Intersectorial instances of management: movements for the reorientation in Health education

Carine Vendruscolo Fabiane Ferraz Marta Lenise do Prado Maria Elisabeth Kleba Jussara Gue Martini About the authors

Abstract

This is a case study using a qualitative approach, whose objective was to understand how the management forums - Local Steering Committee and General Coordinating Committee - of Pro-Health developed in Chapecó, Santa Catarina, Brazil, contributed to the mobilization of teaching-service integration in the municipal context. The information was produced by direct observation of intersectoral meetings and interviews with members representing the management, teaching, service and population of the two management forums happening in 2012-2013. The treatment for the analysis of qualitative data was anchored in the operational proposal. The results distinguish the importance of recognizing the roles of each segment. In spite of conflicts, the intersectoral meeting places are important initiatives of teaching-service integration, especially as a possibility to transform them and contribute to reorient practices and the Health education.

Brazilian National Health System; Higher education policy; Health management; Teaching care integration services


Introduction

Regarding educational action, Paulo Freire argues about the need for educators and pupils to be subjects of their practice, creating it and recreating it through action-reflection-action on everyday life. In this direction, the integration of theory and practice determines praxis as a transforming possibility of reality 11. Freire P. Conscientização: teoria e prática da libertação: uma introdução ao pensamento de Paulo Freire. 3a ed. São Paulo: Centauro; 2001.

2. Freire P. Educação e mudança. 34a ed. Rio de Janeiro: Paz e Terra; 2011.
-33. Freire P. Pedagogia do oprimido. 59a ed. Rio de Janeiro: Paz e Terra; 2015. .

The possibilities of education and adjustment of health work to the issues of citizenship and solidarity allow us to define the spaces for action and reflection on practice as two units in cooperation and transformation - work and education. When in intersection, these particular spaces are transmuted into something new, like an objective image in which the dialogue with other realities is instituted, giving rise to new facts. In order to bring about this transformation of reality, the subjects that form part of the training institutions and the health services need to strengthen relationships, dialogue among each other and plan co-management moments of the learning process 44. Schmidt SMS, Backes VMS, Cartana MHF, Budó ML, Noal HC, Silva RM. Facilidades e dificuldades no planejamento da integração ensino-serviço: estudo de caso. Online Braz J Nurs. 2011,10(2):1-14. .

The National Program for Reorientation of Vocational Training in Health (Pró-Saúde), created in 2005, through the Ministry of Health (MS) and the Secretariat of Labor Management and Health Education (SGTES), in partnership with the Secretariat of Higher Education (SESu), of the Ministry of Education (MEC) 55. Ministério da Saúde (BR). Programa Nacional de Reorientação da Formação Profissional em Saúde – Pró-Saúde: objetivos, implementação e desenvolvimento potencial. Brasília: Ministério da Saúde; 2007. , is convergent with the proposal of reciprocal involvement between educational institutions and health services. It proposes to plan and develop health practices that are articulated and coherent to the local reality, taking into account the guidelines of the Brazilian National Health System (SUS) and the training of professionals oriented to work within this System. To this end, it involves educators and students of a Higher Education Institution (HEI) and professionals working in local health services, considering the teaching-service interaction as a fundamental element for the development of strategies that overcome the organizational challenges of professional training 66. Brehmer LCF. A integração ensino-serviço em experiências do Pró-Saúde na Enfermagem/SC: estratégia para a consolidação da atenção básica à saúde [tese]. Florianópolis: Universidade Federal de Santa Catarina; 2013. .

In this framework the Program uses as a starting point the perspective that the reorientation of training happens simultaneously in different axes (theoretical orientation, practice scenarios and pedagogical orientation), each with three specific vectors and an “objective image” (desirable situation). The axes do not encompass a standardization rule, but an example, considered as structuring elements of change, aiming to the integration between HEIs and health services.

In relation to the follow-up of the implementation of the projects, the first Pro-Health Call for proposals (CFP) created at the national level, the Executive Committee and the Executing Commission, as well as an Advisory Board, including government representatives, professional bodies, leaders of educational institutions and student entities 77. Ministério da Saúde (BR). Portaria Interministerial no 2.101, de 3 de Novembro de 2005. Institui o Programa Nacional de Reorientação da Formação Profissional em Saúde - Pró-Saúde - para os cursos de graduação em medicina, enfermagem e odontologia. Brasília: Ministério da Saúde, Ministério da Educação; 2005. . In the second CFP, in 2007, in addition to these three instances, there were set up the Monitoring Committees at the state level and the Local Management and Monitoring Committees at the municipal level in order to follow, monitor and evaluate the projects that make up the Pro-Health in the territory where the project would develop. The composition of the aforementioned local Management Committee includes the coordinator of the project and the representatives of the municipal health manager (SMS), the Municipal Health Council (CMS), the SUS professionals, the educators and the students of the executing HEI courses participating in the project 88. Ministério da Saúde (BR). Portaria Interministerial no 3.019, de 26 de Novembro de 2007. Dispõe sobre o Programa Nacional de Reorientação da Formação Profissional em Saúde – Pró-Saúde – para os cursos de graduação da área da saúde. Brasília: Ministério da Saúde, Ministério da Educação; 2007. . This instance was created as a space for sharing decision-making power, through dialogue and co-responsibility movements of those involved in the process, as well as a strategy to foster and strengthen teaching-service integration.

