Abstract

Introduction

Teaching-service integration (TSI) is a collective action integrating students, academic staff, and health care professionals aimed at improving the quality of health care, achieving excellence in professional education and training, and promoting workforce development¹1 Albuquerque VS, Gomes AP, Rezende CHA, Dias OV, Lugarinho RM. A integração ensino-serviço no contexto dos processos de mudança na formação superior dos profissionais de saúde. Rev Bras Educ Med. 2008; 32(3):356-62.. Effective TSI contributes to the transformation and enhancement of health education and training, in-service training, and care practices²2 Albiero JFG, De Freitas SFT. Modelo para avaliação da integração ensino- serviço em Unidades Docentes Assistenciais na Atenção Básica. Saude Debate. 2017; 41(114):753-67..

Integration is forged by articulating political, social, and economic processes. Educators and researchers were already talking about TSI in the 1950s; however, it was only in the 1970s that Brazil underwent numerous transformations in the fields of health and education.

Two important early movements were community medicine, concerned with preventing disease and including marginalized groups by encouraging community participation, and faculty-service integration, which incorporated teaching into health services by creating placement programs in health centers and hospitals. However, these initiatives did not lead to a shift in the hospital-centric approach to education and fragmented practice across many specialties, with advances only being witnessed with the introduction of more wide-ranging, integrated, and focused initiatives³3 Gonzalez AD, De Almeida MJ. Movimentos de mudança na formação em saúde: da medicina comunitária às diretrizes curriculares. Physis. 2010; 20(2):551-70..

At the end of the 1970s and beginning of the 1980s efforts were made to encourage multi-department and multi-professional participation in faculty-service integration projects with the support of the Kellogg Foundation⁴4 Chaves MM. Algumas reflexões sobre IDA: antecedentes do ideário UNI. Divulg Saude Debate. 1994; (9):5-9.

5 Ribeiro ECO. A educação dos profissionais de saúde na América Latina: teoria e prática de um movimento de mudança. Interface (Botucatu). 2000; 4(7):139-42. Doi: https://doi.org/10.1590/S1414-32832000000200014.
https://doi.org/10.1590/S1414-3283200000... ^-66 Tancredi FB. Institucionalização e sustentabilidade: desafios permanentes dos UNI. Divulg Saude Debate. 1995; (11):5-10.. Although a move in the right direction, towards education and care tailored to evolving population health needs, much still remained to be done.

Major changes took place in the 1980s and 1990s after the birth of the country’s public health service – the Brazilian National Health System (SUS) setting a system focused on comprehensiveness, humanized care, and health promotion against the prevailing model and making the qualification and commitment of health professionals a vital part of the consolidation of the new system.

In the 1990s, “UNI projects”, “a new initiative for the education of health professionals: union with the community”, became the main focus of attention. Representing the conjunction of three isolated movements that were already underway (TSI, primary health care, and community outreach), this initiative laid the foundations for university-service-community relations³3 Gonzalez AD, De Almeida MJ. Movimentos de mudança na formação em saúde: da medicina comunitária às diretrizes curriculares. Physis. 2010; 20(2):551-70.^,44 Chaves MM. Algumas reflexões sobre IDA: antecedentes do ideário UNI. Divulg Saude Debate. 1994; (9):5-9..

Although these movements made some advances, the challenges of incorporating comprehensiveness and humanization into care practices persisted due to problems institutionalizing this approach or difficulties sustaining the driving forces of change; or more often than not, a combination of these two factors³3 Gonzalez AD, De Almeida MJ. Movimentos de mudança na formação em saúde: da medicina comunitária às diretrizes curriculares. Physis. 2010; 20(2):551-70.^,77 Feuerwerker LCM. Algumas reflexões sobre o desenvolvimento do Programa UNI. Divulg Saude Debate. 2000; (22):63-70..

A new movement known as the Rede UNIDA emerged in 1997, bringing together researchers and educators from the faculty-service integration and UNI movements. Adopting a network-based approach, the movement sought to enhance capacity for change, developing capacities collectively by sharing knowledge and power. The Rede UNIDA brought together people, projects, and institutions committed to promoting change in education and training, professional development, and to building an equitable and effective health system with strong public participation³3 Gonzalez AD, De Almeida MJ. Movimentos de mudança na formação em saúde: da medicina comunitária às diretrizes curriculares. Physis. 2010; 20(2):551-70.^,77 Feuerwerker LCM. Algumas reflexões sobre o desenvolvimento do Programa UNI. Divulg Saude Debate. 2000; (22):63-70..

