The management of academic supervision in the More Doctors for Brazil Project by higher education institutions

Rodrigo Chavez Penha Rosa Gouvêa de Sousa Sandro Schreiber de Oliveira Erika Rodrigues de Almeida Jackeline Gomes Alvarenga Firmiano About the authors

ABSTRACT

The More Doctors Program is a strategic set of actions for the Brazilian National Health System (SUS) aiming at improvements in medical education, professional qualification and retention of doctors in unassisted areas. Among these actions, we highlight the Project More Doctors for Brazil (PMMB), responsible for the emergency supply of doctors. It was conceived as a response to the shortage of professionals in primary care across the country, an extremely important aspect in this set of strategies for SUS. The professional improvement proposed by PMMB has mobilized public higher education institutions to participate as supervisory institutions. They are responsible for supervising the activities developed by doctors and for strengthening the continuing education policy through teaching-service integration actions. This article aims to report on the experience of managing academic supervision in light of the challenge of the implementation of PMMB.

Keywords:
Medical education; Continuing education; More Doctors for brazil Project; Academic supervision

Introduction

The More Doctors Program (PMM) was established by a provisional presidential decree in July 2013 and the law that regulates it was enacted in October of the same year11 Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Lei nº 12.871, de 22 de Outubro de 2013. Institui O Programa Mais Médicos, altera as leis nº 8.745, de 9 de Dezembro de 1993, e nº 6.932, de 7 de Julho de 1981, e dá outras providências. Diário Oficial da União. 23 Out 2013.. The program is a Brazilian public policy that aims to provide medical care for unassisted cities and regions. Its action focuses on primary care and its strategy is based on access to services through the expansion of the municipal care network. The program aims to: increase the number of doctors in primary care, reduce regional inequalities, strengthen primary care, improve medical education targeted at the needs of the Brazilian National Health System (SUS), strengthen the permanent education policy through teaching-service integration, with emphasis on partnerships with higher education institutions by means of academic supervision, promote knowledge and experience exchange between Brazilian health professionals and doctors graduated from foreign institutions, and, last but not least, to qualify doctors for SUS, focusing on its management, healthcare and health education11 Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Lei nº 12.871, de 22 de Outubro de 2013. Institui O Programa Mais Médicos, altera as leis nº 8.745, de 9 de Dezembro de 1993, e nº 6.932, de 7 de Julho de 1981, e dá outras providências. Diário Oficial da União. 23 Out 2013..

The More Doctors Program was conceived in axes that seek to expand and improve infrastructure, education for SUS and emergency supply. Under the name of Project More Doctors for Brazil (PMMB), emergency supply is materialized by means of national and international Notices and through international cooperation for doctors’ adherence to work in primary care. Participant doctors are offered a specialization course and teaching, research and extension activities that permeate the assistance they provide22 Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria Interministerial nº 1.369, de 8 de Julho de 2013. Dispõe sobre a implementação do Projeto Mais Médicos para o Brasil. Diário Oficial da União. 9 Jul 2013.. The assistance component is what promotes the educational processes of academic supervision, which constructs the doctor’s reflection path by means of teaching-service integration, in accordance with the law that regulates the project22 Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria Interministerial nº 1.369, de 8 de Julho de 2013. Dispõe sobre a implementação do Projeto Mais Médicos para o Brasil. Diário Oficial da União. 9 Jul 2013.. This integration is possible through the participation of higher education institutions that perform the academic supervision of the activities carried out by the doctors11 Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Lei nº 12.871, de 22 de Outubro de 2013. Institui O Programa Mais Médicos, altera as leis nº 8.745, de 9 de Dezembro de 1993, e nº 6.932, de 7 de Julho de 1981, e dá outras providências. Diário Oficial da União. 23 Out 2013..

