mainly its always-transitory group of supporters, to try co-management as a method and a device to produce new ways of managing and providing care. A Policy of ‘how’, “how can we do it differently?”, interested in dialog, in producing partnerships to change the practices and subjects that compose the SUS. Perhaps this would be an easy target if we were not in a country that has a long history of authoritarianism of the State. There is always a doubt, a suspicion: “[…] can this really be said in front of the boss?”.
Ranging from the Ministry of Health to the other points of the SUS network, the conversation circles are devices to exercise laterality, promote group work and amplify the participants’ capacity for analysis and intervention. As one of the marks of the PNH, the circles held the educational dimension for the supporters, that is, the update of the discussions and challenges related to the SUS.
In every circle, we were collectively learning that the kind of health we are interested in having, producing and fighting for needs daily doses of democracy. It is fundamental to have “[…] multiple assemblies around ideas that do not exist yet"1818. Blanchot M. A comunidade inconfessável. Brasília: UNB; 2013. (p. 16) so that they can gain strength and expression. It is in these spaces/moments, in the encounter with the other supporters, that we find strange what is common to us33. Blanchot M. O livro por vir. São Paulo: Martins Fontes; 2005., what should not be common to us, and advance in the ethical alignment in favor of collective life.
Institutional democracy or the expansion of the clinic cannot be taken for granted; it is not inherent in the formalization of a team. A collective can be a meeting of individuals from diverse professional categories (or even corporative), a bureaucratized space that complies with a prescription made by others (in a vertical, senseless way). However, the relations that occur in this space/time have the power to debate, dispute, negotiate and agree on diverse forms of working and facing the problems that emerge in the daily routine.
To implement the necessary changes in the SUS effectively, the PNH must be more than a theoretical and methodological prescription. HumanizaSUS desires to be a device, producing collectives that know that strategies are never given in advance. And there are many collectives that sustain the PNH, manufacturing questions, experiences and provisional solutions to the challenges faced in the daily routine of the SUS.
The PNH supporters - workers of the SUS and in favor of the SUS - are summoned ethically and politically to be “intervenors"77. Vasconcelos MFF, Martins CP, Machado DO. Apoio institucional como fio condutor do Plano de Qualificação das Maternidades: oferta da PNH em defesa da vida de mulheres e crianças brasileiras. Interface (Botucatu). 2014; 18(1):997-1011. in order to change what, in health practices and in the SUS, can no longer be common. Supporting, inventing and intervening means affirming the instituting character of the fight for health, for other kinds of health. It means including yourself and getting involved in the hard task of heating this network that sustains the SUS like a daily experience of any individual’s right to health.
A Policy like this, which aggregates innovations produced in diverse reform experiences in the field of health, is not produced without tensions, and to maintain itself, it needs to build many alliances. The PNH was created in the interstice between the System that we have and the one that we desire, among the other health policies and actions, with a malleable attachment to the federal management to move what is already crystallized. On the one hand, the Policy has no great news, as it has gathered successful experiences that compose a “SUS that succeeds”. Many of these experiences have already been studied by Collective Health researchers. On the other hand, the HumanizaSUS’ proposal is exactly to reaffirm that they are practicable. There are concrete accumulations even in the complex Brazilian scenario, and a network is and can be weaved among services, people, ideas and dreams, just like it was necessary to the inscription of the SUS in Brazil’s 1988 Constitution and to the maintenance of health as a dimension of citizenship.
Thus, the “SUS that succeeds” signals an event that bursts into the linearity of facts, in a period in which we have been watching the abandonment of the conception of Welfare State and the praise of the market’s innovations, one of the pillars of the Neoliberal State. Constructing a living memory of the innovative experiences of and in the SUS, one of the guidelines of the PNH, is a strategy to face and, perhaps, dismantle the common discourse “this is how things happen in the public service…”. Throughout the last decade, the supporters have shown that there are subjects who feed on and also update the reform movements, when they insist in constructing a different story for themselves and the others.
When we stimulate/invite the supporters to expand their analyses about the current play of forces, a desolate scenario is presented at many moments. Our daily routine is still marked by dehumanization, that is, by disrespectful, even violent practices that view the biological body as the object of intervention, with managements that are usually solitary, authoritarian and corporative. In addition, we have anaesthetized, exhausted and silenced workers, and working conditions unable to meet the community’s health needs due to lack of adequate financing and to different types of difficulties and challenges. But something happens in some (many?) subjects and collectives. The world is neither ready nor finished, and it is not eternal. We are in the middle, in the midst of a movement whose task is summarized by another supporter:
“Fortunately, nothing is finite in the PNH, because to exercise it, our practice will fatally have to be altered! Giving and receiving support, working in groups, including, being included, all this makes us leave our ‘comfort corner’ to enter into other areas, and not always will they be the ones that we’re already familiar with. The challenge is to overcome the difficulties and become stronger, because I don’t have to find the way alone! The group is there!”.
