Abstract

Introduction

The activities of the Project “Teaching, Health and Development: Network of Knowledge and Practices”¹1. Coelho ICM. Educação em saúde: o cotidiano em movimento. Cad Abem. 2016; 12:127-30. were developed over five years, from 2011 to 2015. The project was a joint proposition of teachers and researchers from higher education institutions located in the States of Paraná and Santa Catarina (Southern Brazil). The Project’s activities were concentrated in the city of Curitiba, State of Paraná, where the Institution that coordinated it since the beginning is located.

The Project was successful, but this does not exempt us from reflecting on aspects that permeated its development, including those that could have been carried out in a better way. Therefore, the authors decided to focus on self-evaluation in this article, providing a critical reflection and searching for alternatives that might have led to better results.

Context and problem

In the 1970s and 1980s, the processes of the 8^th National Health Conference (1986) and of the Constitutional Convention (1987-1989) resulted in the strengthening of the Brazilian Health Reform Movement and in the creation of Brazilian National Health System (SUS) in 1990. At many moments of this long process, stakeholders of the university/academic environment played a significant role²2. Faleiros VP, Vasconcelos LCF, Silva JFS, Silveira RMG. A construção do SUS: histórias da Reforma Sanitária e do processo participativo. Brasília: Ministério da Saúde, Secretaria de Gestão Estratégica e Participativa, Ministério da Saúde; 2006.. Although the core of the criticism and of the proposals for change was targeted at the organization of the system and of the health services, this strong movement triggered a chain reaction and generated changes also in educational institutions.

With the approval of National Curriculum Guidelines (DCN) for health programs between 2001 and 2004, serious concerns emerged in many institutions, entities and movements. These concerns derived from knowledge gaps that existed in medical education and in that of other professions, and also from the lack of teachers capable of playing the new roles established in the pedagogical projects recommended by the Guidelines³3. Ribeiro VMB. Discutindo o conceito de inovação curricular na formação dos profissionais de saúde: o longo caminho para as transformações no ensino médico. Trab Educ Saude. 2005; 3(1):91-121..

Motivated by the necessity of educating professionals with the adequate profile to meet the country’s social needs - professionals capable of learning how to learn, working in teams, communicating, handling situations quickly, and having a propositional capacity -, many institutions started to discuss pedagogical changes, as these characteristics do not match traditional education and the pedagogy of transmission that predominates in universities⁴4. Feuerwerker L. Além do discurso de mudança na educação médica: processos e resultados. Rio de Janeiro: Hucitec; 2002..

In the sphere of Brazilian Association of Medical Education (ABEM), together with Rede UNIDA and the student segment, represented by National Executive Board of Medicine Students (DENEM), some initiatives were important to deal with the context mentioned above. Among them, the creation, in 2004, during the Brazilian Medical Education Congress, of a group to provide subsidies to the understanding of the theme by means of research.

At the same time, teachers were looking for qualification opportunities abroad, while others invested their time and efforts in the development of local projects, like the UNI Projects (A New Initiative in the Education of Professionals: Union with the Community), to prepare the ground for the desired changes. Broader education processes like the “Activators of Processes of Change in the Higher Education of Health Professionals” and the “Foundation for Advancement of International Medical Education and Research” (FAIMER) proposed large-scale education in the specialization level for teachers with the aim of facilitating the implementation of changes. At the same time, some leaderships sought the support of agencies like Coordination for the Improvement of Higher Education Personnel (CAPES), which, with the decisive participation of Management Department for Health Work and Education (SGTES) of the Ministry of Health, published, in 2010, Notice number 24, instituting Pró-Ensino na Saúde⁵5. Ministério da Educação (BR). Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES). Diretoria de Programas e Bolsas no país – DPB. Coordenação Geral de Programas Estratégicos – CGPE. Coordenação de Indução e Inovação – CII. Pró-Ensino na Saúde: Edital No 24/2010. Disponível em: http://www.capes.gov.br/images/stories/download/bolsas/Edital_EnsinoSaude_2010.pdf.
http://www.capes.gov.br/images/stories/d... .

The Notice aimed to foster the creation of research lines and support publications in the area of Health Teaching, using human and infrastructure resources available in higher education institutions, enabling the production of scientific and technological research, fostering the education of MScs and PhDs, and implementing postdoctoral degrees in the area of Health Teaching.

