Abstract

Introduction

The Federal Constitution of 1988 took health as an obligation of the State and a right of all citizens, including those in prison settings. Before this legal apparatus, health care of the segment in question consisted of specific actions and counted with a differential from the Penal Execution Law No. 7.210, of 1984. After almost twenty years, new impetus stemmed from publications of the Interministerial Ordinance No. 1.777/2003, which instituted the National Health Plan in the Prison System (Plano Nacional de Saúde no Sistema Penitenciário, PNSSP) (Brazil, 2005BRASIL, Ministério da Saúde. Plano Nacional de Saúde no Sistema Penitenciário. 2. ed. Brasília, DF, 2005.) and, recently, the National Policy on Comprehensive Healthcare of People Deprived of Liberty in the Prison System (Política Nacional de Atenção Integral à Saúde das Pessoas Privadas de Liberdade no Sistema Prisional, PNAISP), in 2014 (Brazil, 2014BRASIL. Portaria Interministerial nº 1, de 2 de janeiro de 2014. Institui a Política Nacional de Atenção Integral à Saúde das Pessoas Privadas de Liberdade no Sistema Prisional (PNAISP) no âmbito do SUS. Diário Oficial da União, nº 2, Brasília, DF, 3 jan. 2014, p. 18-19.).

The PNSSP foresees the implementation of health teams (doctor, nurse, dentist, psychologist, social worker, nursing technicians and dental hygiene professional) in prisons with more than a hundred inmates, in the ratio of one team for each five hundred inmates. Such services must meet "the needs of attention at the basic level, minimum of assistance in the medium complexity level [...] and components of urgency and emergency care in health, in line with the specifics of the National Penitentiary System" (Brazil, 2005BRASIL, Ministério da Saúde. Plano Nacional de Saúde no Sistema Penitenciário. 2. ed. Brasília, DF, 2005., p. 24).

In 2004, the State of Mato Grosso integrated the PNSSP, whose management is shared between the State Justice and Human Rights Secretariat (Secretaria Estadual de Justiça e Direitos Humanos, Sejudh/MT) and the State Health Secretariat (Secretaria de Estado da Saúde, SES/MT) (Mato Grosso, 2010aMATO GROSSO. Secretaria de Estado de Justiça e Direitos Humanos. Plano de Modernização do Sistema Penitenciário 2010-20Cuiabá, 2010a. Disponível em: <Disponível em: http://www2.mp.pr.gov.br/cpcrime/boletim82/cep_b82_n_11.doc >. Acesso em: 10 abr. 2014.
http://www2.mp.pr.gov.br/cpcrime/boletim... ). We can, therefore, presuppose an institutional partnership not without tensions because it is made up of institutions with different backgrounds, values and missions and ones that start to become involved, to some degree, with the common commitment of "providing full health care for the confined prison population [...]" (Brazil. 2005BRASIL, Ministério da Saúde. Plano Nacional de Saúde no Sistema Penitenciário. 2. ed. Brasília, DF, 2005., p. 1).

The PNSSP is guided by the principles and guidelines of the Brazilian National Health System (Sistema Único de Saúde, SUS) for the implementation of health units that have integrated the public network, however, the peculiarities of the prison context impose particularities that, sometimes, generate ambiguities and barriers that are reflected both in the execution and management of assistance. Obstacles, however, do not preclude the implementation of a policy, and they can, in fact, promote knowledge for improvements in decision making, if monitored throughout the process and understood as part of management in a broader sense (Silva; Melo, 2000SILVA, P. L. B.; MELO, M. A. B. O processo de implementação de políticas públicas no Brasil: características e determinantes da avaliação de programas e projetos. Núcleo de Estudos de Políticas Públicas, Campinas, Cad. 48, p. 01-16, 2000.), constituting an experience that has positive elements to the management practice.

In the field of Public Health, we situate this article in the Health Policy, Planning and Management, that "[...] discusses the policy-making processes (formulation), of the ways of organizing practices (programming), and the management (operationalization) of plans, programs and action projects" (Teixeira et al., 2014TEIXEIRA, C. F. et al. Produção científica sobre política, planejamento e gestão em saúde no campo da saúde coletiva: visão panorâmica. In: PAIM, J. S.; ALMEIDA-FILHO, N. (Org.). Saúde Coletiva: teoria e prática. Rio de Janeiro: MedBook, 2014. p. 585-594., p. 589). However, it focuses on Health Management that, in the broad sense, refers to the actions of formulation and implementation of Health Policies with the perspective of the implement of these actions being mediated by activities that manage the direction of health systems and services and, in the local spheres, refers to the coordination of work processes. Health Management considers also structure arrangements, coordination and mobilization of alliances and partnerships in addition to the political and strategic resources that provide conditions to achieve the objectives of the policies, plans and programs (Guimarães et al., 2004GUIMARÃES, M. C. L. et al. Avaliação da capacidade de gestão de organizações sociais: uma proposta metodológica em desenvolvimento. Cadernos de Saúde Pública, Rio de Janeiro, v. 20, n. 6, p. 1642-1650, 2004.). Thus, decision-making is the responsibility and formal competence of the manager who relies on information to do so, including the existent personal knowledge (technical, political, institutional, social, cultural references among others) and the existing perception of the problem to form an opinion and act (Tanaka; Tamaki, 2012TANAKA, O. Y.; TAMAKI, E. M. O papel da avaliação para a tomada de decisão na gestão de serviços de saúde. Ciência & Saúde Coletiva, Rio de Janeiro, v. 17, n. 4, p. 821-828, 2012.).