PMMB is a comprehensive policy in the history of supply and interiorization of health professionals and approaches the issue of maldistribution of doctors in Brazil, considering aspects like concentration of doctors per region and doctor-inhabitant ratio11 Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Lei nº 12.871, de 22 de Outubro de 2013. Institui O Programa Mais Médicos, altera as leis nº 8.745, de 9 de Dezembro de 1993, e nº 6.932, de 7 de Julho de 1981, e dá outras providências. Diário Oficial da União. 23 Out 2013.. Its technical and legal framework enables the adjustment of the national proposal to the singular interests of each municipality. The academic supervision’s proximity to the doctor in the field, that is, in the city, enables reflections on their working process, on the implementation of the service, on teamwork, and on the territory and its social determinants33 Oliveira APC, Gabriel M, Poz MRD, Dussault G. Desafios para assegurar a disponibilidade e acessibilidade à assistência médica no Sistema Único de Saúde. Cienc Saude Colet. 2017; 22(4):1165-80.,44 Brasil. Ministério da Educação. Gabinete do Ministro. Portaria nº 585, de 15 de Junho de 2015. Dispõe sobre a regulamentação da Supervisão Acadêmica no âmbito do Projeto Mais Médicos para o Brasil e dá outras providências. Diário Oficial da União. 16 Jun 2015.. This educational action, fostered by the praxis of the doctor and team, is aligned with the National Policy for Permanent Health Education, set forth in Directive no. 1996 of the Ministry of Health, released on August 20, 200755 Cruz CSS. Avaliação do Programa de Educação Permanente para Médicos da Estratégia de Saúde da Família na Região Ampliada de Saúde Jequitinhonha de Minas Gerais [dissertação]. Diamantina, MG: Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM); 2013..

Methodology

The experiences analyzed here refer to the field observation performed by the authors of this article. The observation technique is used by different areas and enables to collect information from the perception of behaviors and events at the moment of their performance or occurrence66 Ferreira LB, Torrecilha N, Machado SHS. A técnica de observação em estudos de administração. In: Anais do 36o Encontro da ANPAD. Rio de Janeiro: EnANPAD; 2012. 1-15.. This group of researchers worked in different management levels of PMMB, either in tutorship and supervision at supervisory institutions, in the State Coordination Commission (CCE) or in the central Coordination Office of the Ministry of Education (MEC). It is from this place that the report on and perspectives of the academic supervision’s movements are presented here, especially in the topics related to territory, teaching-service integration and permanent education. To accomplish this, the authors conducted a bibliographic review of databases and of PMMB’s legal and regulatory frameworks, and analyzed the field observation reports of some of the researchers involved.

The bibliographic review was performed in the Evidence-Based Health portal of the Virtual Health Library from 2013 to 2017, using, as first descriptor, More Doctors Program and, as advanced search, academic supervision, academic tutorship, medical education and permanent education. All the descriptors were searched in Portuguese, English and Spanish. The articles were selected according to availability in full text. In the databases, 97 were found, with an overlap of 16 articles. Filters for academic supervision, academic tutorship, permanent education and medical education were applied to the 81 remaining articles.

After the application of the filter, all the selected articles were fully read. Each author identified ideas present in more than one article, and, after the analysis of this selection, three categories emerged: permanent education associated with teaching-service integration; the design of the performance of academic supervision and/or tutorship; and challenges related to the program and/or project. With these three categories in mind, the authors read the field observation reports. At this moment, the methodology used was Bardin’s content analysis77 Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011.. This type of qualitative analysis of the collected data was chosen because it is a methodological technique that can be applied to different discourses and forms of communication. The analysis followed the stages recommended by the technique: pre-analysis, exploration of the chosen material and “treatment of results”77 Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011.. The following categories emerged after the material was analyzed: implementation of the academic supervision; the territory in the academic supervision; permanent education and teaching-service integration; and the future of PMMB actions. To each of these categories, the authors highlighted ideas that were analyzed in light of the regulatory frameworks of the Project More Doctors for Brazil and of the articles selected in the databases.