Against the backdrop of health reform, the creation of the SUS in 1988, the 1996 National Education Guidelines and Framework Law (LDB), and the first National Curriculum Guidelines for Undergraduate Health Courses (DCN) in 2001, various TSI experiences have promoted closer links between academic institutions and health services, seeking to reorganize teaching and health care and develop permanent education actions. However, several challenges remain, including, above all, the sharing of goals and objectives between these two worlds.

It can be observed that reforms have focused more on education plans than health practices, resulting in the development of innovative experiences by public universities aimed at promoting a shift in the traditional model of medical education⁸8 Nunes ED. Saúde Coletiva: história de uma ideia e de um conceito. Saude Soc. 1994; 3(2):5-21.. These experiences have also demonstrated the need to forge new links between teaching and services.

With the creation of the Department of Management of Work and Education in Health (SGTES) in 2003, the establishment of the National Permanent Health Education Policy (PNEPS) in 2004, and the subsequent launch of a number of joint programs by the ministries of health and education aimed at expanding TSI to other areas such as nursing, nutrition, and physiotherapy, the Ministry of Health began to share the responsibility for health education and training, including the organization of human resources and work management.

Together with education institutions (EIs), the SUS began to play a bigger role in the conception, planning, and development of TSI, increasing funding and participating in the management of actions, projects, and programs.

Law 12871 (22 October 2013), which created the More Doctors Program, set new standards in medical education and training, introducing student placements in SUS services in the early stages of degrees, increasing the percentage of placements in primary care, and broadening training to include management and health education, emphasizing the importance of effective TSI.

TSI has thus become a dialectical relationship in which each sector should shape and be shaped by the other. This can be illustrated by Figure 1, with the red circles highlighting the main landmarks in this process.

Viewed from this perspective, integration should take on common meanings and the resulting experiences should produce gains for both institutions, which in turn requires dialogue in favorable spaces with the participation of all in the pursuit of greater stability. SUS managers and medical school administrators therefore play a pivotal role in this process.

At new levels, these relationships clearly make up a policy network⁹9 Bórzel T. Qué tienen de especial los policy networks? Explorando el concepto y su utilidad para el estudio de la gobernación europea. Rev Redes Rediris [Internet] .1997 [citado 12 Out 2020]. Disponível em: http://revista-redes.rediris.es/webredes/textos/policynet.pdf
http://revista-redes.rediris.es/webredes... , as defined by Börzel:

Far from simple, the management of these networks poses administrative challenges, including negotiation and consensus-building, the clear definition of operational rules, counterpart funding, and the development of collective decision-making processes. In polycentric structures such as TSI, decision-making, planning, and evaluation require new approaches, which are often overlooked¹⁰10 Teixeira SMF. O desafio da gestão das redes de políticas. In: Anais do 7o Congreso Internacional del CLAD sobre la Reforma del Estado y de la Administración Pública, Lisboa, Portugal, 8-11 Oct. 2002. Lisboa: CLAD; 2002..

The management of these networks has received little attention and research in this area has traditionally focused on intraorganizational situations, which differ from interorganizational structures in several crucial aspects. Networks are made up of actors, resources, perceptions, and rules¹¹11 Klijn EH, Koppenjan J, Termeer K. Managing networks in the public sector: a theoretical study of management strategies in policy networks. Public Admin. 1995; 7(4):437-54., all of which are key elements to be considered in network management.

This study investigated TSI in the State of Paraná based on the perceptions of education and SUS managers, focusing on modes and processes of evaluation and the characteristics of management, thus gaining an insight into these actors’ concepts and practices, and the factors determining integration. We believe that the findings can make an important contribution to research in the field of health education and training.

Methods

We conducted a qualitative exploratory, descriptive, and explanatory cross-sectional study of the management of TSI in medical schools in Paraná between August and December 2019.

The study included health regions with at least two medical schools that offer complete training cycles. We chose to interview medical school administrators and health managers as these professionals are best placed to provide insights into the workings of TSI in their institutions.

