Abstract

Introduction

The institutionalized policy structure for the education of Human Resources in Health (HRH) in Brazil is called the National Policy for Permanent Education in Health (PNEPS)¹1. Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação na Saúde. Política Nacional de Educação Permanente em Saúde. Brasília, DF: Ministério da Saúde; 2009.. It is a policy regarding training and development of workers for the Brazilian National Health System (SUS) launched in 2004, and their guidelines for implementation were published in 2007. It was an important leap forward in fostering regionally led inter-institutional participation, setting budgets for projects and actions, establishing transparent allocation criteria²2. Ferraz F, Backes VMS, Mercado-Martinez FJ, Feuerwerker LCM, Lino MM. Gestão de recursos financeiros da educação permanente em saúde: desafio das comissões de integração ensino-serviço. Cienc Saude Colet. 2013; 18(6):1683-93..

The main drivers of the PNEPS are anchored in the theoretical and methodological frameworks of permanent education in health (PEH), understood as a political-pedagogical strategy geared towards the problems and needs of the health work process. It presupposes integration between teaching, service, management and control by the society, aiming to transform professional practices and work organization, promoting humanization and improving access and quality of care provided to the population³3. Ceccim RB. Educação permanente em saúde: desafio ambicioso e necessário. Interface (Botucatu). 2005; 9(16):161-77..

The implementation processes of PNEPS in the states and municipalities were subjects of analysis of different studies, showing challenges for the consolidation of the HRH area in Brazil such as: the poor articulation of the health service with the education sector; the lack of evaluation of the results and impacts of the projects developed; scarce financing and difficulties in implementing financial resources; and the mismatch between training and the professional profile required by the health system²2. Ferraz F, Backes VMS, Mercado-Martinez FJ, Feuerwerker LCM, Lino MM. Gestão de recursos financeiros da educação permanente em saúde: desafio das comissões de integração ensino-serviço. Cienc Saude Colet. 2013; 18(6):1683-93.,⁴4. França T, Medeiros KR, Belisario SA, Garcia AC, Pinto ICM, Castro JL, et al. Política de educação permanente em saúde no Brasil: a contribuição das comissões permanentes de integração ensino-serviço. Cienc Saude Colet. 2016; 22(6):1817-28.,⁵5. d’Ávila LS, Assis LN, Melo MB, Brant LC. Adesão ao programa de educação permanente para médicos de família de um Estado da Região Sudeste do Brasil. Cienc Saude Colet. 2014; 19(2):401-16..

In order to overcome the barriers for the effective implementation of the PNEPS, the Ministry of Health (MS) launched in 2017 the process called “Restarting the PNEPS” with the intention of putting the issue of Health Education back on the national public policy agenda⁶6. Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação na Saúde. Política Nacional de Educação Permanente em Saúde: o que se tem produzido para o seu fortalecimento? Brasília, DF: Ministério da Saúde; 2018., in line with the recommendations by international public health organizations, such as the Human Resources Strategy for Universal Access to Health and Universal Health Coverage approved in 2017 by the Pan American Health Organization (PAHO). It presents guidelines that urge countries to establish formal mechanisms to confront the challenges of the HRH area, including the increase in public spending and the efficiency of financing as well as promoting the development of interprofessional teams in healthcare networks⁷7. França T, Magnago C. Políticas, programas e ações de educação na saúde: perspectivas e desafios. Saude Debate. 2019; 43 Spe 1:4-7.,⁸8. Organização Mundial da Saúde. Organização Pan-Americana da Saúde. Resolução CSP29/10: estratégia de recursos humanos para o acesso universal à saúde e a cobertura universal de saúde. Washington, DC: OMS/OPAS; 2017..