The publication of the Notice was grounded on the presupposition that, by stimulating the creation of research lines or majors related to teaching, it would be possible to improve teacher education in postgraduate programs, thus contributing to the advance of changes in undergraduate health programs, especially at a moment of increase in the number of higher education seats and courses in Brazil⁶6. Cyrino EG, Pinto HA, Oliveira FP, Figueiredo AM, Domingues SM, Parreira CMSF. Há pesquisa sobre ensino na saúde no Brasil? ABCS Health Sci. 2015; 40(3):146-55..

Teachers and students from the State of Santa Catarina and especially from the State of Paraná participated in all these spheres and contexts.

Thus, the proper conditions were set for the development of a Project to be submitted to the Notice mentioned above.

The construction of the Project: Its stakeholders and history

The construction of the Project occurred even before the publication of Notice 24/2010. The network of teachers and health professionals involved in the processes of change in the health professionals’ profile and in the consolidation of the SUS, driven by the desire to improve teaching and learning processes, qualify higher education teachers, reorient curricula and pedagogical projects, and implement teaching and health policies in the institutions where they worked, started planning the course “Activators of Processes of Change in the Higher Education of Health Professionals”. Right after this, they started developing projects for Pró-Saúde shared by the groups of each institution involved in this Project.

The learning experience generated by the development of Pró-Saúde projects and the previous know-how acquired with PROMED and similar projects allowed to advance to PET-Saúde, Pró-Residência, FAIMER, and to create the Postgraduate Workgroup in the Brazilian Association of Medical Education and in other teaching associations in the area of Health. The perception of the progressive improvement in the works presented in Brazilian and International Congresses and the difficulties that hindered the publication of studies⁷7. Guimarães R. Pesquisa no Brasil: a reforma tardia. São Paulo Perspec. 2002; 16(4):41-7.,⁸8. Gatti B. Implicações e perspectivas da pesquisa educacional no Brasil contemporâneo. Cad Pesq. 2001; 113:65-81., especially in the area of Health Teaching, in relevant journals, led the group to envision the need to systematize the existing research projects and groups and to put researchers in contact with the institutions involved in the Network. Thus, the proposal of Notice number 24 allowed the institutionalization of relations and productions that were already consolidated.

It was important to involve teachers from undergraduate health programs and researchers from postgraduate programs of the higher education institutions Faculdades Pequeno Príncipe (FPP)⁹9. Grittem L, Meier MJ, Zagonel IPS. Pesquisa-ação: uma alternativa metodológica para pesquisa. Texto Contexto Enferm. 2008; 17(4):765-70., Universidade Estadual de Londrina (UEL)¹⁰10. Vargas LHM, Colus IMS, Linhares REC, Salomão TMS, Marchese MC. A inserção das ciências básicas no currículo integrado do curso de Medicina da Universidade Estadual de Londrina. Rev Bras Educ Medica. 2008; 32(2):174-9.,¹¹11. Turini B, Neto DM, Tavares MS, Nunes SOV, Silva VLM, Thomson Z. Comunicação no ensino médico: estruturação, experiência e desafios em novos currículos médicos. Rev Bras Educ Medica. 2008; 32(2):264-70. and Universidade Federal de Santa Catarina (UFSC). The curricular changes implemented in programs of these institutions, remarkably nursing and medicine, together with the inherent difficulties and conflicts, formed, at the beginning of the new millennium, a rich cauldron of effervescent local experiences.

Mobilizations to acquire a greater political-institutional weight occurred by means of the Medical Education Encounters Paraná-Santa Catarina and of the events promoted by Rede UNIDA, whose main office was located in the city of Londrina for many years. It is important to clarify that, despite having the participation of many professionals from the area of Collective Health, the movement was not dominated by this segment. There was, as there is today, an important and, in general, denser presence of professionals from clinical specialties and from the basic cycles.

Many times, innovative internal processes resulted from alterations in the balance of forces, in which the conservative segments were weakened by the initiatives - many times, bold initiatives - of those who believed in the imperious need of curricular changes. These behaviors, in some way or other, contaminated the process of development of the Project that we are analyzing here and had a decisive influence on its configuration¹²12. González AD, Almeida, MJ. Movimentos de mudança na formação em saúde: da medicina comunitária às diretrizes curriculares. Physis. 2010; 20(2):551-70..

