Abstract

Introduction

The pandemic of Covid-19 represents one of the greatest health challenges on a global scale in this century, requiring health systems to adjust to the needs of this context. In this perspective, the Brazilian Unified Health System (SUS) guarantees universal access to health actions and services to more than 210 million Brazilians, which is essential in facing and controlling Covid-19¹1 Barreto ML, Barros AJD, Carvalho MS, Codeço CR, Hallal PRC, Medronho RA, et al. O que é urgente e necessário para subsidiar as políticas de enfrentamento da pandemia de Covid-19 no Brasil? Rev Bras Epidemiol. 2020; 23(1):1-4.^,22 Barbosa SP, Silva AVFG. A Prática da Atenção Primária à Saúde no Combate da Covid-19. APS Rev. 2020; 2(1):17-9.

After one year and two months of the pandemic in Brazil, more than fourteen million cases and more than 400,000 deaths have been confirmed. Based on the estimate that 80% of the cases are mild or moderate³3 Guimarães F. Approach of the physiotherapist in intensive care units in the context of the Covid-19 pandemic. Fisioter Mov. 2020; 33:e0033001., Primary Health Care (PHC) is a fundamental strategy for comprehensive care, disease control, and support to vulnerable groups²2 Barbosa SP, Silva AVFG. A Prática da Atenção Primária à Saúde no Combate da Covid-19. APS Rev. 2020; 2(1):17-9^,44 Sarti TD, Lazarini WS, Fontenelle LF, Almeida APSC. What is the role of Primary Health Care in Covid-19 pandemic? Epidemiol Serv Saude. 2020; 29(2):e2020166..

Thus, the attributes of health education and community mobilization become key⁵5 Daumas RP, Silva GA, Tasca R, Leite IC, Brasil P, Greco DB, et al. O papel da atenção primária na rede de atenção à saúde no Brasil: limites e possibilidades no enfrentamento da Covid-19. Cad Saude Publica. 2020; 36(6):e00104120., with an emphasis on the work of Community Health Workers (CHWs) and their incomparable cultural competence in the Family Health Strategy (FHS), which is fundamental for the implementation of the expanded concept of health.

Currently, there are approximately 250,864 CHWs in Brazil, a professional group mostly composed of women, who care for more than 126 million people⁶6 Nogueira ML. Expressões da precarização no trabalho do agente comunitário de saúde: burocratização e estranhamento do trabalho. Saude Soc. 2019; 28(3):309-23..

Despite having getting to approve many labor conquests during a period of more than 25 years of institutionalization, the regulation and professionalization of their work falls short of guaranteeing the effectiveness of work-related rights⁶6 Nogueira ML. Expressões da precarização no trabalho do agente comunitário de saúde: burocratização e estranhamento do trabalho. Saude Soc. 2019; 28(3):309-23., with inadequate training and legitimacy in dispute before society and the political, economic, and ideological factors that influence the course of the profession.

We start from the assumption that the professionals’ projects develop in the praxis and historical transformation of the social being. They can be objectified materially and/or ideally, affirming one value or another, some or other guidelines for professional practice that take on collective dimensions and are conformed into a “self-image”⁷7 Paulo Netto J. A construção do projeto ético-político contemporâneo. In: Paulo Netto J. Serviço social e política social. Brasília: CEAD, ABEPSS, CFESS; 1999. (Capacitação, Módulo 1).. Thus, the health crisis seems to be a propitious moment to affirm the professional project and the ethical-political values of the CHWs.

International studies emphasize the importance of CHWs in coping strategies for Covid-19, stressing the need to protect and train them quickly to prevent, detect, and respond to the pandemic, and to maintain routine primary health care services, ensuring that they are designated as an essential part of the workforce⁸8 Ballard M, Bancroft E, Nesbit J, Johnson A, Holeman I, Foth J, et al. Prioritising the role of community health workers in the Covid-19 response. BMJ Global Health. 2020; 5(6):e002550.^,99 Haines A, Barros EF, Berlin A, Heymann DL, Harris MJ. National UK programme of community health workers for Covid-19 response. Lancet. 2020; 395(10231):P1173-5..

It is important to highlight that despite the relevance of the desired action for CHWs in the pandemic of Covid-19, it finds Brazil at a time of de-funding of the SUS and PHC, with the recent reformulation of the National Policy for Primary Care (PNAB) in 2017 (ESF). Even though the definition in the PNAB was to have one CHW for every 750 people, the current policy left to the local manager the task of defining this number¹⁰10 Morosini MV, Fonseca A. Os agentes comunitários na Atenção Primária à Saúde no Brasil: inventário de conquistas e desafios. Saude Debate. 2018; 42 Esp:261-74..