Since its proposal, there have been many projects developed within the scope of Pro-Health in Brazil, however there are few references refering to their impacts. It is believed that the Program presents significant contributions in favor of the teaching-service integration 99. Dias HS, Lima LD, Teixeira M. A trajetória da política nacional de reorientação da formação profissional em saúde no SUS. Cienc Saude Colet. 2013; 18(6):1613-24. , possibly due to the induction of changes in the training model, focusing on the production of knowledge from the concrete scenarios of real-life and based on the commitment to social transformation.

This article presents the results of an investigation carried out within the framework of the forums for local monitoring of the Pro-Health proposal, developed by the Community University of the Region of Chapecó (Unochapecó), in partnership with the Municipal Health Secretariat (GERSA) of Chapecó, Santa Catarina (SC): the Local Steering Committee (CGL) and the General Coordinating Committee (CCG). The objective of the study was to understand how such managerial forums - CGL and CCG - of Pro-Health developed in Chapecó / SC contributed to the mobilization of teaching-service integration in the municipal context.

Method

Case study 1010. Yin RK. Estudo de caso: planejamento e métodos. 4a ed. Porto Alegre: Bookman; 2010. involving management bodies of Pro-Health developed under the responsibility of Unochapecó: the Local Steering Committee (CGL) and the General Coordinating Committee (GCC).

In compliance with the directives of the Pro-Health Program, the CGL was, at the time, composed of 16 members, representing the four segments: management, attention, teaching and social control, which make up the “educational quadrilateral of SUS” 1111. Ceccim RB, Feuerwerker LMC. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis. 2004; 14(1):41-65. . The CCG was composed of representatives of education and service, with 23 full members. These structures met in monthly assemblies, mostly at HEIs headquarters, constituting spaces for planning and monitoring the implementation of the proposal.

For the production and recording of information, direct observation of meetings and focused interviews 99. Dias HS, Lima LD, Teixeira M. A trajetória da política nacional de reorientação da formação profissional em saúde no SUS. Cienc Saude Colet. 2013; 18(6):1613-24. , between October 2012 and February 2013. As an inclusion criterion, participants should be members of one of the inter-sectoral bodies related to the management of Pro-Health , from 2006 to 2012. During the period, 25 members of the forums were identified, who participated in the moments of observation of the meetings.

Six moments of observation of the meetings of the instances were performed, totaling 18 hours, duly registered in a Field Diary. The pre-elaborated observational instrument contained Descriptive Observation Notes (NOD), regarding the aspects relevant to the organization, planning and dynamics of the meetings; and Reflective Notes (NOR), regarding the processes of dialogue, participation, conflicts and other observations made by the researcher.

The interviews (recorded and transcribed in full) were carried out with 11 people: five members of the CGL, three members of the CCG and three participants who were part of both instances, chosen intentionally by the researcher. The data saturation criterion was used when we observed the characterization of a given pattern in the speeches that expressed the sufficiency of information for the study 1212. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 12a ed. São Paulo: Hucitec; 2010. .

The data were analyzed considering the operational proposal for “qualitative data analysis” 11. Pre-analysis of the raw material was carried out, by means of floating reading of the transcripts of the statements and the records in the field diary, in order to constitute the corpus of the information. From this starting point we began the exploration phase of the material constituted by the first codification, aiming at reaching the core of understanding the text. Afterwards, the text was cut into registration units, from which the following categories emerged: a) Dialogical and political space: voices, points of view and powers in the integration movement and participatory accountability; b) Democratic space, of reflection on the practice and recognition of roles: relations of power and the transformation of subjects. The data were discussed considering the theoretical reference of the educator Paulo Freire. Regarding ethical aspects, it was requested the permission from the bodies involved, as well as the favorable opinion of the Ethics Committee on Research with Human Beings, number 242,966 / 2012, meeting the criteria of Resolutions 196/96 and 466 / 12. After formal presentation of the study objectives to the participants, a free and informed consent form was signed. To ensure anonymity, these were identified by codenames that represent characters from classics of literary histories and letter corresponding to the segment represented (management - G, attention - A, social control - CS and teaching - E).

