Abstract

The aim of this qualitative study was at evaluating the limitations of the Family Health Strategy (FSH) based on the daily work of its professionals. Individual semi-structured interviews were conducted with 16 professionals from the Family Health team of a municipality in the metropolitan region of Salvador, Bahia. Content analysis, as proposed by Bardin, and the references of the National Policy of Primary Care and the National Policy of Humanization for Primary Care were used. Two categories were identified: primary care (PC) of the Unified Health System (SUS), and co-management and humanization in PC. For the first category, the current context of the PC was emphasized, characterizing hardships present in the daily work of FHS professionals and the challenges in changing the health care model. For the second category, the concrete conditions wherein these practices take place in daily work were highlighted, going against humanization premises. The problems presented demonstrated lack of characterization in PC, contradicted the precepts of the FHS, and revealed challenges in the proposal for reorienting the health care model.

Keywords:
Primary Health Care; Family Health Strategy; Humanization of Assistance

Introduction

In Brazil, the traditional model focused on the private, hospital-centered, disease-based medical practice, with fragmentation and specialization of medicine, has been questioned by the Health Care Reform movement and has been changing (Costa et al., 2009COSTA, G. D. et al. Saúde da família: desafios no processo de reorientação do modelo assistencial. Revista Brasileira de Enfermagem, Brasília, DF, v. 62, n. 1, p. 113-118, 2009.; Scherer; Marino; Ramos, 2005SCHERER, M. D. A.; MARINO, S. R. A.; RAMOS, F. R. S. Rupturas e resoluções no modelo de atenção à saúde: reflexões sobre a estratégia saúde da família com base nas categorias kuhnianas. Interface: Comunicação, Saúde, Educação, São Paulo, v. 9, n. 16, p. 53-66, 2005.). The historical milestones were the 8th National Health Conference in 1986, when the creation of the Unified Health System (SUS) was approved.

The Family Health Strategy (FHS) was implemented in 1994 by the Ministry of Health, first as a program and, as of 2006, as a proposal for a change and reorientation of the health care model based on primary care - PC (Brazil, 2010BRASIL. Ministério da Saúde. Cadernos HumanizaSUS: atenção básica. Brasília, DF, 2010. v. 2. Disponível em: <Disponível em: https://bit.ly/2nlNo5T >. Acesso em: 7 fev. 2018.
https://bit.ly/2nlNo5T... , ²⁰¹²BRASIL. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília, DF, 2012.). Efforts and responsibilities are required by all levels of government to expand the FHS, offering greater assistance coverage to the population, seeking to improve health indicators, consolidate and qualify primary health care and transform its model. To reach this new paradigm, the FHS should be governed by the SUS principles, emphasizing actions to promote health and prevent diseases (Brazil, 2012BRASIL. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília, DF, 2012.).

HumanizaSUS, which pertains to the National Humanization Policy (PNH), seeks to put SUS principles into practice in the daily life of health services, changing the way management and caring is conducted. It consists of an ethical, political and aesthetic commitment of inclusion and communication between the three main SUS actors (workers, users and managers), so that they collectively act as co-responsible subjects in the care of themselves, the other, and the environment, with the aim to improve relations and processes.²2 BRASIL. Ministério da Saúde. Política Nacional de Humanização: HumanizaSUS. Brasília, DF, [s.d.]. Available at: <https://bit.ly/2NwlnGK>. Accessed on: 8 Jan. 2019. Created by the Ministry of Health in 2003, the PNH defines humanization in SUS as a strategy for the democratization of health management and practices. It is a cross-sectional policy and, therefore, it must also overcome rigid barriers, such as those found in different fields of knowledge, as is the case of the FHS multiprofessional team. It is, above all, an ethical proposal, since it involves the attitude of committed and co-responsible users, managers and health professionals. The PNH is an expanded policy insofar as it is concerned not only with the user, but also with health workers - that is, clinic and management at the micro and macro political level are inseparable (Brazil, 2010BRASIL. Ministério da Saúde. Cadernos HumanizaSUS: atenção básica. Brasília, DF, 2010. v. 2. Disponível em: <Disponível em: https://bit.ly/2nlNo5T >. Acesso em: 7 fev. 2018.
https://bit.ly/2nlNo5T... ).