The study was undertaken in the hubs of the State of Paraná’s four largest health regions, encompassing nine medical schools (75% of the schools providing complete training cycles), including public, non-profit, and private institutions.

We interviewed nine school administrators, the regions’ four municipal health secretaries and three regional health directors, and a member of the Paraná State Teaching-Service-Community Integration Committee (CIESC).

The data were collected using a questionnaire devised to obtain information on participant characteristics and semi-structured interviews divided into five core themes based on the guiding questions of the study: concepts, practices, determining factors, modes and processes of evaluation, and characteristics of TSI management

Invitations to participate in the study were sent to the selected study participants’ work email together with an informed consent form, the interview guide, and the letter of approval of the study protocol from the research ethics committee. The interviews were held in a location designated by the participants. Each interview was recorded and lasted between 25 and 40 minutes. At the beginning of the interview, the interviewer collected the signed informed consent form and form authorizing the use of the recorded material, asked once again whether there were any questions about the study, explained that the participant could withdraw from the study at any time, and reiterated the commitment to confidentiality of the collected information.

The interviews were analyzed using Bardin’s thematic approach to content analysis, involving the following three stages: pre-analysis, selection of units of analysis, and categorization. The latter was non-a priori as the categories emerged totally from the participants’ answers. ATLAS.ti^® was used to facilitate data storage, management, and recovery.

The study protocol was approved by the research ethics committee (CAAE 15095219.1.0000.5505) after receiving approval from the Federal University of Sao Paulo’s research ethics committee (application 0643/2019).

Results and discussion

The following participant characteristics warrant highlighting: the high prevalence of managers/administrators with sensu stricto training (82%) and the average time spent in the position (3.7 years). Having sensu stricto training appeared to facilitate the establishment of links between services and academia and length of time spent in the position (0.5 to 12 years, most participants less than 5.6 years) seemed to hamper the institutionalization of integration, which still depends largely on the personal characteristics of managers. These data are shown in Frame 1.

The analysis the interviews resulted in 27 categories grouped into five core themes: concepts, practices, determining factors, modes and processes of evaluation, and characteristics of TSI management. These categories and their respective meanings are shown in Frame 2.

The TSI management processes were analyzed as a phenomenon that emerges from the everyday practice of the schools and services and not restricted to a set of management techniques or the organizations’ internal relations.

The object of study in the area of administration was management, based on the assumption that management is not limited to the organizations’ internal social relations or a set of planning and control techniques, methods, and/or tools, but rather, and first and foremost, a phenomenon that is born of society, with society, and for society: a social contract and practice that should be legitimized and recognized by all enclaves involved¹²12 Santos EL. O campo científico da administração: uma análise a partir do círculo das matrizes teóricas. Cad EBAPE.BR. 2017; 15(2):209-28..

Managers’ concepts of teaching-service integration

The analysis of the interviews identified 79 context units (CU) and 150 recording units (RU), considered meaning units, which were analyzed and grouped into six categories.

The concepts of education managers (EM) and SUS managers (SM), understood as the comprehension of an object resulting in the elaboration of notions that drive actions, reproduce the potentialities of TSI processes for both systems.

The improvement of education and training that is effectively integrated into the health care network, development of competencies beyond those possible in traditional education and training institutions, impetus to drive curriculum changes capable of satisfying real health needs based on training tailored to reality, and the effective development of the social responsibility of schools are common visions among the managers, demonstrating that TSI is a powerful strategy for fulfilling potential in all these areas at the same time.

Increasing student immersion in social settings helps ensure that professional education and training is consistent with the guiding principles of the SUS, broadens understanding of multiple determinants of health, propels the community to seek their rights, and develops care, education, management, research, and interprofessional skills, fostering system changes and the reorientation of curriculums¹³13 Colliselli L, Tombini LHT, Leba ME, Reibnitz KS. Estágio curricular supervisionado: diversificando cenários e fortalecendo a interação ensino-serviço. Rev Bras Enferm. 2009; 62(6):932-7.