Results

The majority of the participants (22) are women, who come from different areas of health education and with an average time of involvement of two and a half years. If we consider the segments separtely this time increases for representatives of education for four years, two years for the management segment, one year for attention and one year for social control. Therefore, the representatives who remain active for a longer time in the case in question are from the teaching segment. This aspect was fundamental to understand the mobilization of teaching-service integration in the management instances, as will be discussed later.

The following are the categories that emerged from the registry units and that composed the results, based on the ideas of Paulo Freire 11. Freire P. Conscientização: teoria e prática da libertação: uma introdução ao pensamento de Paulo Freire. 3a ed. São Paulo: Centauro; 2001.

2. Freire P. Educação e mudança. 34a ed. Rio de Janeiro: Paz e Terra; 2011.
-33. Freire P. Pedagogia do oprimido. 59a ed. Rio de Janeiro: Paz e Terra; 2015.:

Dialogical and political space: voices, points of view and powers in the movement of integration and participatory accountability

The aspects present in the speeches reflect on the social role of the intersectoral instance and call the attention to the potential of empowerment of the segments within the scope of such articulation. They point out to the responsibility of the subject that is part of the management structure, in view of its political function, mainly related to the University, as an entity with an ethical commitment to the production and socialization of knowledge and with the attribution of enabling the student “ in the world “, with a view oriented to strengthen their autonomy.

“[...] for being a Committee she/he [the segment’s representative] plays an important, social role. And this social role, perhaps because the logic of the university has the responsibility to enable the student to know and recognize the world, is also an overload of responsibility to be carried on!

[...] it is an empowerment of these segments. Being able to have a health representative within a Committee, in principle, politically, is an important thing – I mean social policy, not political party “(Emma - A).

Regarding the partnership between HEI, SMS and GERSA, the main challenge seems to be in the understanding of what is attributed to each one of the segments in the management exercise and in the monitoring of the processes of reorientation of health training. In this context, it is considered that people often have defined positions, which makes dialogue difficult, due to the power relations that are established. The service and the educators participate in a higher grade in the discussions, while the students and the social control do not perceive themselves as co-responsible members in the process.

“[...] I realized that people were already with defined positions and the dialogue did not flow much. He was very focused on the service, in the case of the Secretariat and Unochapecó. The others who were there, the students, even me, from social control, did not have a greater interaction to make the discussions”. (Mr. Darcy – CS)

The role of service management, in the conception of the participants, is to put order in the training, through sharing with the teaching segment of the work demands. This is done in the arguments during the discussions in the management bodies, and may or may not generate consensus. In the daily life of the articulation between spaces, which is incorporated, above all, by the presence of the students and the teachers in the service, putting order in health education is complicated and sometimes generates ambiguous feelings, since such presence is perceived as a favorable differential, but at the same time “bother” the professionals. In this sense, the manager’s role would be to organize the integration among the subjects:

“[…] [the collegiate body] is where the people [service management] senses the demands of the service and puts it to Pro-Health, in order to improve and collaborate with the issue of education. “ (Anna Karenina - G)

“[...] you leave the meeting with a feeling: I said what needed to be said. Some agreed; others did not; it is part of it. But, I did my part. “ (Capitu - G)

“It’s a tight spot, because sometimes you see the presence of the academic day-to-day, but you do not want to miss the opportunity to have this differential [...] Our service is to try to put order in the participation”. (Bibiana - G)

The pronouncements make us think from the point of view of the manager segment, according to which, the service benefits from the presence of the educator and the trainee, as a possibility to attend to their needs and in this way, it would be collaborating with the training. However, training needs are not considered, as advocated by the teaching segment in other lines.

Another aspect that drew attention was the idea that the management bodies of Pro-Health are configured as collegiate structures for monitoring and integration, based on the points of view and voices of the individuals that compose them. From this perspective, different subjects sit at the table and dialogue, making it possible to elaborate proposals, detect problems and think of solutions, using the Program’s guidelines.

“[...] a very important instance of integration between institutions. We have a schedule of meetings and there we make the debates, put forward the proposals, the problems, the possibilities of solutions. It is a moment where integration takes place: everyone sits at the table and everyone argues. [...] everyone has a turn, everyone has a voice. So, yes, it is a space for dialogue, it is a space for democracy, decisions are taken together “. (Capitu – G)

“An important space for dialogue [...] to think about the best way to make these mechanisms of the Ministry of Health to happen, such as Pró-Saúde”. (Guiomar - E)

In this sense, the representatives recognize the integration spaces for monitoring and evaluation of projects developed from the interministerial actions implemented by the University, SMS and GERSA the municipality.

“It is a space to monitor, evaluate and follow, at the same time that we will present the projects, present the steps. We will, according to the point of view of each one, make evaluations and review the form of the execution of these projects”. (Heathcliff – E)

At meetings of the bodies, these perceptions are reinforced and expressed in the participants’ statement on the evaluation of the meetings.