The Basic Health Unit (BHU) should function as a gateway to SUS. The actions and services of the FHS happen within the territory assigned to the Family Health Unit (FHU), expanding and locating spatially and temporally the notion of the health-disease process, as well as enabling the bond between individuals (Brazil, 2010BRASIL. Ministério da Saúde. Cadernos HumanizaSUS: atenção básica. Brasília, DF, 2010. v. 2. Disponível em: <Disponível em: https://bit.ly/2nlNo5T >. Acesso em: 7 fev. 2018.
https://bit.ly/2nlNo5T... ). For the implementation of the strategy, a multiprofessional team is necessary, having at least a group constituted by doctor, nurse, auxiliary nurse or nursing technician, and community health agents. The team can be increased by adding a dental surgeon, oral health auxiliary and/or technician, among others, such as professionals of the Support Center for Family Health (Nasf), a nutritionist, psychologist, physiotherapist, physical educator, speech therapist and social worker (Brazil, 2010BRASIL. Ministério da Saúde. Cadernos HumanizaSUS: atenção básica. Brasília, DF, 2010. v. 2. Disponível em: <Disponível em: https://bit.ly/2nlNo5T >. Acesso em: 7 fev. 2018.
https://bit.ly/2nlNo5T... , ²⁰¹¹BRASIL. Ministério da Saúde. Portaria MS/GM nº 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS). Diário Oficial da União, Brasília, DF, 24 out. 2011. Disponível em: <Disponível em: https://bit.ly/2VA3ATz >. Acesso em: 10 set. 2015.
https://bit.ly/2VA3ATz... ).

Diversity during the work process in the context of the FHS is due to the fact that the work object of these professionals is the human being, whose health they seek to preserve or reconstitute, having as immaterial products the comfort, well-being and satisfaction of patients (Minayo-Gomez; Machado; Pena, 2011MINAYO-GOMES, C.; MACHADO, J. M. H.; PENA, P. G. L. (Org.). Saúde do trabalhador na sociedade brasileira contemporânea. Rio de Janeiro: Fiocruz, 2011.).

Discussing the dynamics of the FHS teams’ work process as to their organization, physical space, work and interprofessional relations contributes to the understanding of their potentialities and weaknesses (Buchele; Coelho, 2010BUCHELE, F.; COELHO, E. B. S. (Org.) A formação em saúde da família: uma estratégia na consolidação do SUS. Florianópolis: Editora UFSC, 2010.). To achieve the proposed objectives, the FHS requires a close personal relationship between the service user and health professionals, who should ideally reproduce this proximity to one another. In the case of teamwork, multiprofessional teams, by being closer to people, shift the focus from the individual to the family, in an attempt to guarantee the provision of integral health care with better resolution capability (Costa et al., 2009COSTA, G. D. et al. Saúde da família: desafios no processo de reorientação do modelo assistencial. Revista Brasileira de Enfermagem, Brasília, DF, v. 62, n. 1, p. 113-118, 2009.). The teamwork developed by the various FHS professionals should take place in an interprofessional manner. Interprofessionality, here, should be understood as the performance of different professionals, with individual authority and respective codes of ethics and professional cultures, interacting in common areas wherein everyone has knowledge, regardless of specialty - involving knowledge integration and interprofessional collaboration (Ellery, 2012ELLERY, A. E. L. Interprofissionalidade na Estratégia Saúde da Família: condições de possibilidade para a integração de saberes e a colaboração interprofissional. 2012. Tese (Doutorado em Saúde Coletiva) - Universidade Federal do Ceará, Fortaleza, 2012.).

Understanding the actions of health workers and the limitations in the work process of FHS professionals from the perspective of the National Policy of Primary Care can contribute to remodeling the current care model of PC in SUS.

This study aims at evaluating the limitations of the FHS based on the daily work of its professionals.

Methodology

This study has a qualitative and descriptive nature and is aimed at the construction of meanings. With this approach, we sought to understand what certain experienced situations and daily individual experiences and meanings represent, and how they shape the individual or a group of individuals (Turato, 2005TURATO, E. R. Métodos qualitativos e quantitativos na área da saúde: definições, diferenças e seus objetos de pesquisa. Revista de Saúde Pública, São Paulo, v. 39, n. 3, p. 507-514, 2005.).

This study was conducted from February to October 2015, in a FHU located in a municipality of the metropolitan region of Salvador, Bahia, with a sample of 16 professionals working in the two FHS teams at that unit.

We included professionals who worked in this service for at least six months, in any of the teams or Nasf, regardless of employment, sex and age.

For data collection, semi-structured interviews were conducted with semi-structured script, with a nurse, a doctor, two nursing technicians, a receptionist, a psychologist, a social worker, a nutritionist, a dentist, an unit manager and six community agents, of which five women and one man. Their speeches were recorded and later fully transcribed (Rosa; Arnoldi, 2008ROSA, M. V. F. P. C.; ARNOLDI, M. A. G. C. A entrevista na pesquisa qualitativa: mecanismos para validação dos resultados. Belo Horizonte: Autêntica, 2008.). There was no need to increase the number of teams surveyed to achieve theoretical saturation of the data (Fontanella et al., 2008FONTANELLA, B. J. B. et al. Amostragem por saturação em pesquisas qualitativas em saúde: contribuições teóricas. Cadernos de Saúde Pública, Rio de Janeiro, v. 24, n. 1, p. 17-27, 2008.).