14 Yrbi D. Educating physicians for the future: Carnegie’s calls for reform. Med Teach. 2011; (33):547-50.

15 Vendrusculo C, Trindade LL, Do Prado ML, Kleba ME. Repensando o modelo de Atenção em Saúde mediante a reorientação da formação. Rev Bras Enferm. 2018; 71(4):1674-82.^-1616 Marin MJS, Oliveira MAC, Otani MAP, Cardoso CP, Moravcik MYAD, Conterno LO, et al. A integração ensino-serviço na formação de enfermeiros e médicos: a experiência da FAMEMA. Cienc Saude Colet. 2014; 19(3):967-74..

Two other aspects also warrant highlighting. The first concerns the incontestable role that TSI plays in the development and maintenance of the SUS, a result that was strongly emphasized by the managers.

The second refers to the understanding that TSI relations, in their intended form, constitute a policy that should be managed and implemented by a network made up of all levels of management of the SUS, service providers, and medical schools.

The improvement of care engendered by a broader vision of disease and illness, enhancement of living conditions, innovations in health care, improvements in the quality of health professionals, and the sensitization of workers to collaborative working are binding effects of TSI that are fundamental for the consolidation of the health system²2 Albiero JFG, De Freitas SFT. Modelo para avaliação da integração ensino- serviço em Unidades Docentes Assistenciais na Atenção Básica. Saude Debate. 2017; 41(114):753-67.^,1616 Marin MJS, Oliveira MAC, Otani MAP, Cardoso CP, Moravcik MYAD, Conterno LO, et al. A integração ensino-serviço na formação de enfermeiros e médicos: a experiência da FAMEMA. Cienc Saude Colet. 2014; 19(3):967-74.^,1717 Forte FDS, Pessoa TRRS, Freitas CHSM, Pereira CAL, Carvalho Junior PM. Reorientação na formação de cirurgiões-dentistas: o olhar dos preceptores sobre estágios supervisionados no Sistema Único de Saúde (SUS). Interface (Botucatu). 2015; 19 Suppl 1:831-43. Doi: https://doi.org/10.1590/1807-57622014.1013.
https://doi.org/10.1590/1807-57622014.10... .

This consolidation and governance of integration requires operational sustainability, political will, intersectoral articulation, and new technological arrangements. The results of integration are boosted when it based on shared management strategies that lead to co-responsibility across the segments involved, resulting in the democratization of the process¹⁵15 Vendrusculo C, Trindade LL, Do Prado ML, Kleba ME. Repensando o modelo de Atenção em Saúde mediante a reorientação da formação. Rev Bras Enferm. 2018; 71(4):1674-82.^,1818 Oliveira ML, Mendonça MK, Alves Filho HL, Coelho TC, Benetti CN. PET-Saúde: (In)formar e fazer como Processo de Aprendizagem em Serviços de Saúde. Rev Bras Educ Med. 2012; 36(1):105-11.^,1919 Leite MTS, Rodrigues CAQ, Mendes DG, Veloso NS, Andrade JMO, Rios LR. O Programa de Educação pelo Trabalho para a Saúde na Formação Profissional. Rev Bras Educ Med. 2012; 36(1):111-8..

Teaching-service integration practices

Despite consistent coherent concepts among the actors involved in integration processes, be it those from the present study or the reviewed literature, practices still hark back to the times before the law that created the More Doctors Program, characterized by standards based on specific, piecemeal integration programs stimulated by inductive central-level policies or exclusively restricted to the schools’ search for spaces for practical training involving the offer of counterpart funding.

With these practices schools do not provide health accountability and services do not participate in education decision-making, denoting outcomes derived from the satisfaction of unilateral needs.

These practices are strongly influenced by the demand for and availability of counterpart funding and resources requested and offered by different entities, conditioning outcomes and generating unequal practices in unique settings.

While the identification of needs and possibilities by both sectors can be positive, challenges such as asymmetrical power relations, resistance to working together resulting in disjointed and unplanned actions, distance between teaching and services, singularities that lead to varying degrees of commitment, and lack of willingness and recognition of the value of integration can hamper the development of effective practice¹⁶16 Marin MJS, Oliveira MAC, Otani MAP, Cardoso CP, Moravcik MYAD, Conterno LO, et al. A integração ensino-serviço na formação de enfermeiros e médicos: a experiência da FAMEMA. Cienc Saude Colet. 2014; 19(3):967-74.^,2020 Aguiar Neta A, Alves MSCS. A comunidade como local de protagonismo na integração ensino-serviço e atuação multiprofissional. Trab Educ Saude. 2016; 14(1):221-35.