During the 2017-2018 period, a set of initiatives was undertaken in Brazil aimed at structuring the public sector HRH policy, with the basic premises of integrating the education and health sectors and aligning HRH training to the needs of health systems⁷7. França T, Magnago C. Políticas, programas e ações de educação na saúde: perspectivas e desafios. Saude Debate. 2019; 43 Spe 1:4-7.,⁸8. Organização Mundial da Saúde. Organização Pan-Americana da Saúde. Resolução CSP29/10: estratégia de recursos humanos para o acesso universal à saúde e a cobertura universal de saúde. Washington, DC: OMS/OPAS; 2017.. Therefore, following the federal legislation that establishes that the SUS planning and budgeting process will move upwards, from the local to the federal level⁹9. Brasil. Presidência da República. Lei nº 8.080, de 19 de Setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União. 20 Set 1990., it was prioritized to initiate a debate with the states and municipalities, actors that effectively promote public policies, articulated with the federal sphere⁶6. Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação na Saúde. Política Nacional de Educação Permanente em Saúde: o que se tem produzido para o seu fortalecimento? Brasília, DF: Ministério da Saúde; 2018.,¹⁰10. Gonçalves CB, Pinto ICM, França T, Teixeira CF. A retomada do processo de implementação da política nacional de educação permanente em saúde no Brasil. Saude Debate. 2019; 43 Spe 1:12-23..

As a measure to reestablish the PNEPS implementation process, the Program for the Strengthening of Permanent Health Education Practices in the Unified Health System (PRO EPS-SUS in Portuguese) was instituted by the Ministry of Health in 2017implying the recovery of the flow of financing and transferring of resources to states and municipalities, with the purpose of stimulating, monitoring and strengthening professional qualification¹⁰10. Gonçalves CB, Pinto ICM, França T, Teixeira CF. A retomada do processo de implementação da política nacional de educação permanente em saúde no Brasil. Saude Debate. 2019; 43 Spe 1:12-23..

Due to this process, a way of contributing to the formulation of a coherent and adequate agenda for the HRH area in Brazil, under the aegis of the PNEPS restarting movement, it is a timely moment to produce evidence in this field, especially now when the institution of this policy turns 15 years. This study aimed to understand the factors that favor or hinder the trajectory of implementing PNEPS in Brazil, as well as the proposals for its strengthening, seen from the perspective of actors that promote it.

Methods

This is a nationwide qualitative study developed in May 2019, interviewing key informants participants in the developing of the PEH policy. These were included according to the following criteria: to be people who act directly in the management, planning or operationalization of the policy, at the municipal, state and federal levels, for at least three years. This time was set due to be considered sufficient for those involved in the process in order to know and take ownership of actions related to PEH.

Assuming that leading a policy has different specificities, structures and challenges in each sphere of government, we sought to include a plurality of stakeholders linked to the main bodies guiding the PEH policy and, therefore, with the capacity to produce the kind of knowledge sought by this study. Thus, they were invited to participate in the research: at the federal level, a manager linked to the Ministry of Health (MS), one linked to the Ministry of Education (MEC) and one from the National Health Council (CNS); at the state level, a manager, by geographic region, linked to the State Health Secretariat (SES) and / or School of Public Health (ESP); at the municipal level, a manager, by geographic region, linked to the National Council of Municipal Health Secretariats (CONASEMS); and a PAHO representative.

Recruitment of participants and data collection happened during a nationwide event in May 2019, in which these institutions were represented. 14 actors participated in the study, including managers, technicians, professionals, coordinators, teachers and counselors, one representative of the Ministry of Health, nine state representatives, three municipal representatives and one from PAHO. MEC and CNS did not participate, as they were not present at the event. The number of participants at the municipal level was lower than planned, while the state participants number was higher than expected, due to the interest of the actors.

Data were collected through a 70-minutes focus group, guided by a script with five questions aimed to know the factors that favor and hinder the implementation of the PNEPS and the proposals for the implementation of public policy in Brazil. All testimonies were recorded on digital audio equipment and later transcribed in full text. The material produced was treated using content analysis, from three consecutive steps: pre-analysis; exploration; and analysis and inference¹¹11. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2011..

The pre-analysis phase edited the statements to remove language and grammatical errors, in order to make the discourse reading more fluid, trying to avoid changes in meaning and content. The statements were coded, giving a code to each participant of the focus group for the purpose of preserving anonymity and presenting the speech fragments in the results. Subsequently, the corpus produced was subjected to successive readings.

