Abstract

The article aims to identify and analyze the institutionalization of Health Surveillance actions in a municipality in the metropolitan region of Porto Alegre, Rio Grande do Sul, Brazil, aiming to perceive its instituted and instituting dimensions, as well as to characterize the logic of this Surveillance’s performance. The theoretical-methodological framework used was Institutional Analysis, in the socio-analytical aspect. The research was carried out in two moments, using participant observation, group meetings with the workers’ collective and the diary of the first author as a tool for collecting information. As a result, the following emerged: the institutionalization of surveillance - due to the analyzer “identification of all surveillance with health surveillance”; the relevance of networking - from specific situations; and the fragility of the worker health surveillance, bearing in mind the analyzer for the invisibility of this surveillance in the system. Educational actions were observed - especially at health surveillance - instituting processes; partnership between health surveillance and primary healthcare and between the different surveillances. Finally, it was realized that in intersectoral actions it is important to bear in mind the cultural, historical and functional differences of the different sectors involved.

Keywords:
Institutional Analysis; Health Surveillance; Work Process; Integrality in Health

Introduction

The public health surveillance (VS) actions are part of the essential Brazilian National Health System (SUS) functions as a public policy, holding a universal, transversal and advisory character of the healthcare model in the territories. The VS is responsible for, in a continuous and systematic manner, collecting and disclosing data concerning health events, aiming to plan and implement public health measures identified to the regulation, intervention and acting on health conditions and determinants (Brasil, 2018BRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Resolução nº 588, de 12 de julho de 2018. Institui a Política Nacional de Vigilância em Saúde. Diário Oficial da União, Brasília DF, 13 ago. 2018. Disponível em: Disponível em: https://bit.ly/2IMewMa . Acesso em: 20 jul. 2018.
https://bit.ly/2IMewMa... ).

We may emphasize that the morbidity and mortality profile per communicable diseases in Brazil suffered an impact, especially post the implementation of the SUS. According to Teixeira et al. (2018aTEIXEIRA, M. G. et al. Conquistas do SUS no enfrentamento das doenças transmissíveis. Ciência & Saúde Coletiva, Rio de Janeiro, v. 23, n. 6, p. 1819-1828, 2018a., p. 1827), the universal access to healthcare services associated to the enlargement and enhancement of the “scope of surveillance, prevention, and disease and risk management actions by the SUS has a fundamental role in the improvement of health conditions and quality of life in the Brazilian population.” The morbidity from vaccine-preventable diseases and proportional mortality from communicable diseases reduced, from 12% of the total deaths in the country in 1980 to 4% in 2015 (Teixeira et al., 2018aTEIXEIRA, M. G. et al. Conquistas do SUS no enfrentamento das doenças transmissíveis. Ciência & Saúde Coletiva, Rio de Janeiro, v. 23, n. 6, p. 1819-1828, 2018a.).

The VS focus is evolving from the surveillance of individuals to the surveillance of diseases and, as of now, to health hazards (Teixeira et al., 2018bTEIXEIRA, M. G. et al. Vigilância em saúde no SUS: construção, efeitos e perspectivas. Ciência & Saúde Coletiva, Rio de Janeiro, v. 23, n. 6, p. 1811-1818, 2018b.). In this sense, Santos argues that the sector is being defied to establish a “healthcare model towards the reduction of disease risk and other aggravations, in which the promotion, protection and the prevention occupy the same place and are granted the same relevance as recovery and care” (Santos, 2017SANTOS, R. F. Vigilância em saúde: direito social à promoção e proteção da saúde. Ciência & Saúde Coletiva, Rio de Janeiro, v. 22, n. 10, p. 3134, 2017., p. 3134).

Under this risk reduction and health promotion approach, the surveillance has to focus on the territory and work in an integrated manner. Such action requires a dialogue among the epidemiological surveillance (VE), s public health surveillance (Visa), environmental health monitoring (VAS), and worker’s health surveillance (VST). However, all surveillances had different organizational and historical processes, hindering their integration (Garcia; L’Abbate, 2015GARCIA, R. A.; L’ABBATE, S. Institucionalização da vigilância em saúde de Campinas (SP) na perspectiva da análise institucional sócio-histórica. Saúde e Debate, Rio de Janeiro, v. 39, n. 107, p. 997-1007, 2015.). Additionally, the “institutionalization of the work processes was built with specific technologies, objects and agents” (Garcia; L’Abbate, 2015GARCIA, R. A.; L’ABBATE, S. Institucionalização da vigilância em saúde de Campinas (SP) na perspectiva da análise institucional sócio-histórica. Saúde e Debate, Rio de Janeiro, v. 39, n. 107, p. 997-1007, 2015., p. 998), causing each surveillance to have their own characteristics. However, in spite of these organizational and historical differences, these institutions received encouragement to work in an integrated manner.