In the pandemic, CHWs were only recognized as essential workers five months after the first confirmed case, when Law no. 14.023 of 2020 was published¹¹11 Brasil. Presidência da República. Lei nº 14.023, de 8 de Julho de 2020. Altera a Lei nº 13.979, de 6 de Fevereiro de 2020, para determinar a adoção de medidas imediatas que preservem a saúde e a vida de todos os profissionais considerados essenciais ao controle de doenças e à manutenção da ordem pública, durante a emergência de saúde pública decorrente do coronavírus responsável pelo surto de 2019. Diário Oficial da União. 9 Jul 2020.. In several Brazilian municipalities there was a shift to working from home, with a reduction in the workload, performing administrative services in the Basic Health Units (BHU), suspension of home visits or relocation to work in health barriers¹²12 Paulista (PE). Secretaria Municipal de Saúde do Paulista. Superintendência de Atenção à saúde. Superintendência de Vigilância em Saúde. Nota técnica n° 2 de 2020. Informativa e orientativa para rede assistencial de saúde para o covid-19. Paulista (PE): Secretaria Municipal de Saúde do Paulista; 2020.^,1313 Ariquemes (RO). Prefeitura Municipal de Ariquemes. Decreto nº 16.312, de 23 de Março de 2020. Autoriza a designação de Agentes Comunitários de Saúde Municipais para atuarem em serviços administrativos e naqueles relacionados à prevenção e ao combate do novo Coronavírus (limpeza das unidades de saúde; aferição, em barreiras sanitárias, da temperatura das pessoas que entrarem na cidade de Ariquemes, dentre outros), nos termos da Recomendação nº 0105/2020 – 2ª PJA, e dá outras providências. Ariquemes (RO): Prefeitura Municipal de Ariquemes; 2020..

According to a study conducted with 1,978 CHWs between May 28 and July 3, 2020, 17% of home visits by CHWs were suspended and 54.7% continued to be conducted in a reduced form, with only 20.9% stating that there were no changes in visits¹⁴14 Nogueira ML, Borges CF, Lacerda A, Fonseca AF, Vellasques AP, Morel CMM, et al. Monitoramento da saúde dos ACS em tempos de Covid-19. Rio de Janeiro: Fiocruz; 2020..

Despite this fact, the understanding of the performance of CHWs during the pandemic needs to be placed within the historical paths of these professionals, considering dilemmas and disputes such as: institutionalization and maintenance of their community connection; legal attributions and social needs in the definition of the scope of performance; necessary training. Additionally there is the implicit dispute of having or not CHWs in SUS, which is inserted in a tension of interests of the State, market and society¹⁰10 Morosini MV, Fonseca A. Os agentes comunitários na Atenção Primária à Saúde no Brasil: inventário de conquistas e desafios. Saude Debate. 2018; 42 Esp:261-74..

Given the importance of these professionals in confronting Covid-19, the objective of this article is to analyze the disputes regarding the work of CHWs in the context of the pandemic, as well as analogous volunteer experiences, reflecting on the future of the profession.

Methodology

This is a qualitative research of analytical nature, developed from the public debate on the Internet about the performance of the CHWs in the pandemic, with triangulation of data from various subjects that think, formulate, develop and dispute the directions of the work and professionalization of the CHWs in Brazil, namely: 1) Ministry of Health (MS), National Council of Health Secretaries (CONASS), National Council of Municipal Health Secretaries (CONASEMS), representing the executive branch; 2) National Confederation of Community Health Workers (CONACS) and National Federation of Community Health Workers (FENASCE), representing the category of CHWs; 3) External Commission for action against the coronavirus of the House of Representatives, representing the legislative branch; 4) UNEafro Brazil and the Campanha Mãos Solidárias & Periferia Viva – (Hands of Solidarity & Periphery Alive), representing the organized civil society (Chart 1).

To this end, searches of the main official documents and public speeches of these subjects were conducted on the official websites and social networks of these organizations, published between March and July 2020.

The article is part of the doctoral thesis entitled “Analysis of the professionalization of Community Health Workers: what is the future of this worker in the Brazilian health system?” developed at the Aggeu Magalhães Research Institute - Fiocruz Pernambuco. The project in which the study is embedded was approved by the Research Ethics Committee of this same institution, and is registered on Plataforma Brasil under CAAE number: 15735119.7.0000.5190.