Considering the different professional perspectives of the subjects, the objective was to capture how they understood and interpreted the symbolic universe in which they were immersed, as well as to identify the personal values that brought them meanings amidst the socially constructed context of the FHS. Recording was facilitated by the field observation, with fieldwork diary notes on the actions developed during the daily work of FHS professionals, as well as the interactions and relationships that occurred throughout the teamwork. According to Morin (2013MORIN, E. Ciência com consciência. 15. ed. Rio de Janeiro: Bertrand Brasil, 2013.), in order to understand what is sought, one must look at both the parts and the whole.

The content analysis method was used for the treatment and examination of the material generated by the interviews. One may define it as a set of communication analysis techniques that, through the use of systematic procedures and objectives to describe the content of messages, is able to allow the inference of knowledge related to the production of these messages (Bardin, 2009BARDIN, L. Análise de conteúdo. Lisboa: Edições 70, 2009.). Thematic category analysis covered three different phases, ranging from pre-analysis, material exploration and treatment of results, to interpretation and inference. The information contained in the messages was treated in such a way as to allow us to see beyond what was heard or read, working with vestiges, significants and signifiers behind the words, which gave rise to these categories (Bardin, 2009).

For each analysis category, subcategories emerged that contributed to a better understanding of the object of study.

To improve on this analysis, this research was grounded on the National Policy of Humanization (Brazil, 2010BRASIL. Ministério da Saúde. Cadernos HumanizaSUS: atenção básica. Brasília, DF, 2010. v. 2. Disponível em: <Disponível em: https://bit.ly/2nlNo5T >. Acesso em: 7 fev. 2018.
https://bit.ly/2nlNo5T... )³3 BRASIL. Ministério da Saúde. Política Nacional de Humanização: HumanizaSUS. Brasília, DF, [s.d.]. Available at: <https://bit.ly/2NwlnGK>. Accessed on: 8 Jan. 2019. and in the National Policy of Primary Care (Brazil, 2011BRASIL. Ministério da Saúde. Portaria MS/GM nº 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS). Diário Oficial da União, Brasília, DF, 24 out. 2011. Disponível em: <Disponível em: https://bit.ly/2VA3ATz >. Acesso em: 10 set. 2015.
https://bit.ly/2VA3ATz... , ²⁰¹⁷BRASIL. Ministério da Saúde. Portaria MS/GM 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, Brasília, DF, 22 set. 2017. Disponível em: <Disponível em: https://bit.ly/2DdWcaE >. Acesso em: 13 dez. 2017.
https://bit.ly/2DdWcaE... ). It should be noted that these narratives were collected during the period in which the Ordinance No. 2,488/2011 that approved this latter policy was in force (Brazil, 2011BRASIL. Ministério da Saúde. Portaria MS/GM nº 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS). Diário Oficial da União, Brasília, DF, 24 out. 2011. Disponível em: <Disponível em: https://bit.ly/2VA3ATz >. Acesso em: 10 set. 2015.
https://bit.ly/2VA3ATz... ).

This study was approved by the Research Ethics Committee of the Faculdade de Medicina of Bahia, Opinion No. 693,112, dated June 21, 2014. To ensure anonymity, fictitious names were given to the survey participants.

Results and discussion

After treatment and analysis of the interview speeches, two thematic units emerged as categories of analysis, “SUS primary care” and “Co-management and humanization in primary care”. Based on these thematic units, the following subcategories emerged (Bardin, 2009BARDIN, L. Análise de conteúdo. Lisboa: Edições 70, 2009.).

SUS primary care

The narratives of the various professionals give their own meanings to the work that is developed in the FHS. Insertion in the PC of SUS and perceptions on the performance and limitations of the strategy are expressed in the field of action, during daily work. It is possible to note the tripod of accountability, in which the other always is the one responsible. Patients hold managers accountable; these hold professionals accountable, who, in turn, hold patients accountable. The patient blames the manager for mismanagement, for failing to meet his constitutional right to health; the manager blames professionals for lack of commitment to work and/or inefficient work process; it remains for professionals to hold patients accountable for the lack of popular participation and for not being autonomous agents and modifiers of their own health.