Due to their transversal character, their actions need to be intra- and multi-sectors. They must be in all instances and points of the Healthcare Network and participate in the articulation and construction of protocol, standard care and health matrix, as well as the in setting of strategies and organization and flow devices (Brasil, 2018BRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Resolução nº 588, de 12 de julho de 2018. Institui a Política Nacional de Vigilância em Saúde. Diário Oficial da União, Brasília DF, 13 ago. 2018. Disponível em: Disponível em: https://bit.ly/2IMewMa . Acesso em: 20 jul. 2018.
https://bit.ly/2IMewMa... ).

The work in the territory demands professionals to have a sharp view “about the health situation of the populations, in a manner to comprehend health, disease and care as inseparable manifestations of the human nature” (Fernandes et al., 2017FERNANDES, V. R. et al. O lugar da vigilância no SUS: entre os saberes e as práticas de mobilização social. Ciência & Saúde Coletiva, Rio de Janeiro, v. 22, n. 10, p. 3173-3181, 2017., p. 3173). Consequently, the relation of healthcare workers to the users has to change, by the replacement of prescriptive actions for horizontal ones. Fernandes et al. (2017FERNANDES, V. R. et al. O lugar da vigilância no SUS: entre os saberes e as práticas de mobilização social. Ciência & Saúde Coletiva, Rio de Janeiro, v. 22, n. 10, p. 3173-3181, 2017., p. 3173) identified that the communication processes of these professionals were “marked by a professional-centered logic, favoring the scientist, vertical and authoritarian discourse, predominant in the spaces inside the Brazilian National Health System.”

The relations to the community must favor the dialogue, with the goal of bringing professionals closer to that collective subject, making it more participative and active in the fight of their problems, increasing the commitment and co-responsibility for the communitarian projects (Camargo-Borges; Mishima, 2009CAMARGO-BORGES, C.; MISHIMA, S. M. A responsabilidade relacional como ferramenta útil para a participação comunitária na atenção básica. Saúde e Sociedade, São Paulo, v. 18, n. 1, p. 29-41, 2009.). However, the institutionalization of surveillance happened through coercive actions, aiming to fight epidemics and endemic diseases in the country. The established workflows often reflect such origin.

Thus, this article seeks to identify and analyze the healthcare surveillance in a municipality located in the Porto Alegre Metropolitan Area, Rio Grande do Sul state. The text analyzes the institutionalization of such processes, aiming to realize its instituted and instituting dimensions, as well as characterize its working logics. Basis for the reflection are the concepts of institutional analysis, in a manner to problematize these forces and compositions and emphasize their importance for the integrality of healthcare.

Methodology

In this study, we used the intervention research as the theoretical methodological approach, which, according to Rocha and Aguiar (2003ROCHA, M. L.; AGUIAR, K. F. Pesquisa-intervenção e a produção de novas análises. Psicologia: Ciência e Profissão, Brasília, DF, v. 23, n. 4, p. 64-73, 2003.), assumes a collective methodology that favors discussions and ruptures with the bureaucratic hierarchies and specialties divisions that fragment the daily life and keep professionals apart.

The municipality in which the intervention research took place is located in the Porto Alegre Metropolitan Area. Its municipal healthcare network consists of Family Health Strategy (ESF), Primary Healthcare Centers (UBS), a hospital and several state-owned and third-party specialized services. During the research, the surveillance changed its staff of civil servants: new employees arrived, approved through a civil service examination, while others have left their jobs. Now, the sector has 44 professionals working in the different surveillances.

In this intervention research, the institutional analysis has a socioanalytic theoretical methodological approach, based in the discourses and practices of the subjects in a group or an organization (L’Abbate, 2003L’ABBATE, S. Análise institucional e saúde coletiva. Ciência & Saúde Coletiva, Rio de Janeiro, v. 8, n. 1, p. 265-274, 2003., ²⁰¹²L’ABBATE, S. Análise institucional e intervenção: breve referência à gênese social e histórica de uma articulação e sua aplicação na saúde coletiva. Mnemosine, Rio de Janeiro, v. 8, n. 1, p. 194-219, 2012.). We choose it because the institutional analysis seeks to critically apprehend the social and organizational realities, which are, in general, naturalized, aiming to contribute to transform the institutions.