Consequently, based on and adapted to the idea of (Uchimura and Bosi, 2002UCHIMURA, K. Y.; BOSI, M. L. M. Qualidade e subjetividade na avaliação de programas e serviços em saúde. Cadernos de Saúde PúblicaRio de Janeiro, v. 18, n. 6, p. 1561-1569, 2002.), we can highlight the importance of the perceptions of subjects in the management process, which are conditioned by their experiences with this policy, program, system, service; and by their integration in a specific cultural, economic and social context (Guattari, apud Castiel, 1994CASTIEL, L. D. O buraco e o avestruz: ensaios sobre a singularidade do adoecer humano. Campinas: Papirus, 1994.). Subjectivity (in both individual and public spheres) in decision-making-in which the manager relies on technical, political, institutional, social, cultural references and perception (permeated by the fluidity of experience) of the theme and interventions-is valued.

The present article analyzes the perception of managers on the management of health policy in the Prison System of Mato Grosso focusing on its current operation characteristics, barriers and strengths. It makes use of a qualitative method appropriate to address the meanings, motivations, beliefs, values, perceptions and enables the understanding of social processes little known and studied, such as the theme of Prison Health, which the review of (Gois et al., 2012GOIS, S. M. et al. Para além das grades e punições: uma revisão sistemática sobre a saúde penitenciária. Ciência & Saúde Coletiva, Rio de Janeiro, v. 17, n. 5, p. 1235-1246, 2012.), pointed to the shortage of publications, characterizing it, also, as a descriptive and exploratory research (Gil, 2002GIL, A. C. Como elaborar projetos de pesquisa. 4. ed. São Paulo: Atlas, 2002.).

Guided by a semi-structured script, two health managers of Prison Systems were interviewed in October 2013, one of the Sejudh/MT and other from the SES/MT, with background formation in administration and nursing, respectively, both had experience in Health Management and direct assistance. The data was supplemented with official documents of public access on Prison Health Management and treated by thematic analysis (Bardin, 2011BARDIN, L. Análise de conteúdo. Lisboa: Edições 70, 2011.), namely: policy and national and State level plans (Brazil, 2005BRASIL, Ministério da Saúde. Plano Nacional de Saúde no Sistema Penitenciário. 2. ed. Brasília, DF, 2005.; ²⁰¹⁴BRASIL. Portaria Interministerial nº 1, de 2 de janeiro de 2014. Institui a Política Nacional de Atenção Integral à Saúde das Pessoas Privadas de Liberdade no Sistema Prisional (PNAISP) no âmbito do SUS. Diário Oficial da União, nº 2, Brasília, DF, 3 jan. 2014, p. 18-19.; Mato Grosso, 2010aMATO GROSSO. Secretaria de Estado de Justiça e Direitos Humanos. Plano de Modernização do Sistema Penitenciário 2010-20Cuiabá, 2010a. Disponível em: <Disponível em: http://www2.mp.pr.gov.br/cpcrime/boletim82/cep_b82_n_11.doc >. Acesso em: 10 abr. 2014.
http://www2.mp.pr.gov.br/cpcrime/boletim... ; ^2010bMATO GROSSO. Secretaria de Estado de Saúde de Mato Grosso. Superintendência de Políticas de Saúde. Plano Estadual de Saúde de MT 2008-2011. Cuiabá, 2010b. Disponível em: <Disponível em: http://www.saude.mt.gov.br/arquivo/2909 >. Acesso em: 20 abr. 2014.
http://www.saude.mt.gov.br/arquivo/2909... ; ^2011aMATO GROSSO. Secretaria de Estado de Justiça e Direitos Humanos. Diagnóstico setorial e avaliação dos programas da SEJUDH/MT: insumos para o Plano Plurianual 2012-2015. Cuiabá, 2011a. Disponível em: <Disponível em: http://www.sejudh.mt.gov.br/UserFiles/File/SEJUDH/DIAGNOSTICO%20SOCIAL%20-%20SEJUDH%20OFICIAL.pdf >. Acesso em: 20 abr. 2014.
http://www.sejudh.mt.gov.br/UserFiles/Fi... ), minutes and management reports (Mato Grosso, 2011bMATO GROSSO. Conselho Estadual de Saúde. Ata da ducentésima sexagésima terceira reunião do CES-MT: 9 de novembro de 2011. Cuiabá, 2011b. Disponível em: <Disponível em: www.saude.mt.gov.br/arquivo/3454 >. Acesso em: 10 jan. 2013.
www.saude.mt.gov.br/arquivo/3454... ; ²⁰¹²MATO GROSSO. Secretaria de Estado de Saúde de Mato Grosso. Relatório de gestão: gerência de saúde do sistema penitenciário, Sejudh/MT. Cuiabá, 2012. Disponível em: <Disponível em: http://www.sejudh.mt.gov.br/saap2.php?IDCategoria=772 >. Acesso em: 16 jul. 2014.
http://www.sejudh.mt.gov.br/saap2.php?ID... ; ²⁰¹³MATO GROSSO. Secretaria de Estado de Saúde de Mato Grosso. Plano Estadual de Saúde de MT 2012-2015 - Superintendência de Políticas de Saúde. Cuiabá, 2013. Disponível em: <Disponível em: http://www.saude.mt.gov.br/upload/documento/249/versao-final-da-oficina-pes-2012-2015_030511-[249-160511-SES-MT].pdf >. Acesso em: 12 abr. 2014.
http://www.saude.mt.gov.br/upload/docume... ; ²⁰¹⁴MATO GROSSO. Secretaria de Estado de Justiça e Direitos Humanos. Secretaria Adjunta de Administração Penitenciária: nossas unidades. Cuiabá, 2014. Disponível em: <Disponível em: http://www.sejudh.mt.gov.br/saap2.php?IDCategoria=395 >. Acesso em: 16 jul. 2014.
http://www.sejudh.mt.gov.br/saap2.php?ID... ).

Research approved by the Hospital Universitário Júlio Müller Research Ethics Committee (Opinion No. 344.952 of 31/7/13) and respondents were identified by the letter G (for Manager, or Gestor, in Portuguese) followed by random numbers, protecting their identity regardless of institutional placement.