21 Silveira JLGC, Kremer MM, Silveira MEUC, Schneider ACTC. Percepções da integração ensino-serviço-comunidade: contribuições para a formação e o cuidado integral em saúde. Interface (Botucatu). 2020; 24:e190499. Doi: https://doi.org/10.1590/Interface.190499.
https://doi.org/10.1590/Interface.190499... ^-2222 Batista CB, Stralen CJ. O Pró-Saúde e seus dilemas na universidade privada. Avaliação. 2018; 23(1):198-216..

Since practices are mainly focused on individualized biomedical care and services are generally not very proactive when it comes to TSI, schools primarily seek care settings.

This limits the effectiveness of integration, as there is little demand for non-health care settings, despite their considerable contribution to the objectives set out in the education and training guidelines.

As education plans focus predominantly on the biomedical model of health care, practices are still often centered around cure and the doctor figure, where care is productivity-oriented, fragmented, and technical. TSI tends to be detached from political and social processes contributing on a smaller scale to the permanent education and satisfaction of other types of professionals in health teams¹⁶16 Marin MJS, Oliveira MAC, Otani MAP, Cardoso CP, Moravcik MYAD, Conterno LO, et al. A integração ensino-serviço na formação de enfermeiros e médicos: a experiência da FAMEMA. Cienc Saude Colet. 2014; 19(3):967-74.^,2323 Silva FA, Costa MSC, Lampert JB, Alves R. Papel docente no fortalecimento das políticas de integração ensino-serviço-comunidade: contexto das escolas médicas brasileiras. Interface (Botucatu). 2018; 22(1):1411-23. Doi: https://doi.org/10.1590/1807-57622017.0062.
https://doi.org/10.1590/1807-57622017.00... .

Regarding integration practices, it is evident that the singularities of the participants and conflicting interests regularly override common goals. This is a common paradox in policy management networks and the failure to recognize this factor and poor management severely limit the integration process.

The low level of mutual commitment to common integration goals can lead to poorly institutionalized practices that are dependent on the understanding of the people who occupy leadership roles and lack permanent funding. This can give rise to inconsistent practice and failure to deliver the desired results.

Practices that are negotiated with every change of administration, adherence, to a greater or lesser degree, to inductive policies, or even the pendular nature of the integration policy, which is marked by advances and setbacks dictated by incumbent political group, illustrate the role personal relationships play in conditioning these relations and demonstrate that piecemeal stimuli are not enough to transform education and training and health practices¹⁹19 Leite MTS, Rodrigues CAQ, Mendes DG, Veloso NS, Andrade JMO, Rios LR. O Programa de Educação pelo Trabalho para a Saúde na Formação Profissional. Rev Bras Educ Med. 2012; 36(1):111-8.^,2424 Finkler M, Caetano JC, Ramos FRS. Integração ensino-serviço no processo de mudança na formação profissional em Odontologia. Interface (Botucatu). 2011; 15(39):1053-67. Doi: https://doi.org/10.1590/S1414-32832011005000023.
https://doi.org/10.1590/S1414-3283201100... ^,2525 Vendrusculo C, Trindade LL, Do Prado ML, Kleba M. Integração Ensino-Serviço no âmbito do Programa Nacional de Reorientação da Formação Profissional em Saúde. Cienc Saude Colet. 2016; 21(9):2949-60..

Factors determining teaching-service integration

The determining elements of these relations can either facilitate or hinder TSI, depending on their relationship with management processes. When they include the intrinsic characteristics of a policy management network – horizontality, polycentricity, and interdependence – they contribute to the development of TSI, and vice versa.

Local capacity to align projects and actions with central guidelines, represented by the development of education and care plans in line with these guidelines understood and accepted by all staff, are considered decisive factors for the success of TSI.