In this approach, it is fundamental to analyze the commission and the demand. However, the first author commissioned the research - it was not a request from that facility nor from the employees. Thus, we had to verify whether this commission had a relation to the professional needs of that public health surveillance. Spagnol (2013SPAGNOL, C. A. A construção de um dispositivo socioanalítico para abordar situações de conflito em equipes de enfermagem. In: L’ABBATE, S.; MOURÃO, L. C.; PEZZATO, L. M. (Org.). Análise institucional e saúde coletiva no Brasil. São Paulo: Hucitec, 2013. p. 333-353.) faced a similar circumstance when studying the conflicts existing in nursing teams.

Thus, at the beginning of research, we set up a meeting with these workers, to establish whether the offer matched their concerns. As a resource, we started a discussion about the actions that contribute to change behaviors - educational or coercive - and their effects on the surveillance work. By the end of discussion, participants said that the research had much in common with their demands, accepting to engage in the study.

Next, we explained the objectives, proposed dynamics, and methodological questions about the research project. Then, all attendees signed an Informed Consent Form, then agreeing upon questions concerning the group’s agenda, followed by an explanation on ethical aspects. Seventeen professions participated in the intervention research and, to ensure confidentiality, participants were under flowers’ names.

Among adopted procedures, we carried out participant observation and discussion groups with the surveillance workers. During the participant observation - from April to May, 2016 - the first author accompanied the workers’ routine activities and observed how actions were performed, their impact and effects of such practices in the daily life. We constructed some analyzers based on such experiences.

Later, we hosted two discussion groups, with the presence of an observer, who accompanied the first author. The meetings took place on July 27 and August 17, 2016, with ten attendees, eight public servants from that healthcare surveillance and two facilitators. On both occasions, representatives from all surveillances attended the meetings.

These meetings enable the restitution of previously shared points and the discussion of new instituted and instituting concerns in the surveillance. With this purpose, we employed different resources, such as the creation of a character called Oswaldo. Thus, instead of describing their own work, participants would describe the work performed by the new employee, Oswaldo.

This was to facilitate dialogue and minimize possible resistance in talking about one’s own work. In one of the activities, the group talked about the character’s routine in the several surveillances and, in another, explained what Oswaldo would do to solve a problem. We used photographs, newspapers, and magazines articles to encourage participation.

Creating Oswaldo was an important resource. We noticed that the group enjoyed telling their histories through the character. Sunflower, one of health surveillance workers said, in the first meeting, that Oswaldo could as well be “Oswalda,” given the female predominance in the teams. In certain moments, they used Oswaldo to verbalize their hardships, anxieties and frustrations. That is the case with Violeta, emphasizing that Oswaldo’s work is only noticed during major tragedies and, on such occasions, his work is usually put to proof and questioned.

On August 15, 2018, we held the last meeting with the collective to convey the results and discuss the knowledge built. In the socioclinic survey, participants re-elaborate the “sense they attribute to their actions, so that studies access a reflective process that is in production” (Fortuna et al., 2014FORTUNA, C. M. et al. Uma pesquisa socio-clínica na França: notas sobre a análise institucional. Fractal: Revista de Psicologia, Rio de Janeiro, v. 26, n. 2, p. 255-266, 2014., p. 257).

We recorded, transcribed and analyzed all meetings. During the study, the researcher kept a diary in which she registered her field observations, feelings, implications, doubts and discoveries. Lourau (1993LOURAU, R. Análise institucional e práticas de pesquisa. Rio de Janeiro: UERJ, 1993.) emphasize that the journal technique does not specifically refer to the research, but rather to the research process. Same author mentions that such resource enables “knowing the day to day of field experience (not the ‘how to do it’ from the ‘norms,’ but rather ‘how it was done’ from the practice)” (Lourau, 1993LOURAU, R. Análise institucional e práticas de pesquisa. Rio de Janeiro: UERJ, 1993., p. 77). The diary notes contributed to identify analyzers, while the institutional analysis concepts worked as a tool box for the analysis and the intervention.

This article is a product of the first author’s doctoral dissertation. The project was submitted and approved by the Ethics Committee from the Vale do Rio dos Sinos University on November 16, 2015, under the CEP no. 15/215.