The Project “Teaching, Health and Development: Network of Knowledge and Practices” was submitted to the Notice published by CAPES as having been developed by FPP, UEL and UFSC. Subsequently, Universidade Estadual de Maringá (UEM) and Universidade Federal de Alagoas (UFAL) also integrated the Project. During the largest part of the time, it had the qualified participation of external consultants that contributed decisively to its development.

The Project’s fundamental perspective is that teaching in the area of health implies associating the teaching-learning process with practices directed at the education of professionals who are able to integrate their knowledge with practice in live scenarios. Based on this, the Project proposed to qualify and amplify scientific, technological and innovation production in Health Teaching, aiming to improve undergraduate and postgraduate education and contribute to the consolidation of the SUS.

The expected results were: Education of two PhDs and six MScs in the three main institutions during the period of execution of the project; establishment of a Research Nucleus in the area of Health Teaching; enhancement and qualification of the scientific, technological and innovation production about Health Teaching; education of qualified professionals who understand the interface between teaching and care, aiming to improve the population’s health; creation of the Health Teaching research line in postgraduate programs; increase in students’ participation in scientific projects.

The proposing institution played an outstanding managerial role concerning both the financial part and the logistic support to the fulfilment of the Project’s objectives. In this higher education institution, the General, Academic, Research and Postgraduate Directors participated actively in the Project’s development, as they believed in the need of advances to improve health professionals’ education.

This involvement was one of the strong points that deserve to be emphasized here, as it is known that institutional support is fundamental to the implementation and development of projects.

Boldness number 1: Teaching, health and development

Similarly to what happens today, in the initial years of the decade of 2010, many individuals defended and worked in favor of the integration between teaching and health, educational activities and provision of health services. This was supported by stakeholders who work in academic environments and by those who work in the environment of the services.

However, generally speaking, intersector interaction was circumscribed to the sectors of health and education. Broad intersectoriality, a consistent interdisciplinary education involving other fields of knowledge, and multiprofessional action with many facets are rarely observed, and few studies have been published with this focus¹³13. Augusto LGS. Saúde, ambiente e desenvolvimento: desafios para a Saúde Pública. In: Martins PH, Fontes B, organizadores. Redes sociais e saúde: novas possibilidades teóricas. Recife: Editora Universitária, UFPE; 2004. p. 93-101.,¹⁴14. Akerman M, Righi LB, Pasche DF, Trufelli D, Lopes PR. Saúde e desenvolvimento: que conexões? In: Tratado de Saúde Coletiva. São Paulo: Hucitec; 2013. p. 109-36..

The Project under analysis here attempted to advance on this ground. The addition of the word “development” to its title signaled an intention that has been fulfilled by means of research projects targeted at the qualification of basic education and at technological development in the area of materials engineering.

Unfortunately, due to the period of maturation of these studies and to the limitation of the Project’s duration in CAPES, the results will emerge only in years to come, outside the period of the Project’s formal development.

Boldness number 2: Network of knowledge and practices

According to a study¹⁵15. Bahia SHA, Batista NA, Batista SHS. Pró-Ensino na Saúde: análise preliminar sobre a vinculação aos Programas de Pós-graduação. In: Anais do 9º Congresso Paulista de Educação Médica; 2014; São José do Rio Preto, BR. Associação Brasileira de Educação Médica; 2014., of the 21 Pró-Ensino Projects analyzed in 2014, eleven proposed to act in academic cooperation networks and seven aimed to constitute research nuclei.

Rovere¹⁶16. Rovere M. Redes. Hacia la construción de redes en salud: los grupos humanos, las instituciones, la comunidade. Rosário: Instituto de Salud Juan Lazarte; 2000., a renowned author who has contributed, from the theoretical and practical point of view, to the development of the networking proposal, registered in one of his studies:

Regarding networked action in the Project, there was much interaction among several professionals from the proposing institutions. However, deeper levels of interpersonal relationships were rarely established, and the levels of recognition, mutual acquaintance and collaboration were rarely surpassed. When there was cooperation (joint operation) and association or partnership (intensification of bonds leading to some form of agreement or sharing, even of resources), they did not have the desired sustainability¹⁷17. Mennin S, Kalishman S, Eklund MA, Friedman S, Morahan PS, Burdick W. Project-based faculty development by international health professions educators: practical strategies. Medical Teacher. 2013; 35 Supl:971-7..