The insertion and meanings of working in SUS

The speeches reflect what is being done at SUS - a SUS that seems to be made “for the poor”, under a “charity” or “volunteer” bias. These professionals are situated within this space and remain without consciously perceiving it. It should be noted that only one professional interviewed had sanitarist training.

Vanessa expresses the condition of “submission” to which patients must subject themselves in case the “motivations required” are not provided. She does not consider the sharing and exchange that must be experienced in the relationship between professional and patient.

Robson and Michele portray what they consider as the advantages offered in this public service, since, once working full time, the professional can enjoy the “tranquility and safety of work”, that is, of the stability that guarantees them “to make something and to make things happen”.

The literature records the erroneous idea that PC is related to the simple, minimum supply of actions aimed at an excluded and vulnerable part of the population without access to market medicine (Brazil, 2010BRASIL. Ministério da Saúde. Cadernos HumanizaSUS: atenção básica. Brasília, DF, 2010. v. 2. Disponível em: <Disponível em: https://bit.ly/2nlNo5T >. Acesso em: 7 fev. 2018.
https://bit.ly/2nlNo5T... ).

Costa (2016COSTA, N. R. The Family Health Strategy: primary health care and the challenge of Brazilian metropolises. Ciência e Saúde Coletiva, Rio de Janeiro, v. 21, n. 5, p. 1389-1398, 2016.) corroborates this idea when he proposes that the expansion of FHS coverage in municipalities is proportional to the prevalence of poverty in its population, which makes it difficult to develop and improve the FHS. In practice, this idea was assimilated by health managers, users of the service and, above all, health professionals who carry speeches such as Helen, who says: I really like this closer relationship with the community and I think they are extremely in need (Helen-Doctor).

The foundational text of the National Humanization Policy for Primary Care seeks to demystify the idea of the professional in the public service as a charitable, religious being with philanthropic attitudes that reveal goodness - someone who is doing a “favor” in performing this service for a community in need, reinforcing a submission relationship, making it difficult, if not impossible, to further develop citizenship and the right to health (Brazil, 2010BRASIL. Ministério da Saúde. Cadernos HumanizaSUS: atenção básica. Brasília, DF, 2010. v. 2. Disponível em: <Disponível em: https://bit.ly/2nlNo5T >. Acesso em: 7 fev. 2018.
https://bit.ly/2nlNo5T... ).

Perception of health professionals on the performance and limitations of the Family Health Strategy

According to the National Policy of Primary Care, the FHS should be able to solve most of the population’s health problems (Brazil, 2011BRASIL. Ministério da Saúde. Portaria MS/GM nº 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS). Diário Oficial da União, Brasília, DF, 24 out. 2011. Disponível em: <Disponível em: https://bit.ly/2VA3ATz >. Acesso em: 10 set. 2015.
https://bit.ly/2VA3ATz... ). In these narratives, there is the limitation of macro-political performance of the FHS when professionals describe the increase of chronic diseases in the general population, the difficulty of articulation with other levels of care, the acquisition of medications, and the academic training still below curricular changes.

Some issues limit the effectiveness and perfection of the FHS, such as the organization of the work process in a unique format for the whole country and all teams, disregarding in part the local differences and the management of spontaneous demand (Malta; Santos, 2003MALTA, D. C.; SANTOS, F. P. O programa de saúde da família (PSF) e os modelos de assistência à saúde no âmbito da reforma sanitária brasileira. Revista Médica de Minas Gerais, Belo Horizonte, v. 13, n. 4, p. 251-259, 2003.).

The overload of work caused by high demand, especially curative, prevents the accomplishment of educational activities and health promotion, something that appears in the speech of nurse Camila:

This finding coincides with the reality of the study by Trad and Rocha (2011TRAD, L. A. B.; ROCHA, A. A. R. N. Condições e processo de trabalho no cotidiano do Programa Saúde da Família: coerência com princípios da humanização em saúde. Ciência e Saúde Coletiva, Rio de Janeiro, v. 16, n. 3, p. 1969-1980, 2011.), in which work overload was shown to limit educational activities and, consequently, the consolidation of a new health care model based on health promotion.

The idea that intervention of the professional in the family environment is capable of changing the hygiene profile of the population, in an attempt to change the patient habits (Malta; Santos, 2003MALTA, D. C.; SANTOS, F. P. O programa de saúde da família (PSF) e os modelos de assistência à saúde no âmbito da reforma sanitária brasileira. Revista Médica de Minas Gerais, Belo Horizonte, v. 13, n. 4, p. 251-259, 2003.), appears in the imaginary of the respondents, as described by this community agent:

The attitude of the health agent is like a subtle confrontation that imposes other bio-social values. That is, the agent has an interpretation and this gives meaning to their experiences with the residents of the neighborhood on the same surrounding reality. The sociocultural dimension is depicted in the interaction between the community agent and people, enabling shared meaning in its plurality. In this process, one observes the force of dialogue or inter-subjectivity as a result of the agent’s work, in which subject and object are not separate. Singularity in each case and plurality in the community are related dimensions, as if individual and society were permanently intertwined.