Results and discussion

In the institutional analysis, the institution concept must be dialectically analyzed, divided into three moments: the moment of the instated, the instituting and of the institutionalization (Lourau, 2014LOURAU, R. A análise institucional. 3. ed. Petrópolis: Vozes, 2014.). Mourão et al. (2007MOURÃO, L. C. et al. Análise institucional e educação: reforma curricular nas universidades pública e privada. Educação e Sociedade, Campinas, v. 28, n. 98, p. 181-210, 2007., p. 185) argue that “all institutions emerge and develop in a certain historical and political moment and constitute themselves in force fields in continuous movement.” Thus, the institutional analysis works by the collective analysis of those involved in the places where the institutions materialize, that is, in the organizations (Fortuna et al., 2014FORTUNA, C. M. et al. Uma pesquisa socio-clínica na França: notas sobre a análise institucional. Fractal: Revista de Psicologia, Rio de Janeiro, v. 26, n. 2, p. 255-266, 2014.)

In this study, the institution under analysis is the “public health surveillance.” Garcia and L’Abbate (2015GARCIA, R. A.; L’ABBATE, S. Institucionalização da vigilância em saúde de Campinas (SP) na perspectiva da análise institucional sócio-histórica. Saúde e Debate, Rio de Janeiro, v. 39, n. 107, p. 997-1007, 2015., p. 999-1000) argue that VS is considered an institution for having “instituted norms, protocol, legislation, knowledge and practices, dynamically questioned in movements instituting changes that are in permanent conflict with the instituted.” Inside this complex movement the institutionalization process happens (Garcia; L’Abbate, 2015GARCIA, R. A.; L’ABBATE, S. Institucionalização da vigilância em saúde de Campinas (SP) na perspectiva da análise institucional sócio-histórica. Saúde e Debate, Rio de Janeiro, v. 39, n. 107, p. 997-1007, 2015.).

As the first author works in the State Center for Public Health Surveillance and, consequently, knows the actions carried out by this area, it facilitated the comprehension of the work developed by the municipal VS. However, the study’s goal was to identify the predominance of either educational or authoritarian and repressive actions. Thus, being a professional, the researcher occupied certain places in the research that affected the production of knowledge and practices. For the municipality workers, her presence also had an impact. In face of it, the professional paid close attention to the effects of her participation in the research.

We assumed that the analysis of implications is essential in the research process. Monceau (2008MONCEAU, G. Implicação, sobreimplicação e implicação profissional. Fractal: Revista de Psicologia, Niterói, v. 20, n. 1, p. 19-26, 2008.) argues that the implication is the relation of the individual to the institution the individual belongs to and cannot be confused with engagement or investment. The institution practically absorbs the individual, regardless of will, that is, it exists even when undesired.

In this research project, identifying analyzers was a fundamental task. Analyzers are events that enable analysis, allowing understanding the “‘invisible’ institution” (Lourau, 1993LOURAU, R. Análise institucional e práticas de pesquisa. Rio de Janeiro: UERJ, 1993., p. 35). To Lourau (2004LOURAU, R. Objeto e método da análise institucional. In: ALTOÉ, S. (Org.). René Lourau: analista institucional em tempo integral. São Paulo: Hucitec, 2004. p. 66-86., p. 69), “the analyzer is what performs the analysis.” Thus, they can be built during the process or spontaneously emerge. Through them, non-verbalized aspects of groups and organizations are in display, as well as their functioning. They help to unveil what was still hidden, disorganize what was organized, given a different sense to facts already known (L’Abbate, 2012L’ABBATE, S. Análise institucional e intervenção: breve referência à gênese social e histórica de uma articulação e sua aplicação na saúde coletiva. Mnemosine, Rio de Janeiro, v. 8, n. 1, p. 194-219, 2012.).

In this study, from certain analyzers, three central aspects stood out: the institutionalization of surveillance, the relevance of networking and the fragility of the worker health surveillance. Chart 1 shows these aspects.

The institutionalization of public health surveillance

The institutionalization of surveillance occurred based on actions to fight epidemics and endemic diseases highly prevalent in the country, impacting mortality rates and the economy (Waldman, 2012WALDMAN, E. A. Os 110 anos de vigilância em saúde no Brasil. Epidemiologia e Serviços de Saúde, Brasília, DF, v. 21, n. 3, p. 365-366, 2012.). It was a successful process, although “marked by an ideology of protecting public health, using vertical tools of a campaign, non-participatory model” (Garcia; L’Abbate, 2015GARCIA, R. A.; L’ABBATE, S. Institucionalização da vigilância em saúde de Campinas (SP) na perspectiva da análise institucional sócio-histórica. Saúde e Debate, Rio de Janeiro, v. 39, n. 107, p. 997-1007, 2015., p. 998). Such actions affected the surveillance theoretical and methodological framework institutionalized in Brazil in the 1970s, resulting in the “epidemiological surveillance” and “public health surveillance” denominations (Garcia; L’Abbate, 2015GARCIA, R. A.; L’ABBATE, S. Institucionalização da vigilância em saúde de Campinas (SP) na perspectiva da análise institucional sócio-histórica. Saúde e Debate, Rio de Janeiro, v. 39, n. 107, p. 997-1007, 2015.).