“a deliberative space, where each subject needs to know their role ‘. (NOD – teaching segment)

“Key space for bridging Teaching and Service”. (NOD – management segment)

“A place for enlarging social conscience and participatory responsibility”. (NOD – healthcare segment)

“A place to learn”. (NOD – social control segment)

The management bodies thus become, on several occasions, democratic, deliberative, dialogical and learning spaces, oriented to qualifying training (education) and, above all, healthcare (service), translating education as a political act. In this movement, the different voices, points of view and powers converge towards integration and a sense of responsibility for the process.

Democratic space, reflection on the practice and recognition of roles: power relations and transformation of the subjects

For the teaching segment, its presence in the opportunities for discussion in the collegiate bodies implies listening to the others and, from reflections, to rethink the University’s proposal, as well as to mobilize dialogues about Pro-Health as a mechanism for consolidating the SUS :

“[…] [the role of teaching] is to understand what the difficulties of the service are, to try to solve, to rethink the university proposal ... to talk with teachers, to rethink the PP [Pedagogical Projects] and, mainly, our function is to bring the discussion about the objectives of Pro-Health, always remembering these mechanisms: what was their purpose and how we can do it in a way that they consolidate themselves and help consolidate SUS!” (Guiomar - E).

In a convergent way, another representative of the teaching segment perceives himself involved in the function of conducting the meetings, in relation to the methodological proposal:

“The role of the teacher [in the committee] is mainly to put forward the methodological question [...] how we organize a meeting, elect a staff, discusses, organizes the times of the meeting, organizes an idea and express it in writing. Another role is to say what theories and what concepts are present in these actions. [...] to bring to these spaces a reflection [...] not to let everything become an “anything goes”, that is, to have a methodological rigor [...]” (Heathcliff - E)

Another side of the quadrilateral, represented by the social control segment, believes that its role is to act as a bridge between education, service and community, especially preparing the community for the actions of the partnership:

“I think [participation of social control] is fundamental because it bridges the question of teaching, leading to service and community, because the goal is to work with the community. If councilmembers take this [have students in the service space] well, the community accepts well [...]” (Alice - CS)

The representative of the healthcare segment realizes that its role is to integrate practice and knowledge, effectively. This possibility compromises, above all, the workers, because it mobilizes the need to be involved with the actions of permanent education in health in the day-by-day services:

“[...] it’s no use knowing about something and not working on it and it’s no use to work on something not knowing more about it! This [integrating teaching and service] makes people to commit! This mobilizes, makes professionals to train more, they study, this is an enrichment of the service! Because the moment we have students, trainees in there, everybody naturally mobilizes to train themselves, to recognize themselves in a space, to leave stagnation “. (Emma - A).

The subjects’ speech helps to perceive what is at the heart of the question: the recognition of the roles goes through an evolution that fosters a sense of belonging to the process, and consequently creates commitment. On the other hand, the lack of definition of attributions, as a member of the educational quadrilateral and, consequently, of the collegial body, and the lack of understanding about that process, causes a feeling of non-belonging, defined by them as “suffering”:

“[...] the first time I attended, I did not really know what it was [...] I think now we begin to understand the roles. At first we had this shock “. (Bibiana - G)

“I did not know where I could contribute! [...] today I think I understand a little more [...] in one of the meetings that I asked what was my role was there? [...] that’s when I came to feel myself belonging! “ (Emma – A)

These issues are reinforced by the observations made during the meetings:

“Those who appear for the first time at meetings, when speaking, express that they have not been clear about what is involved, they feel lost. This was observed on two occasions, at the presentation times of the meeting participants”. (NOR – researcher)

“The Representative of the healthcare segment indicated that the people who have been taking part in the meetings of the body for a shorter time should first take ownership of the process and then participate more”. (NOR – researcher)

“At a time of evaluation of the meetings, some representatives mention the importance of clarifying the segments represented on Pro-Health”. (NOR – researcher)

Participants consider that there should be a verbal agreement to clarify the links between the members of that body, the objectives of the meeting, to allow recognition among them and to awaken in them regarding the feeling of comprehension of the process and, consequently, of belonging and empowerment .

The common interests between the subjects and the delegation of powers of representation to them seem to contribute to enabling the bodies to be structured on a solid and very enriching basis with a view to unveiling the training process. The understanding of the roles of each segment, or each side of the educational quadrilateral, and the social and political commitment of the instance in this context, is fundamental to compose the whole picture.