The Health Management Policy in the Prison Systems of Mato Grosso: barriers and advancements

The management of Prison Health actions in Mato Grosso focuses predominantly on Sejudh/MT, and less expressively on SES/MT. Therefore, the Sejudh/MT has a Prison Health Management linked to the Office of Prison Management, and it is made up of a manager, three administrative assistants, a pharmacist and two economic and social development professionals (Mato Grosso, 2011aMATO GROSSO. Secretaria de Estado de Justiça e Direitos Humanos. Diagnóstico setorial e avaliação dos programas da SEJUDH/MT: insumos para o Plano Plurianual 2012-2015. Cuiabá, 2011a. Disponível em: <Disponível em: http://www.sejudh.mt.gov.br/UserFiles/File/SEJUDH/DIAGNOSTICO%20SOCIAL%20-%20SEJUDH%20OFICIAL.pdf >. Acesso em: 20 abr. 2014.
http://www.sejudh.mt.gov.br/UserFiles/Fi... ). As previously noted, when the state of Mato Grosso integrated the PNNSP in 2004,

Thus, health care human resources in prisons falls under the Sejudh/MT which seems to bring consequences to assistance and management, as will be discussed later.

Under the SES/MT, when Mato Grosso integrated the plan in 2004, health activities in the Prison System were under the area of Mental Health, and became a technical area in 2010, with the creation of the Management of Strategic Action. After consulting the last two State Health Plans, it is possible to note that from 2008 to 2011 health in the Prison System is, briefly and vaguely, one of the main health care guidelines (Mato Grosso, 2010bMATO GROSSO. Secretaria de Estado de Saúde de Mato Grosso. Superintendência de Políticas de Saúde. Plano Estadual de Saúde de MT 2008-2011. Cuiabá, 2010b. Disponível em: <Disponível em: http://www.saude.mt.gov.br/arquivo/2909 >. Acesso em: 20 abr. 2014.
http://www.saude.mt.gov.br/arquivo/2909... ) and in the period from 2012 to 2015 fragility in the implementation of health teams, is seen, in face of which

In the SES/MT the management team currently consists of two professionals-the manager and a higher level technician working at the central level and that can rely on reference technicians for Prison Health issues in three districts (that house penitentiaries), connected to the respective Regional Health Offices (Escritórios Regionais de Saúde, ERS)-regionalized instances of SES/MT. Draws attention the initial insertion of the actions on the area of Mental Health of the SES/MT, which seems to have a reason, given that the link of crimes with madness have been pointed by (Foucault, 2001FOUCAULT, M. Os anormais. São Paulo: Martins Fontes, 2001.), (Rebelo and Caponi, 2007REBELO, F.; CAPONI, S. A medicalização do crime: a penitenciária de Florianópolis como espaço de saber e poder (1933-1945). Interface: Comunicação, Saúde, Educação, v. 11, n. 22, p. 193-206, 2007.), (Carrara, 1991CARRARA, S. Singularidade, igualdade e transcendência: um ensaio sobre o significado social do crime. Revista Brasileira de Ciências SociaisRio de Janeiro, v. 6, n. 16, p. 80-88, 1991.; ¹⁹⁹⁸CARRARA, S. Crime e loucura: o aparecimento do manicômio judiciário na passagem do século. Rio de Janeiro: EdUerj, 1998.) among others. We thus note:

It is appropriate to recall that, in face of enigmatic crimes, from the nineteenth century on, the elucidation of the relationship between crime and madness would result from efforts to understand and differentiate when human actions are promoted by free will, behavior, and therefore, the moral responsibility and the guilt of the criminal or, conversely, when they would be expressions of an illness or mental abnormality, affecting the offender, determining their actions, making them not responsible for these crimes (Carrara, 1991CARRARA, S. Singularidade, igualdade e transcendência: um ensaio sobre o significado social do crime. Revista Brasileira de Ciências SociaisRio de Janeiro, v. 6, n. 16, p. 80-88, 1991.). With this in mind, (Foucault, 1978FOUCAULT, M. História da loucura na Idade ClássicaSão Paulo: Perspectiva, 1978.) distinguish two types of madness: one in which people recognize themselves in the actions motivated by moral choices (eg, jealousy and hate) being understandable by reason, but a reason that would be foreign to the moral world giving rise, successively, to the notions of moral craziness, of degeneration, of the innate criminal, of wickedness. Who should be punished, corrected, protected, healed, and controlled? However, the problem of establishing limits of "normality" and "sanity" (of craze in this case), where the boundaries are blurred and confused, it is also well-known that such postulates influenced the fate of the criminally insane and, in a way, of the different criminal studies¹⁰10For details on the relationship between crime and madness, based mainly on the writings of Michel Foucault, we suggest consulting (Carrara, 1998), and on the basis of distinct criminal studies refer to (Bitencourt, 2012)..

The Prison System¹¹11Formally prison units should house prisoners that have been convicted and are serving a sentence, leaving to the jailhouses to hold the temporaries awaiting trial, but the presence of some in units is true not only for Mato Grosso. Both, however, are characterized by the closed regime. of Mato Grosso is composed of six penitentiaries (five male and one female), forty-nine public jailhouses, five Support Homes (Three Harbor Houses, one Agricultural Colony, an Annex to the Central State Penitentiary (Penitenciária Central do Estado, PCE), two Temporary Holding Centers, summing up to sixty-two prisons units (Mato Grosso, 2011aMATO GROSSO. Secretaria de Estado de Justiça e Direitos Humanos. Diagnóstico setorial e avaliação dos programas da SEJUDH/MT: insumos para o Plano Plurianual 2012-2015. Cuiabá, 2011a. Disponível em: <Disponível em: http://www.sejudh.mt.gov.br/UserFiles/File/SEJUDH/DIAGNOSTICO%20SOCIAL%20-%20SEJUDH%20OFICIAL.pdf >. Acesso em: 20 abr. 2014.
http://www.sejudh.mt.gov.br/UserFiles/Fi... ), apart from the Mental Health Unit¹²12It is linked to the SES/MT and does not integrate the Prison System. It receives people under preventive detention and is located within the Central State Penitentiary (Mato Grosso, 2010a). It is so named to distinguish it from the "infirmary" where the health team works and, in a visit in October 2013, had eighteen its twenty-eight spots occupied..