We understand that the coercive and repressive origins of the “public health surveillance” institutionalization process still have reflections on the “instituted.” To the extent that the vocabulary used by its workers contains expressions that show the perception of biopolitical inspection (Ceyhan, 2012CEYHAN, A. Surveillance as biopower. In: BALL K.; HAGGERTY K. D.; LYON D. (Ed.) Routledge handbook of surveillance studies. New York: Routledge, 2012. p. 38-45.). However, instituting processes appear between employees and surveillances, in which educational actions stand out in the workflow.

The municipality prioritizes educational processes, especially at the Visa. In one of the inspections, the health inspectors found nonconformities in an establishment selling meat. At the end of inspection, they scheduled a meeting with the person in charge for the company, at the Visa headquarters, to discuss the business’ permit. The first author attended the meeting. The Visa employees showed the material photographed during the visit, explained the reasons for seizing and discarding the goods, emphasizing the risks. The inspectors granted a deadline for the establishment to adjust and requested a “step-by-step” document, describing all procedures for each one of the daily employees’ tasks. This “step-by-step” would work as a manual of procedures for every company’s employee. The manual produced with the inspectors’ aid had the goal of helping the establishment to comply with the sanitary rules.

By observing the work performed by this surveillance in the regulated sector, we learned that these professionals sought to correct nonconformities through educational activities and allowing time windows for adjustment. Garibotti, Hennington and Selli (2006GARIBOTTI, V.; HENNINGTON, E. A.; SELLI, L. A contribuição dos trabalhadores na consolidação dos serviços municipais de vigilância sanitária. Cadernos de Saúde Pública, Rio de Janeiro, v. 22, n. 5, p. 1043-1051, 2006.) found a similar scenario when conducting a study in the public health surveillance of three municipalities located in the Porto Alegre Metropolitan Area. In their observations, they identified the educational nature of those professionals, changing their behavior from inspector/police officer to advisor/partner.

However, despite the instituting practices, the instituted - the old way of executing actions - lasted in the memory of some business-owners. In one of the meetings with the workers collective, the reasons that maintain such image emerged. Margarida argued:

This may have contributed for Visa workers to seek for protection as a technical body, for instance, when they request the inspected company to send a representative during the discard of seized goods, photographing or filming the process. Yet another precaution is the recommendation for two or more inspectors to attend inspections. Margarida justified such recommendation:

The recommendation seeks to prevent embarrassments and other risks to these professionals, either individually or as group. We may think that this is the instituted persisting in the memory of the regulated sector. It brings to the memory a surveillance that inspected to identify irregularities and punish, all the while kept dirty inspectors in its staff.

O’Dwyer, Reis and Silva (2010O’DWYER, G.; REIS, D. C. S.; SILVA, L. L. G. Integralidade: uma diretriz do SUS para a vigilância sanitária. Ciência & Saúde Coletiva, Rio de Janeiro, v. 15, p. 3351-3360, 2010. Suplemento 3.) argued that, in the 1990s, numerous scandals emerged in the Brazilian sanitary sector, mostly in the services and pharmaceuticals, unveiling the susceptibility of the system to criminal action. They also said that the “image of the public health surveillance as a bureaucratic agent, subject to corruption may also be an element fostering some hostility from the population” (O’Dwyer; Reis; Silva, 2010O’DWYER, G.; REIS, D. C. S.; SILVA, L. L. G. Integralidade: uma diretriz do SUS para a vigilância sanitária. Ciência & Saúde Coletiva, Rio de Janeiro, v. 15, p. 3351-3360, 2010. Suplemento 3., p. 3357). This conception extends to all surveillances, as the population, quite often, do not tell them apart.

Nonetheless, Margarida claimed that such image does not apply to all of business-owners: “It is stronger among older business-owners, unlike the newest ones.” This claim suggests the possibility that introducing educational processes (instituting) is changing the social view on surveillance.

However, we also observe that the way the professionals from all surveillances develop the educational processes is vertical, based on technical norms, representing the intersection of the instituted.