The narratives below show some of the problems of ineffective management, such as the turnover of professionals, which limits the performance of the FHS.

These speeches are examples of the turnover problem, which sometimes seems contradictory, since the FHU studied was distinguished by the long permanence of doctors - which, since they got the job per bidding, had already been working for more than seven years in both teams of the unit.

Obstacles to current family health practice

Although not included in the interview script, the term “outpatient care” emerged in the speech of most professionals investigated and allowed to proceed with other interpretations. Professionals who have been working on family health for six years have portrayed a past that differed greatly from the current context. The proposal of a “comprehensive and expanded view”, due to its ties to operationalization, has been replaced by a schedule full of prescriptive consultations; they use the expression “outpatient care” to refer to this. Angélica, a community agent, signifies her work as she says:

The expression “outpatient care” was emphatically used by Nasf professionals. Although they recognize the support matrix as a methodological proposal to develop interdisciplinary work in health, they cannot act using this logic, often feeling compelled to return to the previous individual care, which they call outpatient care.

Natália’s narrative thus reaffirms what the PNH discusses about PC not fitting biomedical logic, focused on curative/care assistance, where the individual exposes their complaint and merely expects the prescribed medication (Brazil, 2010BRASIL. Ministério da Saúde. Cadernos HumanizaSUS: atenção básica. Brasília, DF, 2010. v. 2. Disponível em: <Disponível em: https://bit.ly/2nlNo5T >. Acesso em: 7 fev. 2018.
https://bit.ly/2nlNo5T... ).

For Angélica, who has been working for 16 years at the FHS, the current training does not change anything:

She speaks and interprets the words she listens to in the same scene of the worldly relationship in which she is immersed. Thus, the professional speaks of herself and of what she experiences, seeking to explain and understand, because the professional accepts what makes sense to support their own experience in the midst of the difficulties they report and perceive. For her, the current information is insufficient to continue the explanatory health model.

One of the main bottlenecks that have culminated in retrogression for the implementation of FHS is the transfer of the classic biomedical model to PC, reflecting a new practice that is at the same time in crisis and under construction (Junges et al., 2009JUNGES, J. R. et al. Processos de trabalho no Programa Saúde da Família: atravessamentos e transversalidades. Revista da Escola de Enfermagem, São Paulo, v. 43, n. 4, p. 937-944, 2009.; Trad; Rocha, 2011TRAD, L. A. B.; ROCHA, A. A. R. N. Condições e processo de trabalho no cotidiano do Programa Saúde da Família: coerência com princípios da humanização em saúde. Ciência e Saúde Coletiva, Rio de Janeiro, v. 16, n. 3, p. 1969-1980, 2011.).

What if I could choose?

The professionals demonstrated little credibility in the FHS. When questioned, there were doubts as to the choice of building more health units with the strategy or of a hospital in the municipality, which reinforces the idea and valuation of the hospital-centered model.

Andrade et al. (2018ANDRADE, M. V. et al. Transition to universal primary health care coverage in Brazil: analysis of uptake and expansion patterns of Brazil’s Family Health Strategy (1998-2012). PLoS One, San Francisco, v. 13, n. 8, 2018.) shows practical evidence on the expansion of the FHS during the consolidation of PC. They emphasize the magnitude of this expansion in a country with inequalities, where often, in small municipalities, the provision of primary services constitutes the majority, if not the only way to have access to health.

Even when opting for the strategy, this was based on a possibility: So I think if there were more units in the municipality there would be more doctors in the municipality (Robson-CHA).

Priscila’s speech is the only one that reflects an academic training consistent with the model established for the FHS operation.