While there the criterion number of prisoners exists, the PNSSP does not address the prison units with AN open regime or those for pre-trial detainees (housed in jailhouses and police stations). In 2012, Mato Grosso had health teams implemented in seven units (Mato Grosso, 2012MATO GROSSO. Secretaria de Estado de Saúde de Mato Grosso. Relatório de gestão: gerência de saúde do sistema penitenciário, Sejudh/MT. Cuiabá, 2012. Disponível em: <Disponível em: http://www.sejudh.mt.gov.br/saap2.php?IDCategoria=772 >. Acesso em: 16 jul. 2014.
http://www.sejudh.mt.gov.br/saap2.php?ID... )-their location, capacity and quantity of prisoners are reported in Table 1 below.

The quantitative parameter, implementation of a health team for each five hundred prisoners (Brazil, 2005BRASIL, Ministério da Saúde. Plano Nacional de Saúde no Sistema Penitenciário. 2. ed. Brasília, DF, 2005.) is questioned by a manager because it is based on the parameter institutional capacity and not on current population. As a result of overcrowding, which is common, the team is overloaded and this reflects on the provision of inputs (with special attention to pharmaceutical inputs), creating tension between management levels with regards to the competencies and responsibilities of each entity.

There is also the situation of the jailhouses like, for example, in the neighboring district where a unit with capacity for 192 inmates (Mato Grosso, 2014MATO GROSSO. Secretaria de Estado de Justiça e Direitos Humanos. Secretaria Adjunta de Administração Penitenciária: nossas unidades. Cuiabá, 2014. Disponível em: <Disponível em: http://www.sejudh.mt.gov.br/saap2.php?IDCategoria=395 >. Acesso em: 16 jul. 2014.
http://www.sejudh.mt.gov.br/saap2.php?ID... ) is assisted by the Health Management of the Sejudh/MT. Formally they are linked, administratively, to the Commission of Jailhouse Management/Sejudh/MT (Mato Grosso, 2010MATO GROSSO. Secretaria de Estado de Justiça e Direitos Humanos. Plano de Modernização do Sistema Penitenciário 2010-20Cuiabá, 2010a. Disponível em: <Disponível em: http://www2.mp.pr.gov.br/cpcrime/boletim82/cep_b82_n_11.doc >. Acesso em: 10 abr. 2014.
http://www2.mp.pr.gov.br/cpcrime/boletim... ), being the assistance to those inmates a responsibility of the City Health System. However, non-institutionalized informal arrangements are put in place to provide care, being characterized as flexibilization of norms. These arrangements are important as agents of change, transformations, innovations that can stimulate and reinforce new partnerships and the institutionalization of unique and differentiated management processes, always oriented to the achievement of the planned purposes.

The operationalization of PNSSP/Mato Grosso is facing some non-isolated difficulties that hinder the management process. In the case of Health Management/Sejudh/MT, the absence of staff adds to the concentration of prisoners in the capital penitentiary units. With physical proximity to these units and given the shortage of human resources, management finds itself overwhelmed by the technical demands, piling up and blurring with management per se. One consequence is the difficulty of periodic visits to teams of prisons that are not in the capital, as expressed:

Along with the concentration of the units are the physical structural issues of the state (which are beyond the power of Health Management, but that interferes with it), including with respect to the media, also making it difficult to work, because as a manager reported:

Problems of communication, visibility, and transparency in the decisions can also affect health management in the Prison System, for example, publicizing the State Operational Plan (POE). The POE is a management tool that contains the goals, forms of management and administration of health actions and services (Brazil, 2005BRASIL, Ministério da Saúde. Plano Nacional de Saúde no Sistema Penitenciário. 2. ed. Brasília, DF, 2005.). It must be submitted to the State Health Council (Conselho Estadual de Saúde, CES) and the Comissão Intergestores Bipartite (CIB) for consideration, discussion, and approval, and the proposals are subsequently approved within each federal unit through the CIB and between state health and justice managers, and municipal health managers (Brazil, 2005BRASIL, Ministério da Saúde. Plano Nacional de Saúde no Sistema Penitenciário. 2. ed. Brasília, DF, 2005.).

We recall that the POE confirms integration to the PNSSP and must exist for the financial incentive provided in Ordinance No. 1.777/2003, for health services in prisons, to be guaranteed to the state. The minutes of the meeting 263 of the CES 09/11/2011, certifies its existence in Mato Grosso, informing of the progress of the PNSSP with the presentation, discussion and approval of the 2010 POE Annual Report of Health in Prison Systems, highlighting that it is a partnership between Sejudh/MT and SES/MT (Mato Grosso, 2011bMATO GROSSO. Conselho Estadual de Saúde. Ata da ducentésima sexagésima terceira reunião do CES-MT: 9 de novembro de 2011. Cuiabá, 2011b. Disponível em: <Disponível em: www.saude.mt.gov.br/arquivo/3454 >. Acesso em: 10 jan. 2013.
www.saude.mt.gov.br/arquivo/3454... ). Although its approval is published, until now we have not been able to access the document electronically-a difficulty shared by a manager:

The difficulty in financial execution is pointed to by a manager as what hinders the implementation of the POE, consisting of an aspect that deserves further study:

In this scenario, decentralization proves to be advantageous in the case of SES/MT which counts on a reference technician for Prison Health issues in their ERS in three cities that hold penitentiaries out of the capital, these offices can contemplate and expedite the integration of penitentiary health professionals acting there with other SUS professionals. So it is reported:

Health teams from prisons outside the capital had a positive performance in some points (resolvability, proposals/initiatives, relationships to other reference units), as pointed out by both managers. They attribute the differential emphatically to the smaller amount of prisoners and external informal contacts, facilitated because they are smaller cities and because of others employment bonds, enabling agility, shortcuts to healthcare and joint initiatives with the community:

The incompatibility in the organization of the Prison Health service with other specific health services is an impediment appointed by the managers, for example, for chemical dependency/drugs abuse by the inmates and, in this case, the relationship with public health system referral units which are the Psychosocial Support centers (Centros de Apoio Psicossocial, CAPS). This situation disregards the social position of the person/inmate and the characteristics of its context to provide care, hurting the principle of equity in access to health which would take into account the diversity of people, needs, and therefore, differentiated distribution-in the case flexibilization of the service organization to allow access. Let us remember that "a universal standard is not enough if it does not support the right to difference. It is not a pattern of homogeneity, but one of equality" (Sposati, 1999SPOSATI, A. Exclusão social abaixo da linha do Equador. In: VERAS, M. P. B. (Org.). Por uma sociologia da exclusão social: o debate com Serge Paugam. São Paulo: Educ, 1999. p. 128-133., p. 128). The report of possibilities shows viability, diminishing the absolute incompatibility:

The Prison Health units, formally driven by SUS principles and guidelines, when implemented, require adjustments to comply to the specifics of the prison context. Because such units are classified as Basic Health Units (Unidades Básicas de Saúde, UBS) in the Prison System and, in fact, offer medical and dental consultations, inhalations, injections, patches, vaccines, laboratory exams, referrals to specialty treatments, basic medication. With some local variations, they are also open during the weekend (restricted actions) and their routine resembles that of an Emergency room (Pronto Atendimento, PA), with spontaneous demand and non-programmatic attention, except to infectious diseases (tuberculosis, leprosy, HIV/AIDS). It seems to be a distinct basic unit due to the peculiarities of the confinement institution and the prison population served.

So they act as an intermediate between UBS and PA, resolving a significant part of the events and avoiding the complicated escorted exits of the prisoners. However, it is distinct from the typical PA because they work during the day and do not have night shifts, and the emergencies are sent to the local reference units. In addition, we have to consider that the confined population circulates (between jailhouses/penitentiaries and between penitentiaries), floating (with prisoners entering and leaving daily), and demands security, and the scheduled actions require handling of prisoners and depend on the intermediation of other professional categories (prison officer, military police). In this case, we arrive at an issue of availability and willingness of professionals working in environment guided by the discipline and security principles¹³13The Sejudh/MT is one of seven agencies that make up the State Security Unit (Mato Grosso, 2010a). to the detriment of health (Thompson, 1993THOMPSON, A. A questão penitenciária. 4. ed. Rio de Janeiro: Forense, 1993.; Diuana et al., 2008DIUANA, V. et al. Saúde em prisões: representações e práticas dos agentes de segurança penitenciária no Rio de Janeiro. Cadernos de Saúde Pública, Rio de Janeiro, v. 24, n. 8, p. 1887-1896, 2008.), which can generate tensions, hampering the provision of treatment, preventive and health promotion actions. The interactions and the current standards inside and between cells can also filter access. We thus note:

These tensions will reflect (and strengthen) in points cited by managers, as in the case of linking health teams to the Sejudh/MT and not to the SES/MT, affecting both the performance of the professionals who find themselves in embarrassing situations between guidelines and practices (sometimes contradictory to their formation), on the management of health in that context. Both managers recognize the interference of institutional differences in their performances:

The last excerpt leads us to reflect on the apparent incompatibility between justice and the right to health in the context of the Prison System, given that health is based on the principle of social justice. Discussing a new social agenda in Latin America, (Draibe, 2011DRAIBE, S. M. Uma nova agenda social na América Latina?: pontos de partida para análise comparada dos sistemas de proteção social e suas mudanças recentes. In: SOLA, L.; LOUREIRO, M. R. (Org.). Democracia, mercado e Estado: o B de Brics. Rio de Janeiro: FGV, 2011. p. 249-288.) refers to the increasing importance of social rights on the basis of social protection, guaranteed in legislation and assuming the guarantee of the demands and results. Anchored in the values and principles of social justice, the concepts of solidarity and social cohesion put the right to health as part of justice and not incongruous to them as implied above. One gets the impression that justice, by being reduced to security, opposes health. Another point that differs in the orientation of health management in the Prison System of Mato Grosso regards the proposal of decentralization in the implementation of the SUS. The Prison System, within public safety, is the responsibility of the State Government (thus, centralized), but in the health the movement was one of intensification of decentralization and, thus, the fact that the service is inserted directly into a state instance/Sejudh creates ambiguities in management:

The peculiarities of the prison context, the institution, the population served and the interactions that go on there, influence the practice of health professionals which, in turn, is reflected in the actions of managers, as discussed below.

The prison environment and the impact on care and management

In his classic work Discipline and Punish: The Birth of The Prison, following the changes in punitive practices throughout the eighteenth century, (Foucault, 1987FOUCAULT, M. Vigiar e punir: nascimento da prisão. 16. ed. Petrópolis: Vozes, 1987.) narrates how, in the context of a new "political economy of the body," the public spectacles where a whole list of punishments and torture to the bodies of the condemned was inflicted with great violence; end up being replaced by the penalty of detention with more lenient punitive techniques to criminals. Incarceration becomes the penalty for excellence adopted by the legal system and promises to take care of the soul and body of the prisoner, improving their conduct, dominating their physical strength and correcting their spirit. Hence, the preference of the penitentiary body through disciplinary devices, constant surveillance, punishments and corrective measures. However, the author warns that the prison does not come down to the negative function of depriving the criminal of his liberty, punishing him, monitoring him and breaking him in face of a system of docile-usefulness, but that serving the sentence should have deep corrective effects, promoting the transformation of individuals, enabling them to follow the prevailing social order.