The relevance of collaborative work

Surveillances need to work collaboratively and connected to other health sector areas, in addition to institutions outside the system, proved by the fact that a partnership already exists among the surveillances in this municipality. Collaborative work is the instituting way these professionals seek to aggregate into their workflow, and the fact that all surveillances are in the same building helped the process. However, we observed that the existing integration is occasional - it occurs when the case requires shared interventions.

The interaction between surveillance and primary healthcare (AB) is fundamental to provide integral care and to reduce the demand for moderate and high complexity (Teixeira et al., 2018bTEIXEIRA, M. G. et al. Vigilância em saúde no SUS: construção, efeitos e perspectivas. Ciência & Saúde Coletiva, Rio de Janeiro, v. 23, n. 6, p. 1811-1818, 2018b.). However, for the integration to happen, partnership and trust among areas is required. In this municipality, the process is well-advanced, especially for the VE, as cases that require such integration have been identified already. In a visit with Orchid, a VE technician, to an ESF unit in the municipality, the researcher saw one of the professionals from the clinical care team talk to Orchid about the incarceration of a tuberculosis patient, under treatment in the unit. The bond between the community and the primary healthcare service had the inmate’s spouse going to the ESF to communicate it, showing that the decentralization of surveillance actions to the AB and the relation existing between the two areas enabled the fact to be brought to VE’ attention. Before the decentralization, the surveillance would likely not know of the incarceration, for not having the same bonds to the community and to primary healthcare. With the partnership among areas in the healthcare offer, the clinical care team was able to let the surveillance know that the patient needed to continue the treatment in another city - where the inmate was going to serve his term.

The organization of the local healthcare system in units responsible for a territory and in charge for surveillance actions favors the identification of local issues that need to be faced, using the existing resources in the healthcare network and in other sectors (Balista; Santiago; Corrêa Filho, 2011aBALISTA, S. R. R.; SANTIAGO, S. M.; CORRÊA FILHO, H. R. A atenção à saúde do trabalhador nas unidades básicas de saúde do SUS: estudo de caso em Campinas, São Paulo. Revista Brasileira de Saúde Ocupacional, São Paulo, v. 36, n. 124, p. 216-226, 2011a.; Santos; Melo, 2008SANTOS, S. S. B. S.; MELO, C. M. M. Avaliação da descentralização da vigilância epidemiológica para a Equipe de Saúde da Família. Ciência & Saúde Coletiva, Rio de Janeiro, v. 13, n. 6, p. 1923-1932, 2008.). Santos and Melo (2008SANTOS, S. S. B. S.; MELO, C. M. M. Avaliação da descentralização da vigilância epidemiológica para a Equipe de Saúde da Família. Ciência & Saúde Coletiva, Rio de Janeiro, v. 13, n. 6, p. 1923-1932, 2008., p. 1931) emphasized that such action may impact certain health indicators, for “increasing the ability of intervening in them.”

In another opportunity, the first author accompanied Jasmine and Hortensia, from VE, in a visit to another healthcare unit, answering the request of an UBS doctor who had called the surveillance over a suspected measles case. When talking to the patient, they learned she worked in another city and, that a woman in the first months of pregnancy was among her coworkers. Thus, in the event of confirming the disease, the pregnant women would also have to be monitored by the other city.

These episodes appoint the existence of integration among areas. Partnerships can only gain consistency from acknowledge and understanding of the relevant work performed by each area. Consequently, small adjustments and incorporations may arise from collaborative work.

Providing a counterpoint, the approximation of the VAS to the AB was due to external factors. By talking to Sunflower about how it happened, we learned that it was due to the zika virus crisis. The adverse scenario caused the government to take actions that led to shared activities in areas that counted with ESF units.

However, the surveillance and the AB have different idiosyncrasies, histories and cultural experiences. While viable and desirable, the integration between the endemic disease control workers and the community health workers (ACS) must consider such differences, as the convergence caused by external and vertical actions may cause noise and animosity among areas. The microcephaly caused by the zika virus had the ACS to incorporate different roles. The concern that these new roles could interfere in the existing bond between these professionals and the community arouse (Libanio; Favoreto; Pinheiro, 2014LIBANIO, K. R.; FAVORETO, C. A. O.; PINHEIRO, R. Análise da integração da vigilância ambiental no controle da dengue com a estratégia saúde da família: impacto nos saberes e práticas dos agentes comunitários de saúde. Physis: Revista de Saúde Coletiva, Rio de Janeiro, v. 24, n. 1, p. 147-163, 2014.), as well as whether the overload would affect their work. Perhaps, the effects of this process still require further analysis.