The combination of various federal policies (work management, health education, and the expansion of primary care) and synergistic actions at locoregional level, including greater adherence to the National Curriculum Guidelines for Undergraduate Health Courses, has helped strengthen teaching-service integration²⁶26 Barreto DS, Melo Neto J, De Figueiredo AM, Sampaio J, Gomes LB, Soares RS. Programa Mais Médicos e residências de Medicina de Família e Comunidade: estratégias articuladas de ampliação e interiorização da formação médica. Interface (Botucatu). 2019; 23(1):e180032. Doi: https://doi.org/10.1590/Interface.180032.
https://doi.org/10.1590/Interface.180032... .

Permanent organic relations between schools, services, and multi-stakeholder forums and long-term investment in relevant institutions is necessary to avoid discontinuity of integration processes²2 Albiero JFG, De Freitas SFT. Modelo para avaliação da integração ensino- serviço em Unidades Docentes Assistenciais na Atenção Básica. Saude Debate. 2017; 41(114):753-67.^,2323 Silva FA, Costa MSC, Lampert JB, Alves R. Papel docente no fortalecimento das políticas de integração ensino-serviço-comunidade: contexto das escolas médicas brasileiras. Interface (Botucatu). 2018; 22(1):1411-23. Doi: https://doi.org/10.1590/1807-57622017.0062.
https://doi.org/10.1590/1807-57622017.00... .

Effective implementation of TSI requires willingness on the part of the actors involved to assume new roles. Given that TSI is a process that involves teaching in real-world practical settings, joint professional development is essential to ensure that health workers and academic staff acquire the right mix of competencies.

Challenges for consolidating TSI include the fact that staff are underprepared for teaching and professional practice, the lack of staff to supervise students with attitudes that serve as an example for future professionals, poor access to databases and research, and the need to redefine and value the role of the preceptor¹⁷17 Forte FDS, Pessoa TRRS, Freitas CHSM, Pereira CAL, Carvalho Junior PM. Reorientação na formação de cirurgiões-dentistas: o olhar dos preceptores sobre estágios supervisionados no Sistema Único de Saúde (SUS). Interface (Botucatu). 2015; 19 Suppl 1:831-43. Doi: https://doi.org/10.1590/1807-57622014.1013.
https://doi.org/10.1590/1807-57622014.10... ^,1818 Oliveira ML, Mendonça MK, Alves Filho HL, Coelho TC, Benetti CN. PET-Saúde: (In)formar e fazer como Processo de Aprendizagem em Serviços de Saúde. Rev Bras Educ Med. 2012; 36(1):105-11.^,2020 Aguiar Neta A, Alves MSCS. A comunidade como local de protagonismo na integração ensino-serviço e atuação multiprofissional. Trab Educ Saude. 2016; 14(1):221-35.^,2323 Silva FA, Costa MSC, Lampert JB, Alves R. Papel docente no fortalecimento das políticas de integração ensino-serviço-comunidade: contexto das escolas médicas brasileiras. Interface (Botucatu). 2018; 22(1):1411-23. Doi: https://doi.org/10.1590/1807-57622017.0062.
https://doi.org/10.1590/1807-57622017.00... ^,2727 Souza AL, Carcereri DL. Estudo qualitativo da integração ensino-serviço em um curso de graduação em Odontologia. Interface (Botucatu). 2011; 15(39):1071-84. Doi: https://doi.org/10.1590/S1414-32832011005000025.
https://doi.org/10.1590/S1414-3283201100...

28 Silva ATC, Medeiros Junior ME, Fontão PN, Saletti Filho HC, Vital Junior PF, Bourget MMM, et al. Medicina de Família do primeiro ao sexto ano da graduação médica: considerações sobre uma proposta educacional de integração curricular escola-serviço. Rev Bras Educ Med. 2017; 41(2):336-45.

29 Magnago C, França T, Belisario SA, Santos MR. PET-Saúde/GraduaSUS na visão de atores do serviço e do ensino: contribuições, limites e sugestões. Saude debate. 2019; 43(1):24-39.^-3030 Mendes TMC, Ferreira TLS, Carvalho YM, Silva LG, Souza CMCL, De Andrade FB. Contribuições e desafios da integração ensino-serviço-comunidade. Texto Contexto Enferm. 2020; 29:e20180333..

Strategies that promote the constancy of integration actions, increasing the incorporation of teaching into services, committing institutional actors to process outcomes rather than just their own institutional goals, planning and agreeing long-term processes, and including public participation, increase the degree of institutionalization of TSI and make implementation easier.