The subsequent inclusion of UFAL in the Project was grounded on the intention of fulfilling one of the specific objectives of Notice 24/2010, namely: “to stimulate the reduction in the inter- and intra-regional asymmetries of Brazilian postgraduate programs, especially in the Amazon, Northeastern and Central-Western regions, creating regional dissemination and encouragement nuclei as a result of the development of interinstitutional proposals.” However, there was no previous history of cooperation and interaction among the postgraduate institutions or programs, which generated a spasmodic movement that lasted while there were financial resources in the Project to enable the scholars’ visits to the other institutions.

The dialog between the practices developed in the participant institutions occurred by means of the record and exchange of experiences. However, this is or can be only the first stage of a networked construction. To proceed, many other stages must be accomplished and fulfilled. This dialog occurred basically in face-to-face meetings of the Project members and continued, at a distance, by means of interaction mechanisms using Information and Communication technological tools (ICT), which allowed the discussion of themes in a deeper way.

However, the knowledge constructed in the projects was not enough to allow the development of multi-center research projects. The number of research projects and publications in the sphere of each postgraduate program increased, but the interaction among programs did not occur in a consistent way. The creation of research lines in programs where there was not a strong institutional adherence to the Project restricted the opportunities of qualitative development of the partnerships outlined in the planning stage.

It is important to highlight that the postgraduate programs that included the Health Teaching research line in their sphere were afraid to damage their evaluation, respecting the CAPES’ classification of each program, as the Brazilian scientific production in this area of knowledge was still incipient.

The development of the Project: Advances and retreats

Based on the five initial proposals or objectives of the Project, after the years went by, it is possible to identify advances and retreats. In our opinion, as the Project was developed by means of processes, talking about advances and retreats is more adequate than using the terms victories and defeats, that is, in our perception, there are no definitive situations. Although the Project has ended, many of its processes continue to happen, although, in some cases, with characteristics of institutionalized practices.

The first specific objective was “To contribute to the strengthening of research lines related to the area of Health Teaching in postgraduate programs (Master’s and doctoral degrees) of the institutions involved in the project”. The realities were and are distinct depending on the institution. In the case of UEL, the Research Line was created in the Postgraduate Programs of Nursing and Dentistry. Concerning the former, the area is consolidated, as one of the two research lines of the Master’s program, created in 2010, is “The Teaching and Management of Care in Nursing”. With the support of the Project, four theses were developed and defended and 18 were completed after the end of the Project. At FPP, the creation of the Health Teaching Research Line in the sphere of the Master’s and Doctoral Degrees of the Postgraduate Program in Biotechnology Applied to Children’s and Adolescent’s Health, which already existed and has been receiving high grades in the CAPES’ evaluation, generated the production of two Doctoral dissertations and two Master’s theses. At UFSC and UFAL, a lower number of research projects was developed.

The second objective of the Project was “To stimulate the creation of a major in the existing postgraduate programs (Master’s and Doctoral degrees)”. Each institution, according to their characteristics, searched for different forms of making the Research Line evolve to a Major. In the case of FPP, a new Program was created. At UFSC and UEL, efforts to create majors are still under way.

The third objective was “To promote knowledge interchange, stimulating the creation of networks between the institutions involved in the Project and the health services”. The Project played an important role in the maintenance and strengthening of an initiative that preceded it: Research Group in Health Teaching (PENSA). The group has been holding meetings every fifteen days for seven years, and has been a space for exchanges and interchange among researchers from many institutions, some of which unrelated to the Project, interested in the theme of Health Teaching.

The fourth objective was “To enable the creation of nuclei and to promote interaction among research groups and academic teams aiming at proposals for postgraduate programs in the area of Health Teaching”. The advance that deserves to be mentioned here was the development of the Project of the Postgraduate Program in Health Sciences Teaching, Master’s and Doctoral levels. This project obtained, in 2015, CAPES’ recognition and authorization to function in the Master’s level. Maintained by FPP, which had and still has the participation of teachers-researchers from other higher education institutions involved in the Network Project, today there are 91 Master’s students enrolled in the program. Up to December 2016, 15 theses from the first Class (2015) had already been defended, and this number will increase to 19 up to the end of the legal deadline (February/March 2017). The fourth class started its activities in March 2017.