Implementation of the academic supervision

To PMMB, academic supervision is a fundamental tool to support the professionals who adhered to the emergency supply Notices55 Cruz CSS. Avaliação do Programa de Educação Permanente para Médicos da Estratégia de Saúde da Família na Região Ampliada de Saúde Jequitinhonha de Minas Gerais [dissertação]. Diamantina, MG: Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM); 2013.. The selection process of supervisory institutions started by means of Directive no. 14 of the Ministry of Education, published on July 9, 201388 Brasil. Ministério da Educação. Gabinete do Ministro. Portaria nº 27, de 14 de Julho de 2015. Dispõe sobre a adesão de instituições de ensino e programas de residência ao Projeto Mais Médicos para o Brasil enquanto das instituições supervisoras. Diário Oficial da União. 15 Jul 2015.. It provides for the adhesion of Federal Higher Education Institutions to the project, with the subsequent extension to other institutions that also assumed partnerships for the emergency supply11 Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Lei nº 12.871, de 22 de Outubro de 2013. Institui O Programa Mais Médicos, altera as leis nº 8.745, de 9 de Dezembro de 1993, e nº 6.932, de 7 de Julho de 1981, e dá outras providências. Diário Oficial da União. 23 Out 2013.,22 Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria Interministerial nº 1.369, de 8 de Julho de 2013. Dispõe sobre a implementação do Projeto Mais Médicos para o Brasil. Diário Oficial da União. 9 Jul 2013.. At the beginning of the project, representatives of the institutions and groups with experience in similar projects participated in working groups that organized the legal possibilities for the universities’ action, in conformity with the needs of human resources education for SUS. Locally, the groups varied in terms of composition, objectives and methodologies, which made the process plural and diverse. The supervisory institutions began to monitor the doctors through the performance of tutorship and supervision33 Oliveira APC, Gabriel M, Poz MRD, Dussault G. Desafios para assegurar a disponibilidade e acessibilidade à assistência médica no Sistema Único de Saúde. Cienc Saude Colet. 2017; 22(4):1165-80..

The tutorship aims to problematize, enable and monitor the working process of the academic supervision, as well as to produce reports and pertinent information to its action, monitoring and evaluating the supervision team’s reports and records44 Brasil. Ministério da Educação. Gabinete do Ministro. Portaria nº 585, de 15 de Junho de 2015. Dispõe sobre a regulamentação da Supervisão Acadêmica no âmbito do Projeto Mais Médicos para o Brasil e dá outras providências. Diário Oficial da União. 16 Jun 2015.,55 Cruz CSS. Avaliação do Programa de Educação Permanente para Médicos da Estratégia de Saúde da Família na Região Ampliada de Saúde Jequitinhonha de Minas Gerais [dissertação]. Diamantina, MG: Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM); 2013.. The tutorship’s action is continually monitored by the Ministry of Education, by means of its decentralized supporters in each Brazilian state, and by the supervisory institutions that signed the instruments of adhesion to PMMB44 Brasil. Ministério da Educação. Gabinete do Ministro. Portaria nº 585, de 15 de Junho de 2015. Dispõe sobre a regulamentação da Supervisão Acadêmica no âmbito do Projeto Mais Médicos para o Brasil e dá outras providências. Diário Oficial da União. 16 Jun 2015.. As the main objective of the academic supervision is the critical and reflective care practice of the doctor who integrates PMMB88 Brasil. Ministério da Educação. Gabinete do Ministro. Portaria nº 27, de 14 de Julho de 2015. Dispõe sobre a adesão de instituições de ensino e programas de residência ao Projeto Mais Médicos para o Brasil enquanto das instituições supervisoras. Diário Oficial da União. 15 Jul 2015., many management reports produced by the supervisory institutions mention tutorship groups whose operation proposes and promotes exchanges of pedagogical practices among themselves and with the supervisors. Instruments that standardized the performance of the supervision were identified, focusing on visit duration and its objective, among other issues.

Academic supervision encourages the doctor’s technical and healthcare qualification within the context of the strengthening of primary care by means of permanent education and teaching-service integration44 Brasil. Ministério da Educação. Gabinete do Ministro. Portaria nº 585, de 15 de Junho de 2015. Dispõe sobre a regulamentação da Supervisão Acadêmica no âmbito do Projeto Mais Médicos para o Brasil e dá outras providências. Diário Oficial da União. 16 Jun 2015.. This orientation comes from the very regulation of PMMB in its axes11 Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Lei nº 12.871, de 22 de Outubro de 2013. Institui O Programa Mais Médicos, altera as leis nº 8.745, de 9 de Dezembro de 1993, e nº 6.932, de 7 de Julho de 1981, e dá outras providências. Diário Oficial da União. 23 Out 2013.. Some field diaries report the use of didactic-pedagogical resources in the performance of academic supervision. These resources aim to raise the doctors’ awareness in relation to the strengthening of primary care and to associate their working process with this success. In this sense, the academic perspective that surrounds the supervision demands a pedagogical framework of this set of supervising doctors, and this was one of the challenges of the implementation.