The material exploration stages aimed to highlight the semantic order of the corpus – record units (RU) and context units (CU) – to enumerate and categorize them. In this study, the RU corresponded to key terms contained in each speech, while the CU represented contextual cutouts of the RU. The CU grouping was anchored in previous analytical categories that guided the focus group, namely: Factors favorable to the implementation of the PNEPS; Factors that hinder the implementation of the PNEPS; and Proposals for strengthening the PNEPS.

During the inference and interpretation phase, the information was condensed and highlighted, enabling interpretations and critical analysis of the material. The data originated a corpus of analysis from which 103 RU were extracted; of these, the most prevalent were those related to factors that hinder the implementation of PNEPS in the country (RU = 41; 39.8%), as shown in Table 1.

The research project was approved by the Research Ethics Committee of the Faculty of Health Sciences of the University of Brasília, through Opinion nº 3.333.085.

Results

Factors that favored the implementation of the PNEPS

The main factor helping currently the implementation of the PNEPS is the PRO EPS-SUS, launched with the objective of providing institutional and financial technical support to the local authorities, providing to the states and the Federal District (DF), an economic incentive for the elaboration of State Plans for Permanent Education in Health and, for the municipalities and DF for the execution of PEH actions for the Primary Care teams. They were also indicated as favorable factors: the institution of PEH as a policy through regulations, the transfer of resources by the Federal Government and the strengthening of the role of municipalities.

Other factors pointed out were: the involvement of the staff that articulate the EPS in their territories of operation; collegiate spaces, in particular the Regional Inter-managerial Commissions (CIR), which are co-management bodies in the regional space with the objective of constituting a permanent and continuous channel for negotiation and decision between municipal managers and the state for the constitution of a regionalized network¹²12. Santos AM, Giovanella L. Governança regional: estratégias e disputas na gestão da região da saúde. Rev Saude Publica. 2014; 48(4):622-31.; and the Teaching-Service Integration Commissions (CIES), permanent intersectoral and interinstitutional instances that participate in the formulation, conduct, monitoring and evaluation of the PNEPS¹³13. França T, Belisário SA, Medeiros KR, Pinto ICDM, Garcia ACP. Limites e possibilidades das comissões permanentes de integração ensino-serviço: percepções dos gestores. Saude Debate. 2017; 41 Spe 3:144-54.. Under this perspective, the importance of the partnership between CIR and CIES was highlighted, as well as of regionalization, and the CIR is its governance structure.

As elements that favor the implementation of PNEPS the following were also mentioned: the educational quadrilateral³3. Ceccim RB. Educação permanente em saúde: desafio ambicioso e necessário. Interface (Botucatu). 2005; 9(16):161-77., formed by the articulation of teaching, service, management and social control; the manager’s commitment; PEH as a primary care assessment variable; the inclusion of an PEH area in the organizational structure of the health secretariats; and the existence of PEH devices, namely Public Health Schools and Technical Schools.

Factors that hindered the implementation of the PNEPS

The elements that hinder the implementation of the PNEPS are the interruption of resource transfer by the Federal Government since 2011; in the sphere of government, the conceptual misalignment about PEH, the difficulty in implementing financial resources and the difficulty in monitoring and evaluating PEH actions.

The turnover of managers in all spheres, the lack of support and technical reference, low governance and the fragmentation of PEH actions were also pointed out as obstacles to the implementation of the PNEPS.

In addition, according to the participants, the lack of dialogue between the instruments of the work management policy and the area of health education also hamper the effective implementation of the policy, since both are interdependent.

Proposals for PNEPS strengthening

This category encompass the RUs that showed proposals to strengthen the PNEPS, which, in general, corroborate the previous categories, since they focus on the factors that favor and hinder the implementation of the policy. The recommendations point to the role of the Federal Government in maintaining the transfer of resources and technical support to the states; for strengthening networking and collegiate bodies; and for the need for integration between work management policies and health education management policies.