Dialectical hermeneutics was used throughout the process of interpreting the meanings and ideologies present in the documents and public positions of the study subjects, following the following stages of analysis: 1) ordering the data, and 2) classifying the data²²22 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 8a ed. São Paulo, Rio de Janeiro: Hucitec, Abrasco; 2004.. In the first moment, the videos were transcribed, followed by reading the documents and transcripts, sorting by subjects and highlighting the contrasting and/or confluent positions. Once the corpus of the study was finalized, we proceeded to the classification phase, building an analysis matrix in an excel table with the following analytical categories: professional practices; social legitimacy; education and permanent education.

In regard to dialectical hermeneutics, we analyzed, beyond the contents, the meanings of the speech, its intentionality, subjects and context of production, as well as the contradictions inherent to the relationship of the phenomenon with the context in which the object and subjects are inserted²²22 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 8a ed. São Paulo, Rio de Janeiro: Hucitec, Abrasco; 2004..

Results and discussion

Institutional requirements and new practices in the context of the pandemic

One of the issues that the Covid-19 pandemic put under debate in the SUS is the need to rethink how to do health care, both in the context of health care and health management. We highlight here the attributions and new social needs related to the practices developed by CHWs, which become central in facing the current moment characterized by the overlapping of epidemics²³23 Mendes EV. O lado oculto de uma pandemia: a terceira onda da covid-19 ou o paciente invisível [Internet]. Rede APS; 2020 [citado 1 Maio 2021]. Disponível em: https://redeaps.org.br/2021/03/14/o-lado-oculto-de-uma-pandemia-a-terceira-onda-da-covid-19-ou-o-paciente-invisivel/
https://redeaps.org.br/2021/03/14/o-lado... .

According to Yazbek (2009), the scope of professional action is based on the interests of the State, the market, professional corporations, but also on the movement of society that demands different kinds of specialized work to meet social needs, where the professions are analyzed as institutions²⁴24 Yasbek MC. O significado sócio-histórico da profissão. In: CFESS, ABEPSS, organizadores. Serviço social: direitos sociais e competências profissionais. Brasília: CFESS, ABEPSS; 2009. p. 125-41..

The institutionalization of the work of a community representative such as the CHWs goes through several disputes, with their actions being increasingly directed by the biomedical model predominant in PHC teams. The role of bridging between community and service is gradually being strengthened, while the educational and social mobilization practices, based on the understanding of the social determination of the health-disease process, are being weakened¹⁰10 Morosini MV, Fonseca A. Os agentes comunitários na Atenção Primária à Saúde no Brasil: inventário de conquistas e desafios. Saude Debate. 2018; 42 Esp:261-74..

In addition, the incorporation of new management models in PHC, based on the monitoring of results and productivity indicators, as well as the increasing performance of activities inside the BHU, which “bring them closer to a generic auxiliary of the other professionals”¹⁰10 Morosini MV, Fonseca A. Os agentes comunitários na Atenção Primária à Saúde no Brasil: inventário de conquistas e desafios. Saude Debate. 2018; 42 Esp:261-74.. There has been a recent definition of diagnostic support attributions by the 2017 National Primary Care Policy (PNAB) and Law 13.595/2018 with reinforcement of biomedical rationality²⁵25 Brasil. Ministério da Saúde. Portaria nº 2.436, de 21 de Setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União. 22 Set 2017.^,2626 Brasil. Presidência da República. Lei nº 13.595, de 5 de Janeiro de 2018. Altera a Lei nº 11.350, de 5 de Outubro de 2006, para dispor sobre a reformulação das atribuições, a jornada e as condições de trabalho, o grau de formação profissional, os cursos de formação técnica e continuada e a indenização de transporte dos profissionais Agentes Comunitários de Saúde e Agentes de Combate às Endemias. Diário Oficial da União. 18 Abr 2018..

In the pandemic of Covid-19, the Ministry of Health documents that guide the CHWs’ practices prioritized health surveillance and administrative actions inside the services, with directions to “assist in the care through Fast-Track”, organization of the “reception flow”, “assist in vaccination campaign activities”, configuring themselves as deviation of function in relation to the profession’s law¹⁵15 Brasil. Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Recomendações para adequação das ações dos agentes comunitários de saúde frente à atual situação epidemiológica referente ao covid-19. Brasília (DF): Ministério da Saúde; 2020.^,1616 Brasil. Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Orientações gerais sobre a atuação do ACS frente à pandemia de Covid-19 e os registros a serem realizados no e-SUS APS. Brasília (DF): Ministério da Saúde; 2020.. This reality corroborates the study by Lotta and Pavez (2010) where they identified that 64% of the practices performed by CHWs were not foreseen in the legislation²⁷27 Lotta GSL, Pavez TR. Agentes de implementação: mediação, dinâmicas e estruturas relacionais. Cad Gest Publica Cid. 2010; 15(56):109-25..