The territory in the academic supervision

The adhesion to PMMB of 3,756 cities of different sizes reflects the demand for doctors. Initially, more than 13,790 doctors were distributed over Brazil’s 27 federative units99 Almeida ER, Martins AF, Macedo HM, Penha RC. Projeto Mais Médicos para o Brasil: uma análise da supervisão acadêmica. Interface (Botucatu). 2017; 21 Suppl 1:1291-300.. To guarantee supervision and tutorship to all the doctors working in PMMB, instruments of adhesion were signed by the Ministry of Culture and higher education institutions located in all the federative units. Selection, transportation, interaction with health units and their needs were initially on the academic supervision agenda of the doctors participating in PMMB. As some researchers described in their field diaries, from the beginning, managing the territory of the academic supervision was a challenge to the education institutions participating in PMMB. An even greater challenge was the transposition of tables to maps and of maps to the territory, in order to provide academic supervision for the participant doctors.

For the institutional action of the academic supervision, the territory had to be established. Each state had a different adhesion to PMMB in terms of number of enrolled doctors and their distribution. Thus, the territory assigned to supervision was constructed in a singular way in each state. It is important to highlight that, according to the regulatory framework set forth in Directive no. 585 of June 15, 2015 by the Ministry of Culture, each tutor is responsible for guiding the work of up to ten supervisors and each supervisor is responsible for monitoring up to ten participant doctors44 Brasil. Ministério da Educação. Gabinete do Ministro. Portaria nº 585, de 15 de Junho de 2015. Dispõe sobre a regulamentação da Supervisão Acadêmica no âmbito do Projeto Mais Médicos para o Brasil e dá outras providências. Diário Oficial da União. 16 Jun 2015..

The territories described by the tutorships vary a lot, depending on the number of supervisory institutions of each state and on consensuses about territorial divisions. In São Paulo, initially only one institution supervised the entire state, while in Rio Grande do Sul and Minas Gerais, for example, in a short period of time there were already five supervisory institutions. The scenario in the country is diverse, encompassing institutions that supervise thousands of doctors in hundreds of cities and institutions that supervise less than one hundred doctors in less than thirty cities.

The quality of highways and roads, the transportation between cities, the supervision’s profile, the expected and the possible duration of each visit, and the relationship to the municipal management are constantly discussed by the working groups of the supervisory institutions. These groups have different configurations depending on the institution, and this configuration may change over time. Some teams, distributed over extensive territories, decided to hold monthly meetings through web conferencing and some face-to-face meetings, limited because of logistics and reimbursements (Minas Gerais, São Paulo), while others with smaller areas are able to conduct face-to-face meetings on a monthly basis (Rio Grande do Sul).

The territorial design depended on the understanding of each supervisory institution and on the negotiation in each state. After the area of each institution was defined, each tutor had to verify where the participant doctors were distributed in the territory. The challenge posed to the tutors was to guarantee the proximity of the academic supervision for these doctors distributed in territories. Studies of routes and maps are common in descriptions of the tutorship function. Issues like possible accesses and available means of transportation were very important in the construction of the management of the academic supervision. Based on the logistic planning developed by the tutors themselves, possible routes were outlined for the supervisors’ visits to the participant doctors.

As one of the project’s objectives is to supply doctors to places with units where the retention of professionals is difficult, the academic supervision managers believe that this strategy to provide human resources would imply the work of those who are willing to support, monitor and help the PMMB doctors. Even with planning, some questions challenged the supervisors, like time management in the cities, transportation between cities and the team and the management’s demands.

When some professionals decided to become supervisors, adjusting the aspects mentioned above, they had to evaluate their own possibilities of arriving at the places where the doctors were, analyzing the territories and, sometimes, discovering adversities only during or at the end of the route. Rivers, impassable paths or additional risks were known only after the first visits. Together with tutors and managers, different solutions were devised and implemented, according to the type of adversity, the available resources and the unique context of each situation. Some institutions started to use supervisors who lived near the regions where they performed the supervision (Minas Gerais, São Paulo, Bahia, Rio Grande do Sul), while others interspersed doctors in the city where the supervisor lived with doctors in distant cities (Rio Grande do Sul, Santa Catarina). In both cases, the supervisors’ time of permanence away from home and their time of regular work were reduced. These issues stood out in CCE meetings, in tutorship meetings, and in the reports of tutors from the supervisory institutions.