Management processes that address the complexity of integrated systems, provide good communication mechanisms, clearly explain roles, promote joint planning of actions and adequate financial support, contain a support structure, and are capable of dealing with antinomies are key elements of integration processes.

For effective engagement between education institutions and health services – defining joint objectives, demands, and expectations, and establishing formal partnerships to ensure that academic staff and health professionals actively participate in health service planning and in the education process – it is important to consider all aspects of local management and governance. This engagement in turn requires complex mediation due to the singularities and contradictions present in this relationship¹⁹19 Leite MTS, Rodrigues CAQ, Mendes DG, Veloso NS, Andrade JMO, Rios LR. O Programa de Educação pelo Trabalho para a Saúde na Formação Profissional. Rev Bras Educ Med. 2012; 36(1):111-8.^,2222 Batista CB, Stralen CJ. O Pró-Saúde e seus dilemas na universidade privada. Avaliação. 2018; 23(1):198-216.^,2323 Silva FA, Costa MSC, Lampert JB, Alves R. Papel docente no fortalecimento das políticas de integração ensino-serviço-comunidade: contexto das escolas médicas brasileiras. Interface (Botucatu). 2018; 22(1):1411-23. Doi: https://doi.org/10.1590/1807-57622017.0062.
https://doi.org/10.1590/1807-57622017.00... ^,3030 Mendes TMC, Ferreira TLS, Carvalho YM, Silva LG, Souza CMCL, De Andrade FB. Contribuições e desafios da integração ensino-serviço-comunidade. Texto Contexto Enferm. 2020; 29:e20180333..

The singularities of education institutions and health services, including physical infrastructure and human resources, location, level of care and care strategy, and school demand, directly affect the establishment of integration.

Challenges include inadequate practice settings, insufficient preceptors, and the fact that general practitioners and academic staff lack training in student supervision are insufficiently prepared for in-service training²⁸28 Silva ATC, Medeiros Junior ME, Fontão PN, Saletti Filho HC, Vital Junior PF, Bourget MMM, et al. Medicina de Família do primeiro ao sexto ano da graduação médica: considerações sobre uma proposta educacional de integração curricular escola-serviço. Rev Bras Educ Med. 2017; 41(2):336-45.^,3030 Mendes TMC, Ferreira TLS, Carvalho YM, Silva LG, Souza CMCL, De Andrade FB. Contribuições e desafios da integração ensino-serviço-comunidade. Texto Contexto Enferm. 2020; 29:e20180333..

Modes and processes of evaluation of teaching-service integration

The findings show that evaluation is fundamentally based on the perceptions of the actors involved in the process, generally satisfying their own interests and almost never focusing on the processes and outcomes of a cooperative strategy developed by entities seeking to fulfill the same objectives.

In addition to being weak and poorly institutionalized, the evaluation of TSI is commonly treated separately by the education institution and health service. It is also often restricted to methodologies delimited by specific programs, which are inadequate.

When used, indicators are limited to those contained in regulatory and external accreditation procedures, meaning they are insufficient to evaluate processes and specific outcomes of integration and of little use for informing decision making.

Critical factors for sustaining TSI relationships include investment in monitoring and evaluation, the use of indicators to plan actions, and joint analysis of processes²⁹29 Magnago C, França T, Belisario SA, Santos MR. PET-Saúde/GraduaSUS na visão de atores do serviço e do ensino: contribuições, limites e sugestões. Saude debate. 2019; 43(1):24-39..

When referring to modes and processes of evaluation, the participants focused primarily on physical infrastructure, funding, human resources, and the services provided at the care setting. However, there is no systematic evaluation of these aspects, resulting in contradictory assessments of physical infrastructure in the same catchment areas.

The lack of an evaluation team made up of staff from the participating entities and the fact that evaluation is not a priority for managers hampers the consolidation of an effective and efficient evaluation system.

TSI actions lack evidence that demonstrate their importance, by showing the advances that have been made for example, and the challenges that arise during the process. This clearly indicates that future calls for proposals need to include investment in monitoring and evaluation²⁵25 Vendrusculo C, Trindade LL, Do Prado ML, Kleba M. Integração Ensino-Serviço no âmbito do Programa Nacional de Reorientação da Formação Profissional em Saúde. Cienc Saude Colet. 2016; 21(9):2949-60.^,2929 Magnago C, França T, Belisario SA, Santos MR. PET-Saúde/GraduaSUS na visão de atores do serviço e do ensino: contribuições, limites e sugestões. Saude debate. 2019; 43(1):24-39..