The conciliation of those purposes, which seem somewhat contradictory, soon proved even fallacious since from early on the clear failure of the penitentiary model for not meeting the proclaimed purposes was exposed: crime rates did not fall, the rate of repeat offense remained high, routine abuse of power, corruption, institutional violence far from teach respect for the law favoring the perpetuation of misconduct. However, if the prison is still used it is because its operation does not aim to meet its stated purposes, but its true function lies hidden, because the real role played is not to eradicate crime or illicit behavior, but, to manage it, organize it, differentiate it, in other words, it is a form of managing the transgressions, concludes (Foucault, 1987FOUCAULT, M. Vigiar e punir: nascimento da prisão. 16. ed. Petrópolis: Vozes, 1987.). Selective actions and a dynamic that is not autonomous to the interests and game of social forces in the broader context, we can add.

Authors such as (Thompson, 1993THOMPSON, A. A questão penitenciária. 4. ed. Rio de Janeiro: Forense, 1993.), (Silva, 2008SILVA, A. M. C. Nos braços da lei: o uso da violência negociada no interior das prisões. Rio de Janeiro: E+A, 2008.), (Moraes, 2013MORAES, P. R. B. A identidade e o papel dos agentes penitenciários. Tempo Social: Revista de Sociologia da USP, São Paulo, v. 25, n. 1, p. 131-147, 2013.), (Barcinski, Altenbernd and Campani, 2014BARCINSKI, M. M. A.; ALTENBERND, B.; CAMPANI, C. C. Entre cuidar e vigiar: ambiguidades e contradições no discurso de uma agente penitenciária. Ciência & Saúde Coletiva, Rio de Janeiro, v. 19, n. 7, p. 2245-2254, 2014) also pointed out contradictions between the discourses and practices of prisons, because they propose to re-educate, re-socialize, regenerate, care and at the same time, historically, it serves to punish, watch, control and regulate other human beings. In face of this situation, how to operationalize a policy guided by the principles of universality, equity, integrity, commitment and humanization such as the SUS? Let's see:

Thus, there are implications to the duties of health professionals in the face of the demands, in view of the conflict and hierarchy of internal actions, in which legal issues of discipline and security, seem to outdo the health issues, as previously mentioned and expressed in the following excerpts, but that we interpret as typical of the prison context and, therefore, not restricted to a professional category or to the local context:

The referred priority is reflected in the work of health professionals and hence the care of prisoners in various ways. They are not treated in their cells, but in the health unit, and therefore depend on other professionals moving them there, in the same way, they do when they need more complicated procedures to be done outside the prison and require an escorted transportation. However, the same professional and vehicles are required for the displacement of inmates to legal services (forums), therefore, they have delicate choices to make and receive greater pressure for those that interfere in the prisoner's legal situation and those that could mean changes in their destiny (sentence, regime, the license/freedom), these changes influence the internal dynamics. To understand the possible criterion that guides the choice, we can exercise our sociological imagination considering the difference in outcomes, for the inmate and the institution, when there is a failure to attend a hearing or a doctor's appointment or other kinds of health care...

As a result, there is what we call a "forced resolution" of most of the health demands at the local unit (Barsaglini; Arruda, 2014BARSAGLINI, R. A. et al. Trabalhadores de saúde em penitenciárias em Cuiabá/MT: perfil dos profissionais e impressões sobre a instituição. In: CONGRESSO INTERNACIONAL REDE UNIDA, 11., Fortaleza, Fortaleza, 2014. Resumo. Disponível em: <Disponível em: http://conferencias.redeunida.org.br/ocs/index.php/redeunida/RU11/paper/view/702 >. Acesso em: 15 dez. 2014.
http://conferencias.redeunida.org.br/ocs... ), which generates dilemmas and discomforts to the professional that takes the claims to local or central managers, since refusing is problematic in that context. Pressure can come through the prisoners (also deprived of their freedom of choice for service and purchase of non-prescription drugs in the external pharmacies), their families (that calls the infirmary or the administration directly) and other penitentiary workers, but also formally through notifications of the local administration or external legal authorities, or even, both. Let us note in excerpts:

We can think of demarcated territories of power in institutions, where access and performance in their spaces can be embarrassing, hampered as pointed out by a manager about the difficulty in entering the penitentiaries, and one of the strategies to get around that would be through other organizations that act there such as the Pastoral, since the penitentiary is "the house of the Sejudh...", as he said.

Therefore, access to information about the health status of the healthcare team professionals is also cited as difficult, the information is restricted to the Public Security Secretariat. Studies show that working in closed institutions makes professionals vulnerable (Rumin et al., 2011RUMIN, C. R. et al. O sofrimento psíquico no trabalho de vigilância em prisões. Psicologia: Ciência e Profissão, Brasília, DF, v. 31, n. 1, p. 188-199, 2011.; Greco, 2011GRECO, P. B. T. Distúrbios psíquicos menores em agentes socioeducadores dos Centros de Atendimento Socioeducativo do Rio Grande do Sul. 2011. Dissertação (Mestrado em Enfermagem) - Universidade Federal de Santa Maria, Centro de Ciências da Saúde, Santa Maria, 2011.), and if there is a sector that deals with this issue, it appears to act in a closed way, with little visibility and communication with stakeholders. It is worthy of note that the additional hazard pay earned in 2013 was only granted after a long union struggle and a strike by the Prison System servers (Sindespen-MT, 2013aSINDESPEN-MT. Conquista: governo do Estado publica pagamento de insalubridade para servidores penitenciários. Sindicato dos Servidores Penitenciários do Estado de Mato Grosso. Cuiabá, 3 out. 2013a. Disponível em: <Disponível em: http://www.sindspenmt.com.br/noticia_ver.php?id=54 >. Acesso em: 12 jul. 2014.
http://www.sindspenmt.com.br/noticia_ver... ). The existence of a specific sector, along with the acquisition of the said benefit, is the recognition of the exposure and risks to the health of the worker in that environment.