In the conversation circles and dialogs, the supporters narrate an event regarding the change that occurs in their views of what was unexceptional, indicating that they started to find strange things. For example: “[…] I started to perceive more clearly that, in fact, although they should be, the patients were not primarily the focus of the attention”.
Amid the forces of the neoliberal winds that discredit what is public, the PNH supporters, like those who support other federal management policiesee Although our discussion is about the PNH, there are other federal management policies that propose significant changes and have a dialogic relation, directly or indirectly, to HumanizaSUS (through actors in common, in the internal spaces of the Ministry of Health and in interfederative relations), such as: Saúde Mental(Mental Health), Redução de Danos (Damage Reduction), Rede Cegonha (Stork Network), População na Rua(Population on the Street), Promoção à Saúde (Health Promotion), Gestão Participativa (Participatory Management), Educação Permanente (Permanent Education), Educação Popular(Popular Education), among others.[§] and are committed to changes in care and management, gradually align with one another and produce movements in the SUS and in favor of the SUS. One of the supporters questions herself: “we catch ourselves complaining that nothing is done to improve anything, but do we really have to wait for things to happen?”
Support, belonging and immaterialities
Being part of the management was a hard task that one of the supporters summarized as “[…] changing the car tire while it’s running”. This is what we did. At many moments, there was no ethical-political alignment in the Ministry of Health, nor in the states, municipalities and services. We counted on the PNH supporters to influence actors and find breaches and partnerships.
Based on our experience, we highlight that, in many places, the consultants’ arrival was expected as if we could solve the local problems. This is one of the radical bets of the PNH: it is necessary to foster movements. There are no magical, individual solutions, and the answers will come neither from outsidenor from the heights of power. What there is, what we have learned with several supporters in the conversation circles, is a form of doing politics that insists in the construction of the common dimension and is characterized by sharing and belonging exercises.
Participating in HumanizaSUS and in its experiences “[...] happens neither in a linear way nor once and for all – what is experienced is a process of participation, with its comings and goings."1919. Paulon SM, Cardoso AGRC, Eidelwein C, Passos E, Righi LB, Verdi M, et al. Errâncias e itinerâncias de uma pesquisa avaliativa em saúde: a construção de uma metodologia participativa. Saude Transf Soc. 2014; 5(2):20-8. (p. 26). Being part of this bold movement brings to the supporters a mixture of happiness and sorrow, and indicates a commitment to what is public, but also tiredness and the desire to give up.
The notion of immaterial work proposed by Negri and Lazarrato helps us reflect on support and on the other proposals of the PNH. These authors discuss the current moment, in which work and life are increasingly interconnected, in a way that was never seen before. Thus, no resting periods, breaks or holidays are sufficient because it is life that composes the productive process. Now it is the “[…] ‘worker’s soul that must go down to the repair shop. It is his/her personality, his/her subjectivity that must be organized and commanded. The quality and quantity of work are reorganized around its immateriality."2020. Lazarrato M, Negri A. Trabalho imaterial. Rio de Janeiro: DP&A; 2001. (p. 25).
One supporter summarized how he understands his task through the following comment: “[…] this is the problem of working with what we believe in…”. Creativity and capacity for invention have been increasingly summoned to work. The supporters need to produce immaterialities, like the expansion of the ethical-political commitment to the health of any individual, democracy exercises, the qualification of care offers, the humanization of practices, and the construction of a care network. In addition, to many supporters of HumanizaSUS who maintained a relationship with academia, the production and publication of scientific knowledge were included in this long list.
Giving support aims at the production of immaterialities that are not trivial in a world like ours. There has been an ongoing battle “for another militancy"2121. Oliveira GN, Pena RS, Amorin SC, Carvalho SR, Azevedo BM, Martins ALB, et al. Novos possíveis para a militância no campo da Saúde: a afirmação de desvios nos encontros entre trabalhadores, gestores e usuários do SUS. Interface (Botucatu). 2009; 13(1):523-9., a struggle fought in our paradoxical times. In the conversation circles of the PNH, we used to listen to narratives about countless innovations constructed in the daily routine of the health services, and we also witnessed the huge silence and the exhaustion of the subjects involved in this task. Assuming the function of giving support, with the task of making the machine (the war machine1515. Deleuze G. Crítica e clínica. São Paulo: Ed. 34; 1997.) function, constructing a collective that will not be accessary, and exercising a Policy that is intended to be destabilizing produce many tensions that resonate in the individuals involved. It is not without feelings nor without consequences that democracy exercises are produced.