The selection process of supervisors also varied a lot in each supervisory institution: some established criteria and invited individuals who met the criteria (Rio Grande do Sul, São Paulo), while others launched public calls to select individuals among those who applied (Minas Gerais, some Northeastern states). As for the professionals’ profile, some supervisory institutions have supervisors from the area of family and community medicine with experience in preceptorship of students or residents, while others have supervisors from different medical specialties, some of them with no experience in preceptorship.

Permanent education and teaching-service integration

The supervisors’ action was a key point for the resignification of the institutions’ role in projects to expand the care network. The Qualification Program for Primary Care Professionals (PROVAB) was an example of this1010 Gallas NI, Almeida JDL, Faria MA, Paula DMP, Duarte NIG, Mello VRC, et al. O Programa "Mais Médicos" na mídia Brasileira: estado da arte. Obstet J. 2017; 11(2):1-13.. The Ministry of Health’s experience in the use of decentralized references during the execution of projects like PROVAB led the Ministry of Culture to plan the implementation of its own state supporters, including them in the program’s budget with the objective of providing local support for the tutors. In March 2014, the Ministry of Culture implemented the strategy of Institutional Support to the Supervisory Institutions of PMMB by means of a selection process. This first experience began through the selection, education and integration of supporters from the two Ministries in the states of Bahia, Ceará, Rio Grande do Sul and Minas Gerais. Currently, it is employed in all the federative units. The support aims to solve problems and provide clear orientations, guaranteed by effective communication, aligned with the reality lived by tutors and supervisors1111 Franco TAV, Paiva CHA. Programa Mais Médicos para o Brasil: textos e documentos de referência reunidos [Internet]. Brasília: Estação de trabalho observatório história e saúde; 2018 [citado 5 Jan 2018]. Disponível em: http://observatoriohistoria.coc.fiocruz.br/php/level.php?lang=pt&component=17&item=8
http://observatoriohistoria.coc.fiocruz....
.

In view of the challenges of a project of this magnitude, lessons learned with previous experiences had to be, and effectively were, used. PROVAB had already constructed an intersectoral and interinstitutional network in 2012, composed, among other professionals, of supervisors. Many of them describe the supervision experience as something innovative, as it enabled to qualify doctors outside the traditional academic environment, stimulating them to reflect critically on their work and encouraging them to face the difficulties noticed in their daily routine33 Oliveira APC, Gabriel M, Poz MRD, Dussault G. Desafios para assegurar a disponibilidade e acessibilidade à assistência médica no Sistema Único de Saúde. Cienc Saude Colet. 2017; 22(4):1165-80.,1212 Saletti Filho HC, Fontão P. Estratégias de supervisão prática no Provab: a medicina centrada no paciente como proposta de desenvolvimento do cuidado em saúde [Internet]. Comunidade Prat. 2014 [citado 8 Jan 2018]. Disponível em: https://novo.atencaobasica.org.br/relato/37
https://novo.atencaobasica.org.br/relato...
. Reports in the PROVAB system made by individuals involved in local activities, as well as their experience reports, helped higher education institutions and health management agencies to form structures and plan actions.

State policies for permanent health education also weaved, at many moments, intersectoral networks with the presence of teaching and health institutions. From 2010 to 2013, in the state of Minas Gerais, the Permanent Education Program for Family Doctors was developed by the State Department of Health (PEP/SES/MG)1313 Silvério JB. Programa de educação permanente para médicos de família. Rev Med Minas Gerais. 2008; 18 Suppl 4:60-6.. It aimed to improve the effectiveness of primary care based on the pedagogical framework of significant learning associated with clinical competencies necessary to doctors who work in healthcare units1313 Silvério JB. Programa de educação permanente para médicos de família. Rev Med Minas Gerais. 2008; 18 Suppl 4:60-6.. This experience was brought to the academic supervision managers and was used in the development of educational strategies in successive forums led by the Ministry of Education, through the Directorate of Health Education Development.