Discussion

The results of this research show that the elements favoring, hindering and possibly strengthening the implementation of PNEPS are, in general, part of the same set that includes the themes: financing, technical support, institutional integration, articulation in regional and collegiate networks, and conceptual alignment. Such themes were also reported in the study presenting the results of the cycle of workshops, with representatives of the various institutions involved in the planning, programming, execution and evaluation of PEH actions, which occurred within the process of restarting the PNEPS⁶6. Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação na Saúde. Política Nacional de Educação Permanente em Saúde: o que se tem produzido para o seu fortalecimento? Brasília, DF: Ministério da Saúde; 2018.. The present research, however, revealed two new favorable elements: the PRO EPS SUS, which derived precisely from the national debate undertaken on the PNEPS, and the normative that institutes it.

PRO EPS-SUS came after a lengthy interval (2007-2016) without any institutional normative deliberation that would make it possible to leverage the PNEPS implementation process. Added to this, as of 2011, the discontinuity of technical support and the transfer of PNEPS resources to the states intensified the fragility already perceived in its implementation process, especially in the scenario of Schools of Public Health¹⁴14. Cardoso MLDM, Costa PP, Costa DM, Xavier C, Souza RMP. A política nacional de educação permanente em saúde nas escolas de saúde pública: reflexões a partir da prática. Cienc Saude Colet. 2017; 22(5):1489-500.. Configuring itself as a strategy to strengthen PEH actions in the Brazilian territory and to promote management processes in the logic of the health care model, the program received adhesions from all federal units in the country and more than 90% of the Brazilian municipalities¹⁵15. Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Manual técnico 2018 - Programa para o Fortalecimento das Práticas de Educação Permanente em Saúde no SUS - PRO EPS-SUS. Brasília, DF: Ministério da Saúde; 2018..

The need to support the normative that institutes PEH as a national policy by a legal device arose from an intense process of discussion. This discussion, even knowing the advances undertaken by different heterogeneous initiatives that mobilize changes, recognized that these acted in a disjointed way, so that they were not able to promote a national culture of transformation¹⁶16. Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação na Saúde. Política de educação e desenvolvimento para o SUS: caminhos para a educação permanente em saúde: pólos de educação permanente em saúde. Brasília, DF: Ministério da Saúde; 2004.. The norms proposed to highlight the theme of education and development of health professionals, including and making the different segments and social and political actors responsible for the consolidation of SUS.

Under this view, PNEPS calls for integrating the four structuring pillars for health education in SUS: teaching, management, care and control from society¹⁷17. Ceccim RB, Feuerwerker LCM. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis. 2004; 14(1):41-65., whose interlocutors are intertwined in the reality that is expected to change and are, therefore, co-responsible for configuring acts of change. It is precisely due to interinstitutional relations, agreement and negotiation, that PNEPS has been effectively happening in different territories¹⁴14. Cardoso MLDM, Costa PP, Costa DM, Xavier C, Souza RMP. A política nacional de educação permanente em saúde nas escolas de saúde pública: reflexões a partir da prática. Cienc Saude Colet. 2017; 22(5):1489-500..

Collegiate bodies act as inclusive spaces for dialogue, reflection and problematization according to a horizontal relational logic. In this sense, they are powerful devices for the PNEPS, as well as for the operationalization of regionalization, assumed as an important strategy capable of ensuring a more effective action by SUS¹⁸18. Viana ALD, Lima LD. Regionalização e relações federativas na política de saúde no Brasil. Rio de Janeiro: Contracapa; 2011.. The participants of this study consider them as indispensable for implementing and strengthening the PNEPS, and as a vector for the integration of the fields of work management and health education. Other actors pointed out the dissociation between these fields as a difficulty for the implementation of the policy.

Creating convergences between the areas of work and education is indispensable for strengthening PEH actions, thus maximizing their potential and their role in producing effective changes¹⁹19. Lopes MTSR, Labegalini CMG, Silva MEKD, Baldissera VDA. Educação permanente e humanização na transformação das práticas na atenção básica. REME Rev Min Enferm. 2019; 23:e-1161.,²⁰20. Lopes MTSR, Labegalini CMG, Baldissera VDA. Educar para humanizar: o papel transformador da educação permanente na humanização da atenção básica. Rev Enferm UERJ. 2017; 25:e26278.. Therefore, it is necessary to make effective co-management, based on the effective functioning of collegiate spaces, whether they are deliberative or not, with the clarity that the desired changes will not occur without effort, toiling, time and dedication, and that any proposal intentionally collective and dialogued proposal will be interspersed with tensions and disputes²¹21. Slomp Junior H, Merhy EE, Seixas CT, Cruz KT, Bertussi DC, Baduy RS. Mágica ou magia? Colegiados gestores no Sistema Único de Saúde e mudanças nos modos de cuidar. Interface (Botucatu). 2019; 23:e170395..