Aligned with the theoretical production about the Policy and with the principles of transversality and stimulus to the autonomy and leading role of the individuals who compose HumanizaSUS2222. Ministério da Saúde (BR). Cadernos HumanizaSUS: formação e intervenção. Brasília (DF): MS; 2010. (Série B. Textos Básicos de Saúde)., we understand that only nomads know the great wall of China and the size of the desert, just like in Kafka’s minor literature2323. Deleuze G, Guattari F. Mil platôs: capitalismo e esquizofrenia Rio de Janeiro: Ed. 34; 1997. v. 5.,2424. Deleuze G, Guattari F. Mil platôs: capitalismo e esquizofrenia. Rio de Janeiro: Ed. 34; 1995. v. 1., that is, the PNH is a rhizome, produces rhizomes and is fed by them. These are always a multiplicity that grows towards many sides at the same time. With this, we want to stress that, although the supporter knows about the harshness of the desert, s/he continues in it and makes a selection, evaluating with her/his collective where and when to give support. However, at each moment, new experiences emerge and others lose strength, and it is difficult to monitor them. It is necessary to be in the territory to know its dimensions, challenges and to recognize partnerships. Our experience, as well as the dialog with many supporters, shows that there are always new people who start to compose a “[…] community that is eternally provisional and, always, already deserted"33. Blanchot M. O livro por vir. São Paulo: Martins Fontes; 2005. (p. 74).
In this article, we attempted to shed light on some narratives delivered by the PNH supporters that signal that there are other stories to be told and new kinds of health to be invented. It seems to us that the task of giving support in HumanizaSUS is like “Anchoring a ship in space"11. César AC. A teus pés. 6a ed. São Paulo: Ática; 1998.. For this enterprise, a crowd is necessary; many of us are needed.
This “we” inhabits paradoxical times and situations in which health as a dimension of citizenship sometimes advances, sometimes is run over by neoliberal winds. There are constitutional principles that back the construction of bold acts to guarantee the health of the Brazilian population, and the PNH is an example. In addition, there is “an anonymous army"55. Guattari F. Revolução molecular. Rio de Janeiro: Brasiliense; 1981., the workers of the SUS and in favor of the SUS, who insist in the construction of what is public. And, at the same time, we have the naturalization of the abyss between the rich and the poor, of a State that maintains inequalities and of a market whose growth is impelled by the State itself. Thus, this “we” is a strategy because it reaffirms the political character and the richness of the SUS, of the reform movements and of the PNH, as experiences, processes, projects that aim to break with the privatization and impoverishment of life.
Amid the countless challenges of making high-quality public health in a country like ours, there is a movement of resistance that sees the real fragilities of the SUS and breaches for the production of changes. We believe that the supporters produce and include themselves in the collective movements because they reinvent practices, giving us signs of a new smoothness. Although the Brazilian scenario is marked by inequities and inequalities, where, up to now, we could only see regularity, another story can co-exist. There is a network that is produced and heated by many anonymous individuals; among them, the PNH supporters, who maintain health as a dimension of the citizenship of any individual, as summarized by the narrative of a supporter: “we’re a network of supporters in search for a better SUS”.
Finally, we know that HumanizaSUS and the investment in support are policies of the current government and their chronological duration is uncertain. However, we defend that, despite authorial disputes and the alternation in power and project that are inherent in democracy, many echoes will still be heard. As Deleuze and Guattari44. Deleuze G, Guattari F. O que é a filosofia? Rio de Janeiro: Ed. 34; 1992. teach us, it may seem that nothing changes, but we change in the event. And we highlight that
[...] the best way of killing an event that has produced an inflection in the collective sensibility is to re-include it in the calculation of causes and effects. Everything will be labelled as naivety or spontaneity, unless it provides ‘concrete results’. […] as if all this were not “concrete” and could not incite unprecedented and instituting processes!2525. Pelbart PP. Anotai: eu não sou ninguém [Internet]. Folha de São Paulo. 2013 Jul 19 [acesso 20 Jul 2013]. Disponível em: http://www1.folha.uol.com.br/fsp/opiniao/119566-quotanota-ai-eu-sou-ninguemquot.shtml
- 1César AC. A teus pés. 6a ed. São Paulo: Ática; 1998.
- 2Fonseca TMG, Kirst P. Cartografias e devires: a construção do presente. Porto Alegre: Ed. UFGRS; 2003.
- 3Blanchot M. O livro por vir. São Paulo: Martins Fontes; 2005.
- 4Deleuze G, Guattari F. O que é a filosofia? Rio de Janeiro: Ed. 34; 1992.
- 5Guattari F. Revolução molecular. Rio de Janeiro: Brasiliense; 1981.
- 6Santos NR. Posfácio. In: L’ Abbate S. Direito à Saúde: discursos e práticas na construção do SUS. São Paulo: Hucitec; 2010. p. 281-83.