The narratives transcribed reveal how fragile such a change has been in practice, despite all efforts in an attempt to reorient health care models. It is understood by health model “the organization of service production based on a certain arrangement of knowledge from an area, as well as specific social action projects, such as political strategies of certain social groups” (Merhy; Cecílio; Nogueira, 1992MERHY, E. E.; CECÍLIO, L. C. O.; NOGUEIRA, R. C. Por um modelo tecno-assistencial da política de saúde em defesa da vida: contribuição para as conferências de saúde. In: CONFERÊNCIA NACIONAL DE SAÚDE, 9., 1992, Brasília. Cadernos… Brasília, DF: Universidade de Brasília, 1992. v. 1. p. 91-97., p. 91). These professionals reproduce their daily actions, strongly focused on physicians and hospitals and on the disease, in detriment to the determinants of health and the collective (Faria et al., 2010FARIA, H. P. et al. Modelo assistencial e atenção básica à saúde. 2. ed. Belo Horizonte: Núcleo de Educação em Saúde Coletiva, 2010.). It has been notably challenging the proposal of the FHS to incorporate biomedical issues and involve them in a new model of health care that seeks to share professional knowledge, strengthening SUS and transforming the health system (Malta; Santos, 2003MALTA, D. C.; SANTOS, F. P. O programa de saúde da família (PSF) e os modelos de assistência à saúde no âmbito da reforma sanitária brasileira. Revista Médica de Minas Gerais, Belo Horizonte, v. 13, n. 4, p. 251-259, 2003.).

Professional identities versus exchange of professional category roles

The narratives highlight the role played by professionals in the context of the FHS when they are “lost” within the limits defined by their codes of ethics and professional performance.

The community agent Vanessa refers to difficulties in performing her duties because she takes other duties as well, not belonging to her category. Helen fills the reference role doctor that should be developed by the coordinator/manager of the unit. Michele, on the other hand, abdicates from her coordinator role to the detriment of a favoritism regime and ends up selecting and prioritizing patients, contrary to the accessibility and universality proposed by SUS.

There is a lack of clarity, regardless of the level of schooling, as to the tasks and the role that must be played by the various professionals. Another study has pointed out that, in the multiprofessional work of the FHS, the identity of the subjects is not as clear as in other health services (Silva et al., 2006SILVA, L. T. et al. Bioética e atenção básica: um estudo exploratório dos problemas éticos vividos por enfermeiros e médicos no PSF. Cogitare Enfermagem, Curitiba, v. 11, n. 2, p. 133-142, 2006.). The profession of community health agents (CHA) remains without ethical guidelines, since its code of professional ethics is still in the works. Although their attributions are well-defined and described in the National Policy of Primary Care (Brazil, 2011BRASIL. Ministério da Saúde. Portaria MS/GM nº 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS). Diário Oficial da União, Brasília, DF, 24 out. 2011. Disponível em: <Disponível em: https://bit.ly/2VA3ATz >. Acesso em: 10 set. 2015.
https://bit.ly/2VA3ATz... ), the CHA ends up experiencing a dichotomous praxis between the conduct adopted in the accomplishment of the work in these families and the preconization of the law, between having knowledge and knowing how to do it (Siqueira-Batista et al., 2015SIQUEIRA-BATISTA, R. et al. (Bio)ética e Estratégia Saúde da Família: mapeando problemas. Saúde e Sociedade, São Paulo, v. 24, n. 1, p. 113-128, 2015.; Vidal et al., 2015VIDAL, S. V. et al. Agentes comunitários de saúde: aspectos bioéticos e legais do trabalho vivo. Saúde e Sociedade, São Paulo, v. 24, n. 1, p. 129-140, 2015.).

There are many difficulties found by the CHA in their daily work, such as the attitude of some of these professionals to privilege access to people close to or related to the BHU, their lack of previous training, and the devaluation of their knowledge (Siqueira-Batista et al., 2015SIQUEIRA-BATISTA, R. et al. (Bio)ética e Estratégia Saúde da Família: mapeando problemas. Saúde e Sociedade, São Paulo, v. 24, n. 1, p. 113-128, 2015.).

In the narrative below, a community health agent, without any other professional training, feels hurt because he is no longer allowed, as he was in the past, to carry out the blood pressure measurement of users under his responsibility. Although, for him, weighing a child is important, he wants to do it at the user’s residence and not within the health unit, in the Bolsa-Família Program. He wants to offer something more than is prescribed; his discourse and daily practice shows itself as an antagonistic action subject to disorder, interfering in the quality of care offered.

It is noteworthy that the narratives, although divergent with the Primary Care Act of 2011, find subsidies in the new ordinance of 2017. According to this, the CHA is allowed to “perform other duties attributed to them by specific legislation of the category, or other regulations established by the federal, municipal or Federal District administrator” (Brazil, 2017BRASIL. Ministério da Saúde. Portaria MS/GM 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, Brasília, DF, 22 set. 2017. Disponível em: <Disponível em: https://bit.ly/2DdWcaE >. Acesso em: 13 dez. 2017.
https://bit.ly/2DdWcaE... ). This has caused discussion and the fragilization of the work process for FHS professionals.