“[...] if the idea of this Committee exists as something permanent and that incorporates these other spaces of society ... first it has to have the institutional recognition [...] each one could speak of herself, to speak of the space that it represents. If you do not have this recognition, it will get a format like some other boards, where the meeting is done for the sake of the meeting, because the legislation so provides “. (Emma – A)

In the interview, a participant gave her opinion thus allowing others to visualize a space that, although it can be pleasant, does not always allow the subjects to be really listened by the agents and executive policy agencies. According to her, the meetings seem to happen to fulfill a guideline established by the university and there is, in fact, no place for the other segments. In this integration between knowledge and practice, the power relations between knowledge (university) and practice (service) are explicit. There remains an understanding that the university carries the status of power, exercised by knowledge, while the service only performs and is not heard, in fact.

“[...] it was a delightful thing to have a space where you could discuss it. Although I did not think I was being listened to or was not collaborating as much as I could. It’s a two-way street. [...] And our speeches, I do not think they collaborate! I think the University holds the meeting, it leads, because it has to have the meeting! “ (Emma – A)

Some notes draw attention to conflicts related to the defensive attitude and the difficulty of communication between the sides of the quadrilateral. The “tense moments”, to what is perceived, are related to the understanding of the service that suggests to the HEI that it has to act starting from the needs of the service; while on the other hand, the University argues that the training needs also need to be considered in this relation .

“[...]there are some moments that are tense, also of defensive argument. I understand one thing one way, the other understands something else. Sometimes we have difficulties in listening to each other, so the logic is that I need to defend my point of view, after all, I’m here representing the Unochapecó, my fellow teachers”. (Aurélia – E)

“[...] these moments, where we sit at the table to make the debates, are moments that have their positive side, but which also generate tensions”. (Capitu – G)

“The SMS manager comments on the different timing of service and teaching; about the understanding of the whole of Pro-Health, because there are doubts about who can use the ‘permanent education rooms’ equipped with Pro-Health resources in the Health Units, for example. The issues of service needs versus Pro-Health projects that do not match those demands are emphasized [...] The local coordinator emphasizes that the service needs and the users’ needs should be taken into account, but also the needs of teaching , in the logic of “educating for the SUS”. (NOR - researcher).

It is perceived, therefore, that the managing bodies gradually provoke opportunities of transformation of subjects who find the possibility of dialoguing and reflect on their roles as educators and servants of the health area. In this process, relations of power visibly converge towards a maturation of the subjects and the segments they represent.

Discussion

In the field of health, all subjects who are involved in their production in some way represent certain spaces and somehow rule the daily work of health, given the degree of freedom that exists in their action 1313. Franco TB, Merhy EE. Cartografias do trabalho e cuidado em saúde. Tempus. 2012; 6(2):151-63. . This presupposes a common attribution among the members of the management bodies of the Pro-Health which requires certain contractualities between these social and political subjects, since the organization of healthcare is the product of this integration.

Without the possibility of self-reflection and the way to be in the world, people are not able to cross limits, imposed on them, and thus commit themselves 22. Freire P. Educação e mudança. 34a ed. Rio de Janeiro: Paz e Terra; 2011. . In fact, each segment represented in the collegiate body plays an important role in the reorientation of training. Thus, the members of the educational quadrilateral constitute an interinstitutional body and exercise a more democratic and participative possibility of management, in which they find the possibility to exercise the leading role and the collective production 1111. Ceccim RB, Feuerwerker LMC. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis. 2004; 14(1):41-65. .

It is clear in the subjects’ ideas their role in the scope of the proposal. The HEI, for example, perceives itself as articulator of research, teaching and extension, activities that, inseparably, imply demonstrating the transition from theory to praxis, validating the knowledge constructed, which can subsidize changes in reality 33. Freire P. Pedagogia do oprimido. 59a ed. Rio de Janeiro: Paz e Terra; 2015.,1414. Sánchez Vázquez A. Filosofia da práxis. 2a ed. Buenos Aires: Consejo Latinoamericano de Ciências Soaciales – Clacso, São Paulo: Expressão Popular; 2011. . In relation to health practice, as part of its commitment to transformations in this field, training is a socially necessary task, and as such, it keeps ethical and political understandings with society 1010. Yin RK. Estudo de caso: planejamento e métodos. 4a ed. Porto Alegre: Bookman; 2010. . Participants in the intersectoral bodies therefore understand that for effective learning to occur, it is necessary to be guided by practical experiences, facilitating the transition of academics to reality when entering the labor market 1515. Clark CM, Ahten SM, Macy R. Using problem-based learning scenarios to prepare nursing students to address incivility. Clin Simul Nurs. 2013; 9(3):75-83. .