As for the surveillance actions, for the control of Covid-19, it was a consensus among the various management instances of SUS the need for this practice by CHWs, but without assuming the testing of suspected cases.

The CONASS and CONASEMS guidelines emphasize that CHWs should be able to “provide all possible guidance, typical of their work, not only regarding Covid-19, but also regarding other risks and pathologies, especially dengue fever. It advises that there should be “direct delivery by community health workers” of contraceptives, in addition to daily monitoring of “homes where frail elderly people live”¹⁷17 Conselho Nacional de Secretarias Municipais de Saúde – CONASEMS. Conselho Nacional de Secretários de Saúde – CONASS. Covid-19 guia orientador para o enfrentamento da pandemia na Rede de Atenção à Saúde. Brasília: CONASEMS; 2020..

Surveillance actions are also advocated and recognized in the legislative branch:

Regarding the competence to “guide the population about the disease, prevention measures, and signs and symptoms,” the management protocols do not detail how the worker will develop educational guidelines and manage the identified signs and symptoms¹⁵15 Brasil. Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Recomendações para adequação das ações dos agentes comunitários de saúde frente à atual situação epidemiológica referente ao covid-19. Brasília (DF): Ministério da Saúde; 2020.

16 Brasil. Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Orientações gerais sobre a atuação do ACS frente à pandemia de Covid-19 e os registros a serem realizados no e-SUS APS. Brasília (DF): Ministério da Saúde; 2020.^-1717 Conselho Nacional de Secretarias Municipais de Saúde – CONASEMS. Conselho Nacional de Secretários de Saúde – CONASS. Covid-19 guia orientador para o enfrentamento da pandemia na Rede de Atenção à Saúde. Brasília: CONASEMS; 2020..

The educational practices of CHWs can vary within a broad spectrum of pedagogical perspectives that range from the imposition of norms and behaviors, to critical-reflexive mediation on reality and the social determination of the health-disease process²⁸28 Stotz EN, David HMSL, Bornstein VJ. O agente comunitário de saúde como mediador: uma reflexão na perspectiva da educação popular em saúde. Rev APS. 2009; 12(4):487-97..

The “Stay at Home” motto, put forth by the mass media in a normative way during the pandemic, was increasingly losing its meaning for families who are in a situation of social and economic vulnerability, assisted by the CHWs. Added to this is the discourse of the president, opposing to physical distance, making the repercussion of the developed educational processes extremely difficult²⁹29 Lotta G, Wenham C, Nunes J, Pimenta DN. Community health workers reveal COVID-19 disaster in Brazil. Lancet. 2020; 396(10248):365-6..

The management protocols¹⁵15 Brasil. Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Recomendações para adequação das ações dos agentes comunitários de saúde frente à atual situação epidemiológica referente ao covid-19. Brasília (DF): Ministério da Saúde; 2020.

16 Brasil. Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Orientações gerais sobre a atuação do ACS frente à pandemia de Covid-19 e os registros a serem realizados no e-SUS APS. Brasília (DF): Ministério da Saúde; 2020.^-1717 Conselho Nacional de Secretarias Municipais de Saúde – CONASEMS. Conselho Nacional de Secretários de Saúde – CONASS. Covid-19 guia orientador para o enfrentamento da pandemia na Rede de Atenção à Saúde. Brasília: CONASEMS; 2020. made no mention of the importance of CHWs conducting dialogue between popular knowledge and scientific knowledge, with the rescue of traditional knowledge. They also did not offer methodologies for community work in social mobilization, intersectoral articulation, and Popular Education in Health, linked to emerging demands.

As for the clinical management of signs and symptoms, although the 2017 PNAB and Law 13.595/2018 define new attributions such as temperature, blood glucose and blood pressure (BP) measurement²⁵25 Brasil. Ministério da Saúde. Portaria nº 2.436, de 21 de Setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União. 22 Set 2017.^,2626 Brasil. Presidência da República. Lei nº 13.595, de 5 de Janeiro de 2018. Altera a Lei nº 11.350, de 5 de Outubro de 2006, para dispor sobre a reformulação das atribuições, a jornada e as condições de trabalho, o grau de formação profissional, os cursos de formação técnica e continuada e a indenização de transporte dos profissionais Agentes Comunitários de Saúde e Agentes de Combate às Endemias. Diário Oficial da União. 18 Abr 2018., the protocols of work in the pandemic¹⁵15 Brasil. Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Recomendações para adequação das ações dos agentes comunitários de saúde frente à atual situação epidemiológica referente ao covid-19. Brasília (DF): Ministério da Saúde; 2020.