Management/operational characteristics of teaching-service integration

The findings indicate that that every governance process is built around bilateral relationships established between participating entities, despite the fact that catchment areas include multiple actors who are often competing for the same resources.

The motives behind the establishment of integration relationships still stem from unilateral interests, which the parties seek to align in bilateral negotiations.

Defined in this way, as multilateral collectives, networks can become extremely complicated entities that require explanations that go far beyond the dyadic approaches traditionally discussed in organization theory and the literature on strategic management³¹31 Provan KG, Kenis P. Modes of Network Governance: Structure, Management, and Effectiveness. J Public Adm Res Theory. 2019; 18(2):229-52..

Despite the managers’ strong belief that the established governance does not reach the limits that are essential for a system that induces the formation of a policy management network, the use of management processes that are more suited to networks is not considered

Guaranteeing the participation of all from the beginning of the process, joint planning, clear objectives, goals and roles, effective communication, and the formation of management committees to share decision-making and horizontally agree strategies are fundamental elements in the development of integration. Managing systems based on these premises is complex and requires specialized operating units and shared structures, which is not the rule in the systems investigated, in which integration demands are assessed exclusively by the placement provider.

It is necessary to encourage internal communication at different levels of management in each institution and participating organization and create spaces for community participation in activities to overcome poor organization and transparency in agreements³⁰30 Mendes TMC, Ferreira TLS, Carvalho YM, Silva LG, Souza CMCL, De Andrade FB. Contribuições e desafios da integração ensino-serviço-comunidade. Texto Contexto Enferm. 2020; 29:e20180333..

The involvement of both public and private entities, sharing resources under a tangled web of laws and regulations overseen by a wide range of enforcement agencies, adds considerable complexity to an already challenging field. The capacity of local managers to deal with existing antinomies was shown to be a decisive factor in the management of integration.

Agreement instruments provide little support for management processes. The likelihood of unworkable processes or unlikelihood of all necessary actions, the lack of clearly defined objectives, goals, and roles and responsibilities of those involved, and the weaknesses of the instruments before enforcement agencies demonstrate that, as a general rule, traditional agreements, which are easier to prepare, are less effective.

A suitable instrument for network management should include all actors in a single term and set out the requirements for agreement and implementation. In the present study, these requirements did not incorporate the day-to-day management of the systems, meaning that the organizational contracts in the investigated catchment areas were not workable.

Despite the unanimous recognition of the difficulties involved in operationalizing organizational contracts, the Organizational Contract for Public Teaching-Health Action (COAPES) was seen to set out important elements of agreement: the “details”, as one of the managers succinctly put it.

Network management is far from simple, which means that social programs and projects often fail, despite the good intentions of the actors involved¹⁰10 Teixeira SMF. O desafio da gestão das redes de políticas. In: Anais do 7o Congreso Internacional del CLAD sobre la Reforma del Estado y de la Administración Pública, Lisboa, Portugal, 8-11 Oct. 2002. Lisboa: CLAD; 2002..

Final considerations

The findings of this study clearly show that while TSI relations in the schools studied in Paraná are understood as management networks by managers, this is not reflected in practice.

Our results also demonstrate how the lack of a network-based approach to the management of integration processes gives rise to inadequate integration practices, hampers the improvement of evaluation systems, compromises appropriate education and training, and overburdens the health system.

In addition to regulatory aspects, the new requirements of medical education and training envision education that is centered on the health system. The management of this process, which brings together two highly complex socio-technical fields, calls for a shift from current predominantly intraorganizational management models towards new arrangements for interorganizational governance between schools and services. Understanding policy management networks is therefore of critical importance.

Study weaknesses include the fact that the data were derived from interviews with managers with temporary contracts. Strengths include the fact that the study encompassed practically all medical schools that offer complete training cycles in the State of Paraná, the inclusion of all types of schools (public, non-profit, and private institutions), and the fact that the institutions have been in existence for some time.

References

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