Social control, in the construction of SUS, as well as in the space of other social policies - and, in this case, in the scope of Pro-Health - is defended as necessary and indispensable for its consolidation. Its institutionalization in Brazil, especially through management councils, represents an advance in democratization, both in relation to services and political practices, increasing the power of intervention of the population in public actions 1616. Kleba ME, Wendausen A. Empoderamento: processo de fortalecimento dos sujeitos nos espaços de participação social e democratização política. Saude Soc. 2009; 18(4):733-43. . In the case of local management bodies, there is a remarkable relevance of the participation of representatives of social control in the process of permanent self-evaluation of the implementation of Pro-Health, considering them potential partners of the teaching-service integration, as they favor the inclusion of the needs and interests of individuals and collectives in the training process 77. Ministério da Saúde (BR). Portaria Interministerial no 2.101, de 3 de Novembro de 2005. Institui o Programa Nacional de Reorientação da Formação Profissional em Saúde - Pró-Saúde - para os cursos de graduação em medicina, enfermagem e odontologia. Brasília: Ministério da Saúde, Ministério da Educação; 2005. . However, an effective dialogue that constitutes more horizontal relations in these instances requires the ability to problematize the instituted, unveiling historically legitimized power structures and recreating more equitable and respectful ways of relating 1616. Kleba ME, Wendausen A. Empoderamento: processo de fortalecimento dos sujeitos nos espaços de participação social e democratização política. Saude Soc. 2009; 18(4):733-43. .

The findings allow us to understand the relationship between teaching and service under the logic of permanent education which can be a strategy for changing pre-established relationships, starting from each persons´ conceptions regarding health. The theoretical-methodological conceptions that operate in the current configuration of the National Policy of Permanent Education in Health (PNEPS) follow the pedagogical presuppositions formulated by the Pan American Health Organization and the World Health Organization (PAHO / WHO) in the 1980s. The adoption of active methodologies, with the aim of producing meaningful learning, which presupposes addressing significant issues for the subjects involved, who are actively involved and are protagonists of the actions, in full time. Thus, the permanent education proposes to reorder practices, promoting changes in the daily work process, based on the day-to-day critical nodes of the team, based on the specific needs of the workers, supported by the critical, problematizing and reflective pedagogical principle 11. Freire P. Conscientização: teoria e prática da libertação: uma introdução ao pensamento de Paulo Freire. 3a ed. São Paulo: Centauro; 2001.,22. Freire P. Educação e mudança. 34a ed. Rio de Janeiro: Paz e Terra; 2011.,1717. Ministério da Saúde (BR). A educação permanente entra na roda, pólos de educação permanente em saúde: conceitos e caminhos a percorrer. 2a ed. Brasília: Ministério da Saúde; 2005. . This change implies to re-signify the moments of learning, causing them to provoke transformations of the work process, starting with reflective, critical, assertive, committed and technically competent actions 1717. Ministério da Saúde (BR). A educação permanente entra na roda, pólos de educação permanente em saúde: conceitos e caminhos a percorrer. 2a ed. Brasília: Ministério da Saúde; 2005.,1818. Ministério da Saúde (BR). Portaria GM/MS nº 1.996, de 20 de Agosto de 2007. Dispõe sobre as diretrizes para a implementação da Política Nacional de Educação Permanente em Saúde. Brasília: Ministério da Saúde; 2007. .

Corroborating with the above, it is emphasized that empowerment comes from the social interactions that human beings construct as they problematize reality in a reflective way. It is through problematization that emerges the consciousness that gives them power to transform the social relations of domination in the direction of liberation 33. Freire P. Pedagogia do oprimido. 59a ed. Rio de Janeiro: Paz e Terra; 2015. . The possibility of empowering promotes the conquest of spaces of social participation, under the perspectives of citizenship and co-responsibility 1616. Kleba ME, Wendausen A. Empoderamento: processo de fortalecimento dos sujeitos nos espaços de participação social e democratização política. Saude Soc. 2009; 18(4):733-43. .

Pro-Health management bodies are identified as dialogic spaces as well as conflict spaces, in which different voices, points of view and powers for teaching-service integration interact. Dialogue is a basic condition for the knowledge that occurs in the communication between the subjects, starting from an encounter that takes place in praxis, and, therefore, in the commitment to individual and social transformation 33. Freire P. Pedagogia do oprimido. 59a ed. Rio de Janeiro: Paz e Terra; 2015. . In this perspective, the intentionality of each subject manifests itself in the conflict that can generate the construction of something new. Conflict, as a confrontation of positions, therefore implies dialogue as one step towards the establishment of harmony, through the attitude of listening, speaking, and finally understanding 11. Freire P. Conscientização: teoria e prática da libertação: uma introdução ao pensamento de Paulo Freire. 3a ed. São Paulo: Centauro; 2001.

2. Freire P. Educação e mudança. 34a ed. Rio de Janeiro: Paz e Terra; 2011.
-33. Freire P. Pedagogia do oprimido. 59a ed. Rio de Janeiro: Paz e Terra; 2015. . In this direction, listening, as well as speaking, is a condition for dialogical communication between social subjects with different opinions, and therefore, there are times when the discipline of silence must be rigorously assumed, in the perspective interested in the knowledge of others.