Finally, the fifth objective of the Project was “To educate human resources in the postgraduate level, capable of acting and understanding the relations between undergraduate and postgraduate education in the area of health”. In this case, the established goal was the education of six Masters and two PhDs. The goal related to the new Masters was exceeded (ten) and the goal of two PhDs was met. With a total of 38 Masters, 28 of whom received their degrees after the end of the Pró-Ensino na Saúde Project, but undoubtedly resulted from the induction process it triggered, it is clearly necessary to amplify the Postgraduate Program by offering the doctoral degree. This would meet the demand of the Masters who complete their studies at FPP and want to conduct further research in the area, not to mention the high external demand for Masters.

Lessons learned

The most important lessons that the authors extract from the development of this Project are:

• The importance of an external standpoint by means of the presence of an experienced and renowned researcher who, in many occasions, identified possibilities or potentials for improvement, both in each individual and in the network as a whole¹⁸18. Burdick WP, Diserens D, Friedman SR, Morahan PS, Kalishman S, Eklund MA, et al. Measuring the effects of an international health professions faculty development fellowship: the FAIMER Institute. Medical Teacher. 2010; 32:414-21..

• The role of external financial support, provided by ministerial agencies, such as the Ministry of Health/SGTES, and/or fostering agencies like CAPES, was decisive to construct a minimal organizational structure that enabled the Project’s sustainability. In this context, it is difficult to imagine that complex projects involving different institutions and lines of thought can have a successful management using inadequate tools, and there is the need to construct a structure that enables the Project’s sustainability. Furthermore, studies on Health Teaching have been produced by the Project’s participants, but they need more space for publication, as the theme of Health Teaching has not been prioritized by journals yet.

• The institutional support of FPP, which coordinated the Project, was fundamental to the advances that were noted, as the institution’s premise in higher education is that teacher development enables to obtain the desired results in the education of health professionals. This aspect facilitated the implementation and conduction of the proposal.

Perspectives

It is difficult to establish perspectives for Pró-ensino na Saúde in light of the national political and economic conjuncture. Uncertainty predominates and new ingredients that generate insecurity come up every day.

According to Nogueira¹⁹19. Nogueira MA. A difícil normalização democrática e o futuro. Rev Espaço Saude. 2016; 17(2):22-31.:

However, Pró-ensino na Saúde proposals, with or without the revival of a Program by CAPES, with or without the support of the Ministry of Health/SGTES, will continue to have space while there are concrete demands from the health services for a kind of healthcare that requires new types of health professionals.

The strengthening of the Health Teaching area inside CAPES is occurring quickly; a higher number of institutional initiatives targeted at supporting the new practices and knowledge has been approved. This depends, in part, on the mobilization capacity of the stakeholders who acted in the 31 projects approved by the 2010 Notice; in part, on the paths chosen by the sectors of Health and Education; and also on the choice of priority areas for research in Brazil. Many authors²⁰20. Haddad AE, Brenelli SL, Cury GC, Puccini RF, Martins MA, Ferreira JR, et al. Pró-Saúde e PET-Saúde: a construção da política brasileira de reorientação da formação profissional em Saúde. Rev Bras Educ Medica. 2012; 36 Supl 1:3-4.

21. Batista NA, Batista SH, Abdalla IG. Ensino em saúde: visitando conceitos e práticas. São Paulo: Arte & Ciência; 2005.-²²22. Troncon LEA, Bollela VR, Borges MC, Rodrigues MLV. A formação e o desenvolvimento docente para os cursos das profissões da saúde: muito mais que o domínio de conteúdos. Medicina (RP). 2014; 47(3):245-8.have contributed in this space, but the need of a new support and resources to the postgraduate sector are clear to all those involved with teaching in the area of health.

INTERFACE’s initiative to publish a special Supplement is a demonstration that there are actions that can and must be taken. In a context that is distinct from the analyzed reality, whose object were the relationships among users of a health service²³23. Andrade GRB, Vaitsman J. Apoio social e redes: conectando solidariedade e saúde. Cienc Saude Colet. 2002; 7(4):925-34., but with similar processes, the perspectives of this Project and, perhaps, of other projects supported by Notice 24/2010 depend on their stakeholders’ capacity to evolve to a Pró-ensino na Saúde “Movement”.

After all, despite any regrets, as the Portuguese poet Fernando Pessoa already said, “everything’s worth doing if the soul of the doer isn›t small”.

References

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History