The speech of the PNEPS actors recognized that the workers themselves are able to weave support and discussion networks in their territories that lead to the strengthening of PEH actions. The participation and support of managers was also claimed, whose turnover and low priority given to PEH translate into low governance and hinder the development of the policy, as already highlighted by other studies¹³13. França T, Belisário SA, Medeiros KR, Pinto ICDM, Garcia ACP. Limites e possibilidades das comissões permanentes de integração ensino-serviço: percepções dos gestores. Saude Debate. 2017; 41 Spe 3:144-54.,¹⁴14. Cardoso MLDM, Costa PP, Costa DM, Xavier C, Souza RMP. A política nacional de educação permanente em saúde nas escolas de saúde pública: reflexões a partir da prática. Cienc Saude Colet. 2017; 22(5):1489-500.. The manager’s non-involvement stance can be explained, at least in part, by the lack of understanding of what PEH really is. This lack of clarity is not only characteristic of the managers, but of a good part of the actors that are part of the SUS and also of the frameworks of reference that still denote conceptual confusions between continuing education and permanent education¹⁴14. Cardoso MLDM, Costa PP, Costa DM, Xavier C, Souza RMP. A política nacional de educação permanente em saúde nas escolas de saúde pública: reflexões a partir da prática. Cienc Saude Colet. 2017; 22(5):1489-500.,²²22. Cavalcanti FDOL, Guizardi FL. Educação continuada ou permanente em saúde? Análise da produção Pan-Americana da Saúde. Trab Educ Saude. 2018; 16(1):99-122..

The concept of PEH adopted in the Region of the Americas is recent, and in Brazil it only gained notoriety after the publication of the PNEPS²²22. Cavalcanti FDOL, Guizardi FL. Educação continuada ou permanente em saúde? Análise da produção Pan-Americana da Saúde. Trab Educ Saude. 2018; 16(1):99-122., however, derived from the movement of continuing education and many others, and it makes inflections and borrows from different theoretical-methodological approaches, such as problematization, meaningful learning and popular education³3. Ceccim RB. Educação permanente em saúde: desafio ambicioso e necessário. Interface (Botucatu). 2005; 9(16):161-77.,²³23. Nespoli G, Ribeiro VMB. Discursos que formam saberes: uma análise das concepções teóricas e metodológicas que orientam o material educativo de formação de facilitadores de Educação Permanente em Saúde. Interface (Botucatu). 2011; 15(39):985-96..

PEH encompasses in its proposal multiple, plural and not isolated possibilities, therefore, acts that happen daily are still little documented, as well as little recognized as a substantial part of an institutional change strategy. In this context, verticalized and standardized educational offerings end up being more easily identified and understood.

In this context, SUS teaching devices, such as the Schools of Public Health and Technical Schools gain relevance. Jointly, they represent an important role in the configuration of the PNEPS, both in its conceptual bases and in its organizational devices. As a privileged locus for the training of SUS workers, together with the other training structures, they can work for the promotion and dissemination of educational designs built with and for the collective of SUS actors, as supported by PEH.

Another strategy of paramount importance for the understanding of PEH, as well as its strengthening as a policy is the adoption of mechanisms for monitoring and evaluation. These processes are still scarcely implemented in Brazil and are usually pinpointed, although they are important in the field of health policies, as they allow measuring the degree of implementation of an intervention and its effects. In this sense, monitoring and evaluating health education actions is at the same time, a great need and a wide shortcoming for the strengthening of the PNEPS and, consequently, for the consolidation of SUS²⁴24. Carvalho ALB, Souza MF, Shimizu HE, Senra IMVB, Oliveira KC. A gestão do SUS e as práticas de monitoramento e avaliação: possibilidades e desafios para a construção de uma agenda estratégica. Cienc Saude Colet. 2012; 17(4):901-11..