16 Brasil. Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Orientações gerais sobre a atuação do ACS frente à pandemia de Covid-19 e os registros a serem realizados no e-SUS APS. Brasília (DF): Ministério da Saúde; 2020.^-1717 Conselho Nacional de Secretarias Municipais de Saúde – CONASEMS. Conselho Nacional de Secretários de Saúde – CONASS. Covid-19 guia orientador para o enfrentamento da pandemia na Rede de Atenção à Saúde. Brasília: CONASEMS; 2020. did not present such activities. On the other hand, checking oxygen saturation was not foreseen in either the profession’s law or the Covid-19 protocols.

In this regard, previous positions of representatives of the legislature emerge:

Here, the macro-political dispute around the professionalization of CHWs in the Brazilian context is explicit, in an attempt to distance them from socio-educational attributions to the detriment of biomedical practices. The program referenced by Federal Representative 2 and former Minister of Health concerns the former Technical Training Program for Health Agents (PROFAGS)³⁰30 Brasil. Ministério da Saúde. Portaria nº 83, de 10 de Janeiro de 2018. Institui o Programa de Formação Técnica para Agentes de Saúde (PROFAGS), para oferta de curso de formação técnica em enfermagem para agentes comunitários de saúde (ACS) e agentes de combate às endemias (ACE) no âmbito do SUS, para o biênio de 2018-2019. Diário Oficial da União. 12 Jan 2018. which proposed to transform the CHWs into Nursing Technicians, which, added to the flexibilization of the number of CHWs delimited by the PNAB of 2017²⁵25 Brasil. Ministério da Saúde. Portaria nº 2.436, de 21 de Setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União. 22 Set 2017., was endangering its existence over time.

It also draws attention to the contradictory orientations regarding the use of the telephone in the monitoring of families when comparing two documents from the Ministry of Health¹⁵15 Brasil. Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Recomendações para adequação das ações dos agentes comunitários de saúde frente à atual situação epidemiológica referente ao covid-19. Brasília (DF): Ministério da Saúde; 2020.^,1616 Brasil. Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Orientações gerais sobre a atuação do ACS frente à pandemia de Covid-19 e os registros a serem realizados no e-SUS APS. Brasília (DF): Ministério da Saúde; 2020. in this regard. The first postulates the use of the phone as a safety measure for the CHWs and users in social isolation, while the second voids it for family registration actions.

As for the use of social networks and cell phone applications such as whatsapp, it is understood that this was already a reality in professional practice, even if not institutionalized, which would require expanding access to technologies and connectivity, qualifying workers for the best use of the tools both in the field of social communication and health surveillance. Nevertheless, the fact that one out of every four people in Brazil does not have access to the Internet³¹31 Núcleo de Informação e Coordenação do Ponto BR. Pesquisa sobre o uso das tecnologias de informação e comunicação nos domicílios brasileiros: TIC Domicílios 2019. São Paulo: Comitê Gestor da Internet no Brasil; 2020., reveals a new condition of equity in SUS and the indispensable importance of maintaining home visits by the CHWs.

Visits are guided to be carried out in the “peri-domiciliary” areas, and should maintain a “distance from the patient of at least 2 meters”¹⁵15 Brasil. Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Recomendações para adequação das ações dos agentes comunitários de saúde frente à atual situação epidemiológica referente ao covid-19. Brasília (DF): Ministério da Saúde; 2020.. Some local managers have chosen to suspend home visits or displacement of health barriers, issuing municipal decrees¹²12 Paulista (PE). Secretaria Municipal de Saúde do Paulista. Superintendência de Atenção à saúde. Superintendência de Vigilância em Saúde. Nota técnica n° 2 de 2020. Informativa e orientativa para rede assistencial de saúde para o covid-19. Paulista (PE): Secretaria Municipal de Saúde do Paulista; 2020.^,1313 Ariquemes (RO). Prefeitura Municipal de Ariquemes. Decreto nº 16.312, de 23 de Março de 2020. Autoriza a designação de Agentes Comunitários de Saúde Municipais para atuarem em serviços administrativos e naqueles relacionados à prevenção e ao combate do novo Coronavírus (limpeza das unidades de saúde; aferição, em barreiras sanitárias, da temperatura das pessoas que entrarem na cidade de Ariquemes, dentre outros), nos termos da Recomendação nº 0105/2020 – 2ª PJA, e dá outras providências. Ariquemes (RO): Prefeitura Municipal de Ariquemes; 2020..