The program Bolsa-Família, instituted by Law No. 10,836 of January 9, 2004, and regulated by Decree No. 5,209 of September 17, 2004, aims at serving poor and extremely poor families in the provision of basic actions (health, education and social assistance). For such, beneficiary families should be assisted by an FHS (Brazil, 2015BRASIL. Ministério do Desenvolvimento Social e Combate à Fome. Manual de gestão do Bolsa-Família. 2. ed. Brasília, DF, 2015.).

Robson, in saying that he “lends his ear,” refers to qualified listening and reception that is offered by the health professional, regardless of his professional category; this indicates bond and the strengthening of the relationship between professional and user.

The respondents get confused in the borderline between care completeness and the co-responsibility of care, with “hard work” that does not end after the consultation or application of a vaccine, ultimately assuming responsibilities that go beyond what is prescribed:

Co-management and humanization in primary care

Things here don’t go forward: the inadequacy of physical work space

All speeches were unanimous in denouncing the inadequate physical structure of the health unit in which the respondents work, having an insufficient number of offices, absence of room for procedures such as nebulization or application of injectable drugs (these are performed in the vaccine room) and lack of privacy due to partitions between offices - instead of masonry walls -, among others. Physical space was considered the biggest obstacle in the interviews.

Other studies have already mentioned that facility precariousness negatively affects the performance of activities recommended by the FHS, dehumanizing work and health care (Nora; Junges, 2013NORA, C. R. D.; JUNGES, J. R. Política de humanização na atenção básica: revisão sistemática. Revista de Saúde Pública, São Paulo, v. 47, n. 6, p. 1186-1200, 2013.; Trad; Rocha, 2011TRAD, L. A. B.; ROCHA, A. A. R. N. Condições e processo de trabalho no cotidiano do Programa Saúde da Família: coerência com princípios da humanização em saúde. Ciência e Saúde Coletiva, Rio de Janeiro, v. 16, n. 3, p. 1969-1980, 2011.).

The ambiance, seen as an improvement in working conditions and servicing, is one of the guidelines proposed by HumanizaSUS: “to create healthy, welcoming and comfortable spaces that respect privacy, that allow for changes in the work process and are spaces for people to meet”.⁴4 BRASIL. Ministério da Saúde. Política Nacional de Humanização: HumanizaSUS. Brasília, DF, [s.d.]. Available at: <https://bit.ly/2NwlnGK>. Accessed on: 8 Jan. 2019. The problems related to ambiance, as previously pointed out in the literature (Nora; Junges, 2013NORA, C. R. D.; JUNGES, J. R. Política de humanização na atenção básica: revisão sistemática. Revista de Saúde Pública, São Paulo, v. 47, n. 6, p. 1186-1200, 2013.), compromise the entire work process in the FHS since they cause demotivation in professionals and managers, as well as discomfort to users, especially regarding lack of privacy. Because of the very structure of the center itself, right. […] Because if you speak too loud, whoever is in the other office can listen. So, for that matter, there are patients who end up talking about the discomfort they have with this. (Cléo-CHA)

The absence of a nebulizer appeared in the speeches, which is contrary to the one proposed in the manual of physical structure for family health units (Brazil, 2008BRASIL. Ministério da Saúde. Secretaria de Atenção à Saúde. Manual de estrutura física das unidades básicas de saúde: saúde da família. Brasília, DF: Departamento de Atenção Básica, 2008.).

The respondents’ discourse on the concrete conditions in which they perform their daily work practices denounces the lack of rooms for performing health education, as well as for the application of medicine such as benzetacil and team meetings; there is poor harmony between the work process and the premises of humanization. Home visits, team meetings and health education were being left in the background, to the detriment of an schedule full of consultations that were set for a single day of the week, generating long queues.

Camila, with a controversial discourse, explains the lack of medication as due to the great user demand, an aspect also pointed out in other studies (Nora; Junges, 2013NORA, C. R. D.; JUNGES, J. R. Política de humanização na atenção básica: revisão sistemática. Revista de Saúde Pública, São Paulo, v. 47, n. 6, p. 1186-1200, 2013.; Trad; Rocha, 2011TRAD, L. A. B.; ROCHA, A. A. R. N. Condições e processo de trabalho no cotidiano do Programa Saúde da Família: coerência com princípios da humanização em saúde. Ciência e Saúde Coletiva, Rio de Janeiro, v. 16, n. 3, p. 1969-1980, 2011.). The use of diminutives expresses a perception that minimizes the violation of the constitutional right to health.