Other studies on the reorientation of health training 1919. Carvalho SOB, Duarte LR, Guerrero JMA. Parceria ensino e serviço em unidade básica de saúde como cenário de ensino-aprendizagem. Trab Educ Saude. 2015; 13(1):123-44.,2020. Silva MAM, Amaral JHL, Senna MIB, Ferreira EF. O Pró-Saúde e o incentivo à inclusão de espaços diferenciados de aprendizagem nos cursos de odontologia no Brasil. Interface (Botucatu). 2012; 16(42):707-17. , in a convergent way with this research encourage the expansion of spaces of interlocution between university, services, community leaderships, health councils, so that the participants may share achievements, difficulties, yearnings, experiences and as main feature, to discuss the role of each one in the formation and the reorganization of care. For this, communication, shared responsibility and negotiation are fundamental, both in the educational process and in planning activities.

It is also worth remembering that learning for work goes beyond the limit of individual learning and implies significant participation of others. This coordination of behaviors requires an institutional change, typical of the permanent education movements. It is a conceptual and practical change, through behaviors of subjects involved in other subjects 2121. Davini MC. Enfoques, problemas e perspectivas na educação permanente dos recursos humanos de saúde. In: Ministério da Saúde (BR). Política nacional de educação permanente em saúde. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde) (Série Pactos pela Saúde 2006; v. 9). . The way they make their choices has to do with their ability to participate 2222. Vendruscolo C, Ferraz F, Prado ML, Kleba ME, Reibnitz KS. Teaching- service integration and its interface in the context of reorienting health education. Interface (Botucatu). 2016; 20(59):1015-25. and also with the distribution of power in this intersectoral space. Thus, transforming power relations into more horizontal interactions requires modifying affinities that are pre-established, making them more flexible 1616. Kleba ME, Wendausen A. Empoderamento: processo de fortalecimento dos sujeitos nos espaços de participação social e democratização política. Saude Soc. 2009; 18(4):733-43. .

Interviews and observations revealed dialogic spaces, with moments of conflict, which would justify the reorganization of the time and place of meetings, as well as the need for the subjects’ appropriation of the process and even the institutionalization of the instances. In this case, it is necessary to emphasize the dialogue as more than a gratuitous and unpretentious chat, because it is through it that the encounter between the subjects mediated by the world takes place, in which reflection and action are oriented towards reality, initially “dictated” and then “unveiled,” and which now needs to be transformed and humanized 33. Freire P. Pedagogia do oprimido. 59a ed. Rio de Janeiro: Paz e Terra; 2015. .

In addition, the power relations established in that intersectoral space are related to the thinking-doing dialectics, represented by the university (educators and students) and by the service (managers and professionals), mediated by social control. The practice of the educational quadrilateral representatives finds barriers in the ability to listen to the other and to be heard with interest and otherness, since in general they are sometimes more concerned with their individual proposals and needs.

Conclusion

The management bodies mobilize the teaching-service integration as they are recognized as dialog spaces in decision-making spaces. Conflict is present, as in all collective management spaces, and in this case, it has to do with the knowing-doing dialectics, whose representative entities are, respectively, the university and the health service. It is worth remembering that in these processes, the key is to know how to live and deal with conflicts, through management tools that make it possible to transform power relations into more horizontal and more flexible interactions, and in the case studied, this strategy seemed to be incorporated by the participants.

It was possible to characterize the collegiate instances as dialogic, deliberative and learning spaces, in which are created possibilities of transformation of teaching, health practices and, above all, the subjects that constitute them. When considering this dimension of reconstruction of the subjects’ practices, it is expressed the possibility of possible transformations in the daily work processes, both in the scope of teaching, as well as in the service.

The recognition of the roles of each segment in the management forums of the Pro-Health proposal developed by Unochapecó presents a slow progress in relation to the commitment of each subject. However, the shared interests and delegation of powers of representation conferred upon each member seems to contribute to structure those collegial bodies on a solid and enriching basis oriented to unveil the training process in the health area. The lack of understanding of some participants about their role in the management of that process sometimes causes a feeling of non-belonging and estrangement, which presupposes that such understanding / involvement is fundamental to make up the whole of the formation quadrilateral.

Instances are spaces that promote the exercise of citizenship and democracy, in which word and dialogue can be configured as powerful tools. This research shows that through the need to train people who believe in these tools as forces that allow them to learn from their own mistakes and advance to historical forms of life; as well as by bringing the reality of health services and training to discussion, it can be shown that the subjects that make up the educational quadrilateral in the management bodies of Pro-Health may reinvent themselves and, gradually, reinvent the way of producing health in that region.