About the abovementioned aspects, the public position of CONASEMS states:

It is evident in this position structural issues, i.e. the difficulty of purchasing Personal Protection Equipment (PPE) in the market, as the main justification to initially guide municipalities not to put CHWs in the field, weakening the FHS and PHC as the organizer of the network.

A study with 1,456 health professionals interviewed revealed that less than half received PPE to work during the pandemic, with CHWs and Endemic Control Agents (ECA) receiving the least (19.25%), compared to nursing (52.94%), medical (62.28%), and other professionals (47.80%)³²32 Lotta G, Lima DD, Magri G, Corrêa M, Beck A. A pandemia de Covid-19 e os profissionais de saúde pública no país. São Paulo: Fundação Getúlio Vargas, Núcleo de Estudos da Burocracia; 2020..

Such aspects reveal a clear technical and social division of labor, with de-legitimization of the CHWs and the value of life by the Brazilian State.

Ethical political values and social legitimacy in the face of community mobilization and organization processes

The complexity of the problems arising from the structural inequalities amplified in the pandemic, point to the importance of resuming community action in the scope of the CHWs’ work, with ample possibilities for intersectoral work, identification of partners and resources in the community.

This evidence is strengthened by the denials’ posture of the federal government, exempting itself from coordinating the crisis and social protection of vulnerable populations²⁹29 Lotta G, Wenham C, Nunes J, Pimenta DN. Community health workers reveal COVID-19 disaster in Brazil. Lancet. 2020; 396(10248):365-6.. This has led civil society to create its own strategies of community organization and confrontation, with two remarkable experiences: Popular Health Agents trained by UNEafro Brazil; and Popular Health Agents trained by the Campanha Mãos Solidárias & Periferia Viva – (Hands of Solidarity & Periphery Alive) (frame 2)²⁰20 Méllo LMBDM, Albuquerque PC, Lima AWS, Gouveia HC, Cordeiro ES, Lages I, et al. Agentes populares de saúde: ajudando minha comunidade no enfrentamento da pandemia de Covid-19. Recife: Fiocruz; 2020.^,2121 UNEafro Brasil. Agentes populares de saúde: protocolos e orientações [Internet]. 2020 [citado 20 Maio 2020]. Disponível em: https://agentespopularesdesaude.org.br/
https://agentespopularesdesaude.org.br/... .

UNEafro Brazil is a Social and Popular Movement that “is organized in centers of action in several areas”, mainly in “pre-university preparatory courses for young people and adults from public schools, primarily blacks”³³33 UNEaFro Brasil. História [Internet]. São Paulo: UNEafro Brasil; 2020 [citado 16 Jul 2020]. Disponível em: https://uneafrobrasil.org/historia/
https://uneafrobrasil.org/historia/... . The Popular Health Agents had proposed to... “support, above all, the communities where the organization’s popular education centers are located”, taking care of people who are with symptoms of Covid-19 without medical attention²¹21 UNEafro Brasil. Agentes populares de saúde: protocolos e orientações [Internet]. 2020 [citado 20 Maio 2020]. Disponível em: https://agentespopularesdesaude.org.br/
https://agentespopularesdesaude.org.br/... .

The Mãos Solidárias & Periferia Viva Campaign is “an initiative of social movements, unions, students, from the countryside and the city, who join efforts to sow values and practices of solidarity in the context of Covid-19. In it, the Community Health Workers are volunteers “who care about the lives of their neighbors and their community”, willing to sew a solidarity network²⁰20 Méllo LMBDM, Albuquerque PC, Lima AWS, Gouveia HC, Cordeiro ES, Lages I, et al. Agentes populares de saúde: ajudando minha comunidade no enfrentamento da pandemia de Covid-19. Recife: Fiocruz; 2020..

UNEafro’s experience indicates that the popular health agents should communicate with “professionals who volunteer to do the distance monitoring and care of people”. There is an offer of a thermometer, masks, cleaning material, antipyretic and oximetry, outside the SUS, and the suggestion to look for SAMU (public emergency system) in serious cases²¹21 UNEafro Brasil. Agentes populares de saúde: protocolos e orientações [Internet]. 2020 [citado 20 Maio 2020]. Disponível em: https://agentespopularesdesaude.org.br/
https://agentespopularesdesaude.org.br/... .