- 7Vasconcelos MFF, Martins CP, Machado DO. Apoio institucional como fio condutor do Plano de Qualificação das Maternidades: oferta da PNH em defesa da vida de mulheres e crianças brasileiras. Interface (Botucatu). 2014; 18(1):997-1011.
- 8Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Política Nacional de Humanização. HumanizaSUS: documento base para gestores e trabalhadores do SUS. Brasília (DF): MS; 2010.
- 9Passos E, Barros E, Nunes G, Teixeira R, Paula T. Apresentação. Interface (Botucatu). 2014; 18(1):805-6.
- 10Campos GWS. Apoio matricial e institucional em Saúde: Liane Righi entrevista Gastão Wagner de Souza Campos. Interface (Botucatu). 2014; 18(1):1145-50.
- 11Pereira Júnior N. O apoio institucional no SUS: os dilemas da integração interfederativa e da cogestão [dissertação]. Campinas (SP): Universidade Estadual de Campinas; 2013.
- 12Deleuze G. Foucault. 5a ed. São Paulo: Brasiliense; 2005.
- 13Martins CP, Luzio CA. Experimentações no apoio a partir das apostas da Política Nacional de Humanização – HumanizaSUS. Interface (Botucatu). 2014; 18(1):1099-106.
- 14Benevides R, Passos E. A humanização como dimensão pública das políticas de saúde. Cienc Saude Colet. 2005; 10(3):561-71.
- 15Deleuze G. Crítica e clínica. São Paulo: Ed. 34; 1997.
- 16Benevides R. Mensagem para os 10 anos da PNH [Internet]. Brasília (DF); 2013 [acesso 28 Nov 2013]. Disponível em: http://www.redehumanizasus.net/67594-mensagem-de-regina-benevides-para-os-10-anos-da-pnh
- 17Barros ME, Silva FH. O trabalho do cartógrafo do ponto de vista da atividade. In: Passos E, Kastrup V, Tedesco S, organizadores. Pistas do método da cartografia: a experiência da pesquisa e o plano comum. Porto Alegre: Sulina; 2014. p. 128-52.
- 18Blanchot M. A comunidade inconfessável. Brasília: UNB; 2013.
- 19Paulon SM, Cardoso AGRC, Eidelwein C, Passos E, Righi LB, Verdi M, et al. Errâncias e itinerâncias de uma pesquisa avaliativa em saúde: a construção de uma metodologia participativa. Saude Transf Soc. 2014; 5(2):20-8.
- 20Lazarrato M, Negri A. Trabalho imaterial. Rio de Janeiro: DP&A; 2001.
- 21Oliveira GN, Pena RS, Amorin SC, Carvalho SR, Azevedo BM, Martins ALB, et al. Novos possíveis para a militância no campo da Saúde: a afirmação de desvios nos encontros entre trabalhadores, gestores e usuários do SUS. Interface (Botucatu). 2009; 13(1):523-9.
- 22Ministério da Saúde (BR). Cadernos HumanizaSUS: formação e intervenção. Brasília (DF): MS; 2010. (Série B. Textos Básicos de Saúde).
- 23Deleuze G, Guattari F. Mil platôs: capitalismo e esquizofrenia Rio de Janeiro: Ed. 34; 1997. v. 5.
- 24Deleuze G, Guattari F. Mil platôs: capitalismo e esquizofrenia. Rio de Janeiro: Ed. 34; 1995. v. 1.
- 25Pelbart PP. Anotai: eu não sou ninguém [Internet]. Folha de São Paulo. 2013 Jul 19 [acesso 20 Jul 2013]. Disponível em: http://www1.folha.uol.com.br/fsp/opiniao/119566-quotanota-ai-eu-sou-ninguemquot.shtml
- cSUS = Sistema Único de Saúde (Brazil’s National Health care System).
- dAccording to Foucault and Deleuze, a device is a network whose compositionis heterogeneous, a set of lines of different natures that configure a machine that makes one see and speak (lines of visibility and enunciation) articulated with the dimensions of power and creation (lines of strength and subjectivation).
- eAlthough our discussion is about the PNH, there are other federal management policies that propose significant changes and have a dialogic relation, directly or indirectly, to HumanizaSUS (through actors in common, in the internal spaces of the Ministry of Health and in interfederative relations), such as: Saúde Mental(Mental Health), Redução de Danos (Damage Reduction), Rede Cegonha (Stork Network), População na Rua(Population on the Street), Promoção à Saúde (Health Promotion), Gestão Participativa (Participatory Management), Educação Permanente (Permanent Education), Educação Popular(Popular Education), among others.
- *Fragment of a poem authored by Ana Cristina César.
- Publication in this collection
03 Nov 2016
- Date of issue
22 Sept 2015
18 Apr 2016