References

  • 1
    Freire P. Conscientização: teoria e prática da libertação: uma introdução ao pensamento de Paulo Freire. 3a ed. São Paulo: Centauro; 2001.
  • 2
    Freire P. Educação e mudança. 34a ed. Rio de Janeiro: Paz e Terra; 2011.
  • 3
    Freire P. Pedagogia do oprimido. 59a ed. Rio de Janeiro: Paz e Terra; 2015.
  • 4
    Schmidt SMS, Backes VMS, Cartana MHF, Budó ML, Noal HC, Silva RM. Facilidades e dificuldades no planejamento da integração ensino-serviço: estudo de caso. Online Braz J Nurs. 2011,10(2):1-14.
  • 5
    Ministério da Saúde (BR). Programa Nacional de Reorientação da Formação Profissional em Saúde – Pró-Saúde: objetivos, implementação e desenvolvimento potencial. Brasília: Ministério da Saúde; 2007.
  • 6
    Brehmer LCF. A integração ensino-serviço em experiências do Pró-Saúde na Enfermagem/SC: estratégia para a consolidação da atenção básica à saúde [tese]. Florianópolis: Universidade Federal de Santa Catarina; 2013.
  • 7
    Ministério da Saúde (BR). Portaria Interministerial no 2.101, de 3 de Novembro de 2005. Institui o Programa Nacional de Reorientação da Formação Profissional em Saúde - Pró-Saúde - para os cursos de graduação em medicina, enfermagem e odontologia. Brasília: Ministério da Saúde, Ministério da Educação; 2005.
  • 8
    Ministério da Saúde (BR). Portaria Interministerial no 3.019, de 26 de Novembro de 2007. Dispõe sobre o Programa Nacional de Reorientação da Formação Profissional em Saúde – Pró-Saúde – para os cursos de graduação da área da saúde. Brasília: Ministério da Saúde, Ministério da Educação; 2007.
  • 9
    Dias HS, Lima LD, Teixeira M. A trajetória da política nacional de reorientação da formação profissional em saúde no SUS. Cienc Saude Colet. 2013; 18(6):1613-24.
  • 10
    Yin RK. Estudo de caso: planejamento e métodos. 4a ed. Porto Alegre: Bookman; 2010.
  • 11
    Ceccim RB, Feuerwerker LMC. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis. 2004; 14(1):41-65.
  • 12
    Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 12a ed. São Paulo: Hucitec; 2010.
  • 13
    Franco TB, Merhy EE. Cartografias do trabalho e cuidado em saúde. Tempus. 2012; 6(2):151-63.
  • 14
    Sánchez Vázquez A. Filosofia da práxis. 2a ed. Buenos Aires: Consejo Latinoamericano de Ciências Soaciales – Clacso, São Paulo: Expressão Popular; 2011.
  • 15
    Clark CM, Ahten SM, Macy R. Using problem-based learning scenarios to prepare nursing students to address incivility. Clin Simul Nurs. 2013; 9(3):75-83.
  • 16
    Kleba ME, Wendausen A. Empoderamento: processo de fortalecimento dos sujeitos nos espaços de participação social e democratização política. Saude Soc. 2009; 18(4):733-43.
  • 17
    Ministério da Saúde (BR). A educação permanente entra na roda, pólos de educação permanente em saúde: conceitos e caminhos a percorrer. 2a ed. Brasília: Ministério da Saúde; 2005.
  • 18
    Ministério da Saúde (BR). Portaria GM/MS nº 1.996, de 20 de Agosto de 2007. Dispõe sobre as diretrizes para a implementação da Política Nacional de Educação Permanente em Saúde. Brasília: Ministério da Saúde; 2007.
  • 19
    Carvalho SOB, Duarte LR, Guerrero JMA. Parceria ensino e serviço em unidade básica de saúde como cenário de ensino-aprendizagem. Trab Educ Saude. 2015; 13(1):123-44.
  • 20
    Silva MAM, Amaral JHL, Senna MIB, Ferreira EF. O Pró-Saúde e o incentivo à inclusão de espaços diferenciados de aprendizagem nos cursos de odontologia no Brasil. Interface (Botucatu). 2012; 16(42):707-17.
  • 21
    Davini MC. Enfoques, problemas e perspectivas na educação permanente dos recursos humanos de saúde. In: Ministério da Saúde (BR). Política nacional de educação permanente em saúde. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde) (Série Pactos pela Saúde 2006; v. 9).
  • 22
    Vendruscolo C, Ferraz F, Prado ML, Kleba ME, Reibnitz KS. Teaching- service integration and its interface in the context of reorienting health education. Interface (Botucatu). 2016; 20(59):1015-25.

History

  • Received
    30 Mar 2017
  • Accepted
    06 Apr 2018
  • Online publication
    10 July 2018
UNESP Botucatu - SP - Brazil
E-mail: intface@fmb.unesp.br