The integration of surveillance to other sectors is also fundamental for the effectiveness of actions. In one of the meetings, Tulipa explained how the analysis of maternal and infant mortality. She said that, at first, only the surveillance analyzed them, but as of this research, all professionals in the network who worked in the entire process, from the prenatal care until the end, attend the analysis meeting. Jasmine emphasized that this action affects the network for showing failures in the service provided. Martins, Rezende and Lana (2009MARTINS, E. F.; REZENDE, E. M.; LANA, F. C. F. Causas e evitabilidade dos óbitos perinatais investigados em Belo Horizonte, Minas Gerais. Reme: Revista Mineira de Enfermagem, Belo Horizonte, v. 13, n. 4, p. 550-557, 2009.) analyzed the perinatal deaths occurred in Belo Horizonte, Minas Gerais state. The investigation evidenced a high potential for preventing the deaths and failures in the healthcare provided. Authors emphasized that the study is an important tool to explain the cause and circumstances of these deaths, affecting the system reorganization and prevention of evitable deaths.

Concerning the inter-sectorial actions, Violeta claimed that the Visa engages in actions at Long-Term Care Facilities for the Elderly, along with the Human Rights and Social Development Secretariat and the Public Prosecutor’s Office. Sunflower also said that, in the Aedes aegypti infestations, the engagement of the army and other municipal public service areas is fundamental. In addition to it, the group also said that, during the floods, the surveillances and other bodies also supported the State Emergency Response Center in controlling the situation.

That said, the collaboration among sectors results from the articulation of people from different areas, with different powers and wills, aiming to solve complex issues. It is a new way of governing, working and building public policies, aiming to overcome the fragmentation of knowledge and social structures, in addition to improving the population’s health (Grossi; Guilamelon, 2006GROSSI, P. K.; GUILAMELON, L. F. Intersetorialidade na política de saúde do idoso. Textos & Contextos, Porto Alegre, v. 5, n. 2, p. 1-9, 2006.). However, working in collaboration with other sectors still is an instituting challenge in many sectors, with the intersection of logics specifics to each area.

Worker health surveillance

We observed fragilities concerning VST actions. While accompanying the Visa in inspections, the researcher found inadequacies that would affect the employees’ health in visited companies. The issues identified not always are due to unawareness and may as well result from conscious decisions made by the employers, aiming cost-reductions. In this sense, a collaborative work between the Visa and the VST would be fundamental.

The researcher observed such conduct during a Visa visit in a company. In this establishment, the production process was appropriate and performed compliant to the norms, but particles of the product appeared in part of the assembly line, posing health hazard to the workers’ health. Two employees appointed by the management. When the surveillance informed them that an exhaust fan had to be installed and the entire assembly line had to be acclimatized - and not only part of it - one of them stated that such request had already been placed, but management declined it, claiming it would be costly. The Visa public servant requested the management to be aware of requirements and of the deadline to fix the issue.

The Visa’s concern with health work environments emphasizes its sensibility towards the workers’ health. However, the surveillance still does not count with a service directed to such control.

This visit exemplifies the importance of the VST accompanying the Visa during inspections. The workers perform their duties in different establishments, and many of them receive Visa’s inspection.

During one of the meetings, the causes for the low visibility of this surveillance emerged. Tulipa said that

However, the VST calls for reflection. It is part of the National System of Public Health Surveillance, with the goal of promoting health and reducing the morbidity and mortality of the workers’ population, through the integration of actions that may intervene in the aggravations and their determinants (Vasconcellos; Gomez; Machado, 2014VASCONCELLOS, L. C. F.; GOMEZ, C. M.; MACHADO, J. M. H. Entre o definido e o por fazer na vigilância em saúde do trabalhador. Ciência & Saúde Coletiva, Rio de Janeiro, v. 19, n. 12, p. 4617-4626, 2014.). Yet, the surveillance may suffer local pressure coming from the economic power and municipal administrators.

In the analyzed municipality, the VST is located within VE, even though professionals claim they would rather make it independent. However, to be effective, the VST would have to work in collaboration with other sectors, being especially important the partnership with other surveillances and with AB. The closeness to the VE allows being aware of the notified cases, while the partnership with the Visa and VAS would help to prevent the harms caused by work duties, given its ability of identifying occupational and environmental hazards.