Angélica points out the various difficulties that distanced her everyday work from the principles of humanization in health and, in a highly sensible manner, speaks of the “weight” to be able to move on:

The major challenge of the SUS is political since none of the governments, after the sanitary reform, compromised to SUS in accordance with what was established in the Constitution, given the underfinancing of the public system - suggesting a not very optimistic scenario for its sustainability (Paim, 2013PAIM, J. S. A Constituição Cidadã e os 25 anos do Sistema Único de Saúde (SUS). Cadernos de Saúde Pública, Rio de Janeiro, v. 29, n. 10, p. 1927-1953, 2013.).

Doniec et al. (2018DONIEC, K. et al. Brazil’s health catastrophe in the making. The Lancet, London, v. 392, n. 10.149, p. 731-732, 2018.) point out the likely practical consequences of Constitutional Amendment No. 95/2016, with a lack of investment in strategic areas of health care (Brazil, 2016BRASIL. Presidência da República. Emenda Constitucional nº 95, de 15 de dezembro de 2016. Altera o Ato das Disposições Constitucionais Transitórias, para instituir o Novo Regime Fiscal, e dá outras providências. Diário Oficial da União, Brasília, DF, 15 dez. 2016. Disponível em: <Disponível em: https://bit.ly/2lGL90C >. Acesso em: 12 nov. 2018.
https://bit.ly/2lGL90C... ). The SUS, which is still under construction, is also in a state of crisis and regression, revealed by the increase in social inequalities, the strengthening of the private sector and the reduction in the quality of public services.

On the National Humanization Policy (PNH)

When questioned about the PNH, it was possible to observe a lack of knowledge on the part of most professionals. Even those who claim to know politics, under a reductionist view of the scope of guidelines and actions, refer to it only in the context of welcoming.

In the aforementioned perceptions, HumanizaSUS is reduced to the reception practiced in an incipient way since it obeys a token distribution format. This is still performed without a pre-established parameter, disregarding all professionals involved in health care, which is opposed to the concept defined by the PNH. For such,⁵5 BRASIL. Ministério da Saúde. Política Nacional de Humanização: HumanizaSUS. Brasília, DF, [s.d.]. Available at: <https://bit.ly/2NwlnGK>. Accessed on: 8 Jan. 2019. this welcoming must be collective, recognizing what the other has to offer as a legitimate and unique need for health through qualified listening, giving priorities based on the evaluation of vulnerability, severity, and risk, building a relationship of trust, commitment and bond between teams and services, the worker and the teams, and the patient with his/her social network.

A recent review study pointed out an operational complication in the organization of services, with harm to the welcoming and integrity of care-work (Barbosa et al., 2013BARBOSA, G. C. et al. Política Nacional de Humanização e formação dos profissionais de saúde: revisão integrativa. Revista Brasileira de Enfermagem, Brasília, DF, v. 66, n. 1, p. 123-127, 2013.). Thus, in order to implement the PNH, it becomes imperative that workers be able to transpose and produce new ways of shaping their work.

An illness without treatment: the barriers of referral and counter-referral

These narratives reveal the reality of counter-referral within the PC context and characterize it as an obstacle towards humanized care. Robson summarizes: There is no counter-referral. There may even be a referral, but it does not return (Robson-CHA).

The absence of an effective system for referral and counter-referral to other levels of assistance, especially regarding specialized examinations and/or consultations, was already pointed out by other authors (Nora; Junges, 2013NORA, C. R. D.; JUNGES, J. R. Política de humanização na atenção básica: revisão sistemática. Revista de Saúde Pública, São Paulo, v. 47, n. 6, p. 1186-1200, 2013.; Trad; Rocha, 2011TRAD, L. A. B.; ROCHA, A. A. R. N. Condições e processo de trabalho no cotidiano do Programa Saúde da Família: coerência com princípios da humanização em saúde. Ciência e Saúde Coletiva, Rio de Janeiro, v. 16, n. 3, p. 1969-1980, 2011.).

Final considerations

This study identified the pains and joys of working in SUS and the obstacles to developing health actions in PC. According to the professionals interviewed, despite being the main entrance door to the health system, the current FHS experiences difficulties and limitations with regard to changing the health model. The stories narrated by these professionals show that, although they pointed out their activity in daily health practices, they are lost in the midst of an infinity of attributions and reinforce the limitations faced in order to carry out their actions. For these professionals, the FHS that is currently being performed decharacterizes PC and is no more than outpatient care with previously scheduled appointments. The performance of the professionals that develop the FHS still does not fully reach what is recommended for humanization in health as the guiding principle of PC. The care provided at the health center analyzed still meets the biomedical model and has been distancing itself from the FHS proposal. It is necessary that the professionals of the FHS recognize their work in health and remodel their practices in order to contribute to the effective transformation of health care models and management of SUS services.

References

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