In the Campanha Mãos Solidárias & Periferia Viva there is a recommendation to articulate with SUS services as a way to know where specific care and testing for Covid-19 are being provided. The CHWs responsible for the area where there is ESF coverage should be contacted²⁰20 Méllo LMBDM, Albuquerque PC, Lima AWS, Gouveia HC, Cordeiro ES, Lages I, et al. Agentes populares de saúde: ajudando minha comunidade no enfrentamento da pandemia de Covid-19. Recife: Fiocruz; 2020..

The similarity of practices between the volunteer Popular Agents and the CHWs indicates, on the one hand, the importance of their work in the community context and the need for its expansion in PHC; on the other hand, reveals gaps of action that may be being filled by organized civil society, with emphasis on intersectoral actions and social support present in the Campanha Mãos Solidárias & Periferia Viva and biomedical practices in the experience of UNEAfro.

In a study on the performance of PHC in the pandemic of Covid-19, FHS professionals stated that they knew of social support actions that were being developed by community leaders, but that often did not have the support of the BHU³⁴34 Bousquat A, Giovanella L, Medina MG, Mendonça MHM, Facchini LA, Tasca R, et al. Desafios da Atenção Básica no enfrentamento da pandemia da Covid-19 no SUS. Relatório de Pesquisa. USP, Fiocruz, UFBA, UFPEL, OPAS Brasil. Rede de Pesquisa em Atenção Primária à Saúde da Abrasco. Rio de Janeiro: Rede de Pesquisa em APS Abrasco; 2020..

Added to this is the position of the category in defense of working from home and the position of denunciation regarding the lack of working conditions brought by Federal Representative 3:

We can conclude that the proposal for all CHWs to work from home, without criteria based on the existence of risk factors, points to a weakening of professionalization by reducing the link and, possibly, the legitimacy in front of the population, as pointed out by other studies along its institutionalization¹⁰10 Morosini MV, Fonseca A. Os agentes comunitários na Atenção Primária à Saúde no Brasil: inventário de conquistas e desafios. Saude Debate. 2018; 42 Esp:261-74.^,3535 Queirós AAL, Lima LP. A institucionalização do trabalho do agente comunitário de saúde. Trab Educ Saude. 2012; 10(2):257-81..

In health crises of this magnitude, the right to health, comprehensive care and social participation are ethical and political values expected from all health professionals, which dialogues with the “active solidarity” defined by the Hands of Solidarity & Periphery Alive Campaign. In it, “the people are collective subjects, capable of fighting and conquering rights”²⁰20 Méllo LMBDM, Albuquerque PC, Lima AWS, Gouveia HC, Cordeiro ES, Lages I, et al. Agentes populares de saúde: ajudando minha comunidade no enfrentamento da pandemia de Covid-19. Recife: Fiocruz; 2020. (p. 8), pointing “to the construction of a popular project for the country, where the solidarity of sharing is a principle”²⁰20 Méllo LMBDM, Albuquerque PC, Lima AWS, Gouveia HC, Cordeiro ES, Lages I, et al. Agentes populares de saúde: ajudando minha comunidade no enfrentamento da pandemia de Covid-19. Recife: Fiocruz; 2020. (p. 8).

Such formulation refers to values very present in the beginning of the CHWs’ history that, according to Queirós and Lima (2012), will only be rescued from the reactivation of the political struggle of these workers³⁵35 Queirós AAL, Lima LP. A institucionalização do trabalho do agente comunitário de saúde. Trab Educ Saude. 2012; 10(2):257-81., which will restart after the pandemic.

Professional education and permanent education: disputes, possibilities and shortcomings portrayed in the pandemic

The education policies for CHWs have oscillated in the historical itinerary of the professionalization of this category, between light and fragmented education, to a curricular education duly certified at a technical level. The fragility of the implementation of the Technical Course for Community Health Workers (CTACS) goes through both the lack of investment by managers alleging insufficient financial resources; as well as the questioning of the appropriate, necessary, and desired profile for the profession; or the possibility of claiming a salary increase corresponding to the technical level³⁶36 Bornstein VJ, David HMSL. Contribuições da formação técnica do agente comunitário de saúde para o desenvolvimento do trabalho da equipe Saúde da Família. Trab Educ Saude. 2014; 12(1):107-28..