Regarding the proposals for the implementation of the PNEPS and according to the participants in this study, in addition to getting the financial resources back, it is essential to position the Ministry of Health in a way that it may assume its role as the organizer of HRH training in the country. The Ministry should have clear direction regarding policy, technical guidelines, institutional support, and influence as a protagonist in health governance, continuously articulating with the other entities of the federation. In this regard, it is important to point out that for many participants in the focus group, technical support is more essential than financial support. They consider that technical support allows the recognition and acceptance of local demands as a starting point for the collective construction of alternatives to face the identified problems²⁵25. Andrade MC, Castanheira ERL. Cooperação e apoio técnico entre estado e municípios: a experiência do programa articuladores da atenção básica em São Paulo. Saude Soc. 2011; 20(4):980-90.. Following this understanding, the support is comprehensive and involves, among others, guidance strategies, education, technological and material support.

Furthermore, the lack of articulation between federative entities in the process of implementing the PNEPS, that was found in the focus group and mentioned by another study¹⁰10. Gonçalves CB, Pinto ICM, França T, Teixeira CF. A retomada do processo de implementação da política nacional de educação permanente em saúde no Brasil. Saude Debate. 2019; 43 Spe 1:12-23., suggests the need for greater efforts to be compliant with the Federative Pact established by the constitution and specifically for the health sector, in the Pact for Health²⁶26. Brasil. Ministério da Saúde. Secretaria Executiva. Departamento de Apoio à Descentralização. Coordenação-Geral de Apoio à Gestão Descentralizada. Diretrizes operacionais dos Pactos pela Vida, em Defesa do SUS e de Gestão. Brasília, DF: Ministério da Saúde; 2006.. This pact elevates the HRH policy as a structuring axis of SUS and urges the Ministry of Health, States and Municipalities to support each other and induce changes in the field of health education.

It is worth mentioning that the PNEPS restart movement initiated in 2017, led initiatives that tried to circumvent some of the obstacles highlighted by the actors in this study; but even more, it brought the theme of PEH back to the center of the debate, even in the midst of a national scenario that hampered and made unfeasible any progress in this direction. This fact can be attributed to the interests of federal administration, which converged with state and municipal bodies, together with bodies of control by the society, in an articulated and sustained movement in governance, in line with recommendations from international organizations.

In view of the above, the importance of keeping the movement to resume and induce implementation in the PNEPS, as well as its monitoring and evaluation, is highlighted, so that the actions triggered may not be interrupted, as such interruption would lead to a setback, considering what was observed in previous years⁷7. França T, Magnago C. Políticas, programas e ações de educação na saúde: perspectivas e desafios. Saude Debate. 2019; 43 Spe 1:4-7..

Conclusion

The study showed that there is a set of measures that need to be maintained and strengthened, while another set should be revised and reconfigured for the implementation of the PNEPS, as a strategy for the development of HRH in Brazil. Among the elements that need to be ensured, since they favor the implementation of the PNEPS, are: financing, which ensures the transfer of resources to municipalities and states, and collegiate management spaces. On the other hand, the conceptual misalignment of PEH and the fragmentation of actions and areas encompassed by the HRH policy were considered challenges that need to be overcome.

Furthermore, there is an urgent need to establish mechanisms by the federal management that are compatible with the needs of states and municipalities regarding the operationalization of policy in the territories, such as technical support and monitoring and evaluation instruments. Putting the PNEPS agenda back on the health education agenda is undoubtedly the most important, and at the same time the most challenging factor for its implementation.

It is undeniable that the PNEPS design process, by the federal administration, and at the same time involving the most different actors in its leadership are essential processes for its implementation. However, the operationalization of a policy of this magnitude, and the proposal to act as the transforming and structuring axis for strengthening the SUS, reveal and confronts numerous challenges. These challenges, in order to be overcome, require a series of additional strategies that lead to the achievement of the main objective, in this case in the PNEPS, to promote changes in dominant health practices in order to improve the population’s health.

References

Publication Dates

History