In addition, the State Coordination Commission (CCE) was created by means of Directive no. 2921 of the Ministry of Health, published on November 28, 20131414 Silva LAA, Leite MT, Pinno C. Contribuições das comissões de integração ensino-serviço na educação permanente em saúde. Trab Educ Saude. 2014; 12(2):403-24.. This commission, which has its own regulations and is subordinated to the National Coordination Office, aims at drawing the institutions involved in PMMB closer and at helping to solve conflicts and meeting the demands arising during the course of the project. In many CCEs, there were representatives of PROVAB and PMMB, like higher education institutions, state and municipal managers, state supporters of the Ministries of Health and Education, members of the Pan American Health Organization, and representatives of the Open University of SUS, among other actors involved in the operationalization of PMMB, in order to approach different aspects according to the local context. However, it is possible to notice variations in the composition of CCEs according to local conjunctures. In Minas Gerais and Rio Grande do Sul, for example, this commission has a tripartite coordination, with one representative of the municipal managers, one representative of the supervisory institutions, and one state manager.

The future of the actions of PMMB

Throughout the academic management of the tutorship and of the supervision, some strategic actions were strengthened, like the emphasis on permanent education and teaching-service integration. Therefore, some of the themes that involve the academic supervision are assistance, management and education, and the challenges faced by supervisors are related to how and with whom to discuss the themes, or how to particularize learning during the service. This motivates the supervisory institution to expand its attention from supervision to the health units’ teams, and also to focus on the improvement in supervision through pedagogical practices targeted at adults. In this context, their education is treated as a necessity to perform their function, a diagnosis that is similar to the reflection proposed by Ribeiro and Prado, in which preceptorship perceives itself as an act of teaching, needing reflection and qualification as such1515 Ribeiro KRB, Prado ML. A prática educativa dos preceptores nas residências em saúde: um estudo de reflexão. Rev Gauch Enferm. 2013; 34(4):161-5..

The academic supervision’s and tutorship’s actions to review the approach traditionally given to issues involving teaching and service promote permanent education focusing on active learning methodologies. Thus, social interactionism, dialogism1616 Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria nº 2.921, de 28 de Novembro de 2013. Dispõe sobre a constituição das Comissões Estaduais e Distrital do Projeto Mais Médicos para o Brasil e institui incentivo financeiro de custeio para a manutenção e execução de suas atividades para os próximos. Diário Oficial da União. 29 Nov 2015; p. 129-30., complex thought and scientific method are considered powerful educational strategies to enable the necessary change in the teaching of the adequate practice of family and community medicine (and health). This involves knowing and dealing with the context in which medicine is learned and practiced, and it also involves the educator’s active observation - a professional who must be supported, stimulated and recognized in their practice1616 Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria nº 2.921, de 28 de Novembro de 2013. Dispõe sobre a constituição das Comissões Estaduais e Distrital do Projeto Mais Médicos para o Brasil e institui incentivo financeiro de custeio para a manutenção e execução de suas atividades para os próximos. Diário Oficial da União. 29 Nov 2015; p. 129-30..

The active teaching-learning methodologies aim to foster criticism in people, maximizing their curiosity based on real situations or through exercises performed in real settings1616 Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria nº 2.921, de 28 de Novembro de 2013. Dispõe sobre a constituição das Comissões Estaduais e Distrital do Projeto Mais Médicos para o Brasil e institui incentivo financeiro de custeio para a manutenção e execução de suas atividades para os próximos. Diário Oficial da União. 29 Nov 2015; p. 129-30.. Many of them stimulate the subject’s autonomy, respect their life history, and articulate different points of view, even in situations of divergent thinking1717 Lima VV. Espiral construtivista: uma metodologia ativa de ensino-aprendizagem. Interface (Botucatu). 2017; 21(61):421-37.. These pedagogical proposals potentialize learning with health professionals and are aligned with the strategies described for PMMB.