In light of the pandemic of Covid-19, it is clear the need of scientific, technical and political bases of Biological Sciences, as well as Collective Health and Social and Human Sciences for improving the performance of CHWs. These would allow a better knowledge about the coronavirus and the physiopathology of Covid-19, application of epidemiology with qualification of health surveillance, planning and management of community work in a critical and participative way, which is only possible from a polytechnic education³⁷37 Frigotto G. Teoria e práxis e o antagonismo entre a formação politécnica e as relações sociais capitalistas. Trab Educ Saude. 2009; 7 Suppl 1:67-82..

In tandem with professional education, the SUS recommends investing in permanent and continuing education, enabling the qualification not only of CHWs but also of their teams. However, until the end of this research, no national strategy aimed at qualification for action in the pandemic was presented, even though there is a Network of Technical Schools of the SUS (RETSUS) experienced in large-scale education.

In a public speech recorded and published on CONACS’ social networks¹⁸18 Brasil. Confederação Nacional dos Agentes Comunitários de Saúde. Live sobre curso técnico para ACS’s e ACE’S [Internet]. Facebook; 2020 [citado 16 Jul 2020]. Vídeo: 1h11min. Disponível em: https://www.facebook.com/CONACSOFICIAL/videos/974264779687639
https://www.facebook.com/CONACSOFICIAL/v... , on July 7, 2020, a representative of the MS announced that the federal government would provide professionalizing technical education. Without confirming that it would do so immediately, he is asked about offering education for Covid-19, replying:

Resorting to the sources indicated above, a 23-minute institutional video was identified, where a representative of the Ministry of Health presents the “Primary Health Care Protocol for CHWs and Endemic Control Agents on Covid-19”. The language of the video³⁸38 Brasil. Ministério da Saúde. Vídeo sobre Protocolo da Atenção Primária à Saúde para ACS e ACE sobre Covid-19. Realização da Secretaria de Gestão do Trabalho e da Educação na Saúde [Internet]. Brasília: Ministério da Saúde 2020 [citado 1 Jul 2020]. (23 min.) Disponível em: https://www.youtube.com/watch?v=3sZytHn1YEI
https://www.youtube.com/watch?v=3sZytHn1... is no different from reading the protocol itself, and is therefore a normative and not a education course as it appears in the speech given here.

As for CTACS it states:

The announcement of exclusive funding from the federal government may make the proposal more viable; however, the emphasis on the dimension of clinical practice and the absence of RETSUS as education institutions in the CTACS also draw attention.

Moreover, even though the nursing preceptorship for technical training is recognized, there was an absence of political-pedagogical guidelines for them to conduct continuing education processes with the CHWs, aimed at understanding and facing Covid-19 in a better way.

Advances and challenges of the professionalization of CHWs in Brazil

As advances and challenges posed to CHWs, before and after the pandemic, frame 3 below was prepared, considering the analytical categories of the study.

Thus, the pandemic revealed new and old dilemmas, pointing to challenges regarding the professionalization of CHWs whose discussions need to be deepened:

1. Conducting surveillance from tele-monitoring and / or maintenance of home visits.

2. Displacement (or not) of health barriers and organization of flows within the BHU.

3. Performing (or not) biomedical procedures such as checking temperature, blood pressure, and O₂ saturation.

4. Articulation of intersectoral actions and social support that enable the fulfillment of social isolation in pandemic contexts.

5. Training of leaders and health promotion agents, based on the use of traditional lore and popular education in health.

6. Improving the use of available digital technologies for social communication.

7. Polytechnic education and the profession’s ethical and political project.

Therefore it is essential to assume the unfinished agendas to improve the work of CHWs in the communities.

Concluding remarks

The lack of institutional support, education and permanent education for CHWs in the pandemic was made evident, culminating in their leaving their territories, with possible loss of professional legitimacy, at the same time revealing the devaluation of PHC and the FHS as a care model.

The quarrels around the professionalization of CHWs so that they incorporate more and more biomedical knowledge and practices and less and less community work, based on popular health education, became explicit in the public positions of several subjects that occupy the State structures.

The self-image and professional project of CHWs are at a historical crossroads, as are the directions of societies themselves. The emergence of volunteer agents, formed by civil society organizations, reveals the importance and need for the expansion of CHWs in PHC, and at the same time leads us to reflect on the importance of greater community bonding and active solidarity values as ethical-political principles of the profession.

It is urgent to build an agenda around the professional and political education of CHWs that is demanded for the new times of crisis imposed on communities and by the dismantling of social protection policies and the SUS.

References

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