Another advancement considered positive refers to the change initiatives in the training of health professionals to work, added to the elaboration of the respective specialty care protocols. If the technical expertise is the same required for service, it is not ignored that the approach and management of care are differentiated in the penitentiary context. In his study of the daily lives of health professionals, (Lopes, 2014LOPES, V. A. Experiência de profissionais de saúde em unidade prisionais em Cuiabá/MT. 2014. Dissertação (Mestrado em Saúde Coletiva) - Instituto de Saúde Coletiva da Universidade Federal de Mato Grosso, Cuiabá, 2014.) noted the offer of individual technical skills or in conjunction with other categories, which, given their very different functions, the professionals consider, in part, not suitable for the specificity of the service prison health, which makes them learn effectively in the exercise of their practice. Nevertheless, we note efforts to address them and also adapt them to the health service reality in that context, as shown in the excerpt:

Cooperation between the State Secretariats (Sejudh/MT and SES/MT) and district Secretariats is relevant for the optimization of resources and integration of professionals to the public network and training processes, and which is even foreseen in the PNSSP as a competence shared by the entities involved (Brazil, 2005BRASIL, Ministério da Saúde. Plano Nacional de Saúde no Sistema Penitenciário. 2. ed. Brasília, DF, 2005.). However, while operational, the expected cooperation shows nuances of improvisation, little articulated or little institutionally strengthened. We thus note:

The initiative of specific protocols to professional health categories, is positive and important to protect the autonomy of the professional within the legitimate and legal limits of the profession, such as the Nursing Manual of Standards and Routines (Mato Grosso, 2012MATO GROSSO. Secretaria de Estado de Saúde de Mato Grosso. Relatório de gestão: gerência de saúde do sistema penitenciário, Sejudh/MT. Cuiabá, 2012. Disponível em: <Disponível em: http://www.sejudh.mt.gov.br/saap2.php?IDCategoria=772 >. Acesso em: 16 jul. 2014.
http://www.sejudh.mt.gov.br/saap2.php?ID... ). We emphasize that the participation of unions and professional councils would be productive in this process, as well as the understanding of the Continuing Health Education linked to changes in professional practices.

Despite the drawbacks, and precisely because of the often unfavorable conditions, it is understood that health teams can work and make a difference in assistance to prisoners-including because it is a work with little outward visibility. Apparently, they can meet the needs in order to control the situation within what is sustainable in the midst of what we characterize, in another study, as performance that oscillates "between the necessary and possible care in the prison context" (Barsaglini et al., 2014BARSAGLINI, R. A.; ARRUDA, M. B.; LOPES, V. A. Saúde penitenciária: experiência de profissionais atuantes na atenção em unidades prisionais de Cuiabá/MT e na gestão das ações no nível central (SES-MT e SEJUDH-MT). Relatório de pesquisa/Capes. Instituto de Saúde Coletiva - Universidade Federal de Mato Grosso, 2015.). At times, for example, in the face of the increase in cases of tuberculosis¹⁴14The high incidence of tuberculosis is known in the penitentiaries, and the State of Mato Grosso is no exception to this trend, however, we question the motives of this increase reported, whether an active search, cases of coinfection, the concerns of political repercussions because the capital hosted a World Cup event in 2014. Anyway, it deserves specific analysis that is beyond the purpose of this research. in 2013 (Sindespen-MT, 2013bSINDESPEN-MT. Tuberculose: 10% dos pacientes em Mato Grosso são presos da Penitenciária Central do Estado. Sindicato dos Servidores Penitenciários do Estado de Mato Grosso. Cuiabá, 4 out. 2013b. Disponível em: <Disponível em: http://www.sindspenmt.com.br/noticia_ver.php?id=56 >. Acesso em: 12 jul. 2014.
http://www.sindspenmt.com.br/noticia_ver... ), the situation may get out of hand, expressing the fragility of the health service, as cited by a manager. The fact is that in such cases, not only does the health sector gain visibility, because of the threat posed to both the free population, local workers and others that pass through (professionals, visitors), in addition to the prisoners who every day receive their freedom and return to the open society; but also the reality of the prison which eventually comes up.

Finally, and not least, we ask managers their view of the Prison System and the population served/held, because we are in the perception plane, and we understand that this perception feeds on experience and is, in practice, is also guided by the dominant values of our society.

In this case, consideration about the prison population served by the health service, in the view of managers, brings the ambiguity with which the prisoners are seen different for disobeying the law, for disrupting the social order, but also equal to others regarding the right to health to be provided by the State.

The perception of the prisoner as a "client" suggests the use of a particular service provided and someone whom they must serve, in this case, even not being an ordinary person (but they should be "treat as if they were..."), which embeds their abnormality or slide-legal (and moral), for which they were already judged by the competent body (the justice system), not being the health sector competence to do it again. It is noteworthy that the penalty is deprivation of liberty, suggesting that upon entering the prison the person is subjected to other forms of punishment, material or symbolic (Silva, 2008SILVA, A. M. C. Nos braços da lei: o uso da violência negociada no interior das prisões. Rio de Janeiro: E+A, 2008.), but also, that their situation is temporary, for they will return to society as mentioned below.