Academic supervision monitors the doctor in their daily routine. This demands of supervision pedagogical practices targeted at the working adult who is outside the formal and traditional space of the classroom. Problematization based on real situations and team review become learning triggers1616 Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria nº 2.921, de 28 de Novembro de 2013. Dispõe sobre a constituição das Comissões Estaduais e Distrital do Projeto Mais Médicos para o Brasil e institui incentivo financeiro de custeio para a manutenção e execução de suas atividades para os próximos. Diário Oficial da União. 29 Nov 2015; p. 129-30.. Reflections on work, contextualized limitations and forms of facing problems in teams and in the community are devices with which the supervision operates to stimulate the professional’s qualification. This proposal of shared action requires that the supervision team undergo permanent education, too. Thus, meetings to exchange experiences, use of social media to exchange information, and courses about teaching practices are constantly identified in the supervisory institutions and, in themselves, are a challenge to the academic tutorship, which is responsible for organizing the supervision’s working process.

To accomplish this, the academic supervision has actions in the field, regional actions and team actions55 Cruz CSS. Avaliação do Programa de Educação Permanente para Médicos da Estratégia de Saúde da Família na Região Ampliada de Saúde Jequitinhonha de Minas Gerais [dissertação]. Diamantina, MG: Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM); 2013.. This design results from the maturation of this function: by investing in the medical professional, the supervision understands that it has an impact on the team’s and city’s actions and invites everybody to participate in the dialog and learning processes. This repercussion is aligned with the rationality through which the Family Health Strategy operates, as it inserts the medical professional’s learning based on triggers like the health unit, the team and the community. This adjusts the doctor’s performance in the Family Health Strategy1818 Melo BC, Sant'Ana G. A prática da metodologia ativa: compreensão dos discentes enquanto autores do processo ensino-aprendizagem. Comun Cienc Saude. 2012; 23(4):327-39.. Thus, when supervision mobilizes professionals positively towards the encounter between health needs and the practice at the health unit, the community care model of the Family Health Strategy is strengthened. With this, supervision instruments and practices generate products like municipal protocols, recycling courses, review of medical records or critical events, development plans for the professional, improvement in skills, planning of the unit’s actions, incentive to the family and community approach, meetings between the team and managers (municipal and regional), and evidence-based studies and qualification processes.

The experience of the academic supervision and tutorship model has brought many benefits to the health system and to universities. It has stimulated discussions and interactions with municipal managements, and, together, they have devised better alternatives to overcome problems. The university could find people with vocation for teaching who had not had the opportunity to “experience academia” and, due to their action as supervisors, were in contact with the universities.

Final remarks

The continuity of PMMB has been permanently on the agenda of doctors, managers and supervisory institutions, and the issue of academic supervision is central in this perspective. Challenges like the maintenance of healthcare for peripheral and neglected populations and municipal budgets’ impossibility of covering this assistance are definitive to the program’s continuity99 Almeida ER, Martins AF, Macedo HM, Penha RC. Projeto Mais Médicos para o Brasil: uma análise da supervisão acadêmica. Interface (Botucatu). 2017; 21 Suppl 1:1291-300.. On the other hand, academic supervision plays a role in another central issue, even more relevant than the first, which is the quality of and the support given to the professionals who provide this assistance99 Almeida ER, Martins AF, Macedo HM, Penha RC. Projeto Mais Médicos para o Brasil: uma análise da supervisão acadêmica. Interface (Botucatu). 2017; 21 Suppl 1:1291-300.. Without this action, academic supervision may have no effect at all.

The definitions of directions and priorities will guide the future maintenance of the assistance and the development of its quality. The advances and experiences reported during the program’s first four years allow us to understand that academic supervision is able to identify and correct the health professionals’ trajectories in order to guarantee high-quality care and the program’s management. The entire network constructed during this period, where thousands of doctors met and recognized each other as protagonists of an effective action to improve the health services, may be the greatest legacy of the tutorship and supervision model.