Balista, Santiago and Corrêa Filho (2011bBALISTA, S. R. R.; SANTIAGO, S. M.; CORRÊA FILHO, H. R. A descentralização da vigilância da saúde do trabalhador no município de Campinas, São Paulo, Brasil: uma avaliação do processo. Cadernos de Saúde Pública, Rio de Janeiro, v. 27, n. 4, p. 759-768, 2011b.) emphasized that the decentralization of actions for the AB increases the identification, assessment and intervention on the hazards found in work environments. Such action is strategic to increase the solving and the coverage of services. However, despite knowing that AB employees may perform part of the VST activities, the surveillance teams have to be organized to provide technical and matrix support for the care networks (Vasconcellos; Gomez; Machado, 2014VASCONCELLOS, L. C. F.; GOMEZ, C. M.; MACHADO, J. M. H. Entre o definido e o por fazer na vigilância em saúde do trabalhador. Ciência & Saúde Coletiva, Rio de Janeiro, v. 19, n. 12, p. 4617-4626, 2014.).

The VST invisibility and its location in the VE give food for thought. The Visa’s role cannot only be assessing goods for consumption, under a health perspective, because the market has an interest in it, wanting a “quality stamp” for selling the goods. Assessing the production chain of these goods, including the consequences to the workers’ health and the environmental harm caused by industrial processes has to be included in the agenda. Thus, the Visa, by evaluating not only the good, but also the production chain, would give VST and environmental monitoring a greater visibility, in their workflow and a greater effectiveness in the control actions. However, this setting would hardly be of the market’s interest (Leão; Vasconcelos, 2015LEÃO, L. H. C.; VASCONCELLOS, L. C. F. Cadeias produtivas e vigilância em saúde, trabalho e ambiente. Saúde e Sociedade, São Paulo, v. 24, n. 4, p. 1232-1243, 2015.). The VST invisibility - integrated to other surveillances - represents the instituted and the Visa’s control actions over the work environment appoint to the instituting of the institutionalization of this surveillance.

Final remarks

In this intervention research we analyzed the public health surveillance institution, to perceive instituting powers and instituted manners, as well as discerning some institutionalization processes. Among surveillances, Visa stood out by its educational actions, with the workers subjects exercising its instituting practices. We can see these both in the contact with system users as in the collaborative actions. However, this activity, more often than not, occurs in a normative and vertical manner, due to the way as the analyzed institution was institutionalized. Likewise, even though this surveillance stands out for prioritizing educational actions, the regulated sector still has a memory of a coercive and repressive instituted. This instituted view expands to other surveillances.

In relation to collaborative work, the public health surveillance institution faces challenges to work in an integrated and connected manner - with other surveillances, other health areas and establishments in the public and private network. The multisector actions emerge as important devices for the articulated work. In this sense, the presence of instituting movements is unquestionable in the analyzed municipality. The communication among sectors emerges as a possibility of solving occasional issues. That is the case with the meetings for the analysis of maternal and infant mortality, actions in Long-Term Care for the Elderly Institutions and the partnership to the AB. Despite being an instituting process, movements and incorporations resulting from these partnerships are already identified, so that the collaborative work is, therefore, institutionalized.

The partnership with the AB is fundamental. Its closeness to the territory facilitates the intervention over the existing risks, helping to better comprehend the health situation of that population. The connection between these workers and the community allow more dialogical relationship, less prescriptive, facilitating educational and health promotion actions.

As for the VST processes, we noticed a certain fragility, especially because its practices has low visibility and, in addition, it is located in the epidemiological surveillance. The notifications of diseases and deaths related to the work activity are low and the inspection of companies is insufficient. The growing proximity of VST and VE is important as it enables the awareness of cases, while the proximity of the Visa and the VAS is indispensable for enabling the prevention of work and environmental harm. The workers argue that turning the worker health surveillance an independent surveillance would be a challenge, keeping the partnership with the other surveillances and the collaborative work. However, the invisibility of VST actions is an issue requiring attention.

In the intervention research we were able to think how possible it was to increase the coefficient of transversality in the groups, given that the workers who engaged in it shared experiences by narrating instituting and instituted processes and their institutionalization paths, in a way to broader the senses built in living their work realities. Through the meetings, we were able to produce a transversality of views, ideas and propositions, while they brought potentialities, hardships, challenges and questions to be though and worked in their contexts.

Lastly, we realized that the research was important for rethinking - collectively - the work process and the ways as the surveillance institution produces institutionalizations. The fact of discussing different perspectives produces effects on the practices and on the different ways of looking at the daily life. We suggest the conduction of similar research projects in other territories, for the ability of producing new practices and ways of working.

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