The refraction that the prison creates does not seems to be only on SUS principles, as we have seen because the prisoner can go from defendant to victim in the intricacies of the institution. In fact, he will be subject both to the official standards and those governing intra and inter-cell relations imposing a new place (Smith, 2008; Coelho, 2005COELHO, E. C. Oficina do diabo e outros estudos sobre criminalidadeRio de Janeiro: Record, 2005.). Note, also, reference to treatment is as "humane", which implies that one should treat the prisoner as such, leading us to believe that that would be the usual treatment¹⁵15The situation of many penitentiaries and prisoners in Brazil is not known, they only comes up when "big" events happen such as the massacre of Carandiru, in 1992, coordinated rebellions in 2006 and recently the rebellion in Maranhão, in late 2013. In Mato Grosso, a local newspaper material provides clues as to how this situation might be in reporting the death of an inmate by overdose resulting from an allegedly forced ingestion of the "death drink" (alcoholic drink with cocaine) stating that "in the cell, there were more than forty prisoners and no one could explain what happened" (Rosa, 2014)..

The first report above on the goal of your work being to contribute to redeem, restore, re-socialize the prisoner and, accordingly, that he be treated "humanely" leads to the Corrective Penal School that, as stated by (Vay and Silva, 2012VAY, G. S.; SILVA, T. M. A escola correcionalista e o direito protetor dos criminosos. Revista LiberdadesSão Paulo, n. 11, p. 69-89, set./dez. 2012.), although weakened in our legislation is kept alive in the thoughts of attorneys, politicians, police and society in general. The idea that the prisoner can be cured/reformed, as if weak individual bearer of a social pathology, in need of assistance measures which might remedy this weakness is strengthened in the practice of health care in penitentiaries, understood as a right to be respected as stated by managers. Thus, inflicting more suffering, in addition to the deprivation of liberty, not meeting their health needs would be a mistake.

There is also information that the offender is a stranger, at least to the health sector. According to the current model of SUS guidelines, knowledge of an enrolled population allows to properly organize visits. However, it notes that the information produced on the prisoners by the government (quantitative, numerical), does not effectively meet the needs of the health sector. Increasing their knowledge of individuals in institutions is critical for the disciplinary power to be exercised and to regulate their conduct (Foucault, 1987FOUCAULT, M. Vigiar e punir: nascimento da prisão. 16. ed. Petrópolis: Vozes, 1987.). That's what this author has designated practice exam establishing homogeneity and does not allow to see the person, but only a contingent¹⁶16Compile and quantifying data of the prison population was the responsibility of the government, of the former Secretaria do Interior e Justiça of Mato Grosso since the 1970s. In 1971, an overall registration and classification of the inmates in public penitentiaries with data on the crime committed, sex, marital status, origin, color, profession, and age. Thus, "by discovering the individual traits of each prisoner, grouping them and turning them into statistics by homogenizing them, the police made of the prisoner an object of knowledge. At the same time created a criminal profile and the necessary individualization for the exercise of their power" (Arruda, 2010, p. 110)..

As for the perception of the prison institution, reports suggest who would be the inmate and little confidence in the possibilities of recovery, or redemption, although it exists to witness a few cases. When saying "redeem", a term that alludes to salvation and liberation, the question is whether it would be the release from prison or from a life of crime, seeming like the prisoner had been arrested and would possibly continue there... Structural social issues prior to incarceration, the unfavorable environment, coupled with high recurrence rates reported in other studies (Thompson, 1993THOMPSON, A. A questão penitenciária. 4. ed. Rio de Janeiro: Forense, 1993.; Torossian, 2012TOROSSIAN, M. S. Análise sobre a reincidência criminal na abordagem comportamental. Revista Eletrônica do CEAF, Porto Alegre, v. 1, n. 2, p. 01-07, 2012. Disponível em: <Disponível em: http://www.mprs.mp.br/areas/biblioteca/arquivos/revista/edicao_02/vol1no2art1.pdf >. Acesso em: 6 maio 2014.
http://www.mprs.mp.br/areas/biblioteca/a... ), support this perception:

In short, we can understand that human resources are essential to the effectiveness of programs and policies and it is assumed there is an interrelationship between the routine professionals practices of health and the economic, social and symbolic conditions of existence (Diuana et al., 2008DIUANA, V. et al. Saúde em prisões: representações e práticas dos agentes de segurança penitenciária no Rio de Janeiro. Cadernos de Saúde Pública, Rio de Janeiro, v. 24, n. 8, p. 1887-1896, 2008.).

Final remarks

The PNSSP and, recently, its proposal as policy, represented significant progress in attention to the prison population, however, its operation, although relevant, shows to be incipient in the State, in the perception of managers.

The concentration of management in Sejudh/MT, including with health professionals tied to it, and not to the SES/MT, suggests that the established partnership fulfills more bureaucratic than operational functions. Indeed, there is a predominance of autonomy in health management decisions by Sejudh/MT, and slight sharing with SES/MT in specific moments, such as when involving common issues in this dimension or in situations requiring specific health expertise for which the institution has legitimacy. It is understandable that the meeting of historically different institutions and individuals generates tension, but it can also promote institutional learning that supports the improvement of the process. Therefore, reflectivity is important and is not natural and should be urged by those involved and reinforced the formally agreed responsibility.

Thus, the managers point out to us the obstacles to the operation of PNSSP, but also advances, showing the non-passivity and creativity before these obstacles that can bring innovations to management. A point worth mentioning refers to inconsistencies in the values that govern one or the other sector where safety, discipline, and legal issues actually show tension with every citizen's right to health care, regardless of their social status. It seems that the prison context provides peculiarities to the assistance, which are reflected in management, because sometimes adjustments are made when facing differences, mobilizing the principle of equality, and sometimes they are compromised.

The health needs of prisoners that are not supplied internally require reference and find institutional barriers not only because of the organization of the services, but because of the discrimination barriers to the population served/held sometimes shrouded in technical and bureaucratic nuances, affecting, thus, the right to health. So what integrality would be possible? What promotion of health? This lack of synchronism may affect the management that should beware so that lack of care does not become the punishment.

The prison deals with deprivation of liberty of its prisoners, but sometimes it seems to extend to professionals (of both assistance and management), leaving to managers the dilemmas between the necessary care, possible care and the right to health of all citizens.

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