References

  • 1
    Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Lei nº 12.871, de 22 de Outubro de 2013. Institui O Programa Mais Médicos, altera as leis nº 8.745, de 9 de Dezembro de 1993, e nº 6.932, de 7 de Julho de 1981, e dá outras providências. Diário Oficial da União. 23 Out 2013.
  • 2
    Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria Interministerial nº 1.369, de 8 de Julho de 2013. Dispõe sobre a implementação do Projeto Mais Médicos para o Brasil. Diário Oficial da União. 9 Jul 2013.
  • 3
    Oliveira APC, Gabriel M, Poz MRD, Dussault G. Desafios para assegurar a disponibilidade e acessibilidade à assistência médica no Sistema Único de Saúde. Cienc Saude Colet. 2017; 22(4):1165-80.
  • 4
    Brasil. Ministério da Educação. Gabinete do Ministro. Portaria nº 585, de 15 de Junho de 2015. Dispõe sobre a regulamentação da Supervisão Acadêmica no âmbito do Projeto Mais Médicos para o Brasil e dá outras providências. Diário Oficial da União. 16 Jun 2015.
  • 5
    Cruz CSS. Avaliação do Programa de Educação Permanente para Médicos da Estratégia de Saúde da Família na Região Ampliada de Saúde Jequitinhonha de Minas Gerais [dissertação]. Diamantina, MG: Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM); 2013.
  • 6
    Ferreira LB, Torrecilha N, Machado SHS. A técnica de observação em estudos de administração. In: Anais do 36o Encontro da ANPAD. Rio de Janeiro: EnANPAD; 2012. 1-15.
  • 7
    Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011.
  • 8
    Brasil. Ministério da Educação. Gabinete do Ministro. Portaria nº 27, de 14 de Julho de 2015. Dispõe sobre a adesão de instituições de ensino e programas de residência ao Projeto Mais Médicos para o Brasil enquanto das instituições supervisoras. Diário Oficial da União. 15 Jul 2015.
  • 9
    Almeida ER, Martins AF, Macedo HM, Penha RC. Projeto Mais Médicos para o Brasil: uma análise da supervisão acadêmica. Interface (Botucatu). 2017; 21 Suppl 1:1291-300.
  • 10
    Gallas NI, Almeida JDL, Faria MA, Paula DMP, Duarte NIG, Mello VRC, et al. O Programa "Mais Médicos" na mídia Brasileira: estado da arte. Obstet J. 2017; 11(2):1-13.
  • 11
    Franco TAV, Paiva CHA. Programa Mais Médicos para o Brasil: textos e documentos de referência reunidos [Internet]. Brasília: Estação de trabalho observatório história e saúde; 2018 [citado 5 Jan 2018]. Disponível em: http://observatoriohistoria.coc.fiocruz.br/php/level.php?lang=pt&component=17&item=8
    » http://observatoriohistoria.coc.fiocruz.br/php/level.php?lang=pt&component=17&item=8
  • 12
    Saletti Filho HC, Fontão P. Estratégias de supervisão prática no Provab: a medicina centrada no paciente como proposta de desenvolvimento do cuidado em saúde [Internet]. Comunidade Prat. 2014 [citado 8 Jan 2018]. Disponível em: https://novo.atencaobasica.org.br/relato/37
    » https://novo.atencaobasica.org.br/relato/37
  • 13
    Silvério JB. Programa de educação permanente para médicos de família. Rev Med Minas Gerais. 2008; 18 Suppl 4:60-6.
  • 14
    Silva LAA, Leite MT, Pinno C. Contribuições das comissões de integração ensino-serviço na educação permanente em saúde. Trab Educ Saude. 2014; 12(2):403-24.
  • 15
    Ribeiro KRB, Prado ML. A prática educativa dos preceptores nas residências em saúde: um estudo de reflexão. Rev Gauch Enferm. 2013; 34(4):161-5.
  • 16
    Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria nº 2.921, de 28 de Novembro de 2013. Dispõe sobre a constituição das Comissões Estaduais e Distrital do Projeto Mais Médicos para o Brasil e institui incentivo financeiro de custeio para a manutenção e execução de suas atividades para os próximos. Diário Oficial da União. 29 Nov 2015; p. 129-30.
  • 17
    Lima VV. Espiral construtivista: uma metodologia ativa de ensino-aprendizagem. Interface (Botucatu). 2017; 21(61):421-37.
  • 18
    Melo BC, Sant'Ana G. A prática da metodologia ativa: compreensão dos discentes enquanto autores do processo ensino-aprendizagem. Comun Cienc Saude. 2012; 23(4):327-39.

History

  • Received
    15 Feb 2018
  • Accepted
    26 Oct 2018
UNESP Botucatu - SP - Brazil
E-mail: intface@fmb.unesp.br