Abstract

This article seeks to know the perception of state health secretaries, their professors, and their directors on the contributions of state schools of Public Health to the Brazilian National Health System (SUS). Being a qualitative research, the state health secretaries were interviewed, as well as the directors and professors of these schools. The content of the interviews was analyzed in the light of Bardin’s framework. The contributions of the schools to SUS were highlighted, showing the strategic role they play, emphasizing the provision of professionals trained in these schools and who occupy management positions in the SUS; the technical support offered to municipalities; and the recognition of workers for the work developed by these schools. However, one must note that these institutions face difficulties, especially insufficient financial and human resources. Schools are strategic for SUS, being fundamental instruments to maintain the policy of permanent health education and to qualify the health workforce. The difficulties reported indicate the need to prioritize policies of permanent education and professional qualification aimed at health workers.

Keywords:
School of Public Health; Permanent Health Education; Brazilian National Health System

Introduction

This article seeks to present the perception of state health secretaries, their professors, and their directors on the contributions of state schools of Public Health to the Brazilian National Health System (SUS).

The emergence of public health schools is based on the construction of knowledge in public health; the formulation and/or execution of programs and policies aimed at the qualification of workers; and the need to respond and improve the conditions, opportunities, and challenges for health in the face of policies implemented over time. In different contexts, schools were founded on the improvement of a public policy of training and construction of teaching-learning-service scenarios, in the perspective of an intersectoral agenda between education and health. Therefore, they play an important role in implementing and strengthening SUS.

One must emphasize that the state schools of Public Health are located at the intersection of two fields: education and health. The field of education, as pointed out by Nunes (2007NUNES, T. C. M. Democracia no ensino e nas instituições: a face pedagógica do SUS. Rio de Janeiro: Editora Fiocruz, 2007., p. 58):

Nevertheless, state schools of Public Health also have their own needs and characteristics, considering that they are schools of SUS and for SUS, and therefore need to meet what is recommended in the principles and guidelines of the system.

In this sense, Nunes (2009NUNES, T. C. M. Uma escola viva: “vida de escola”. [S. l.: s. n.], 2009.) argues that the school of Public Health should be engaged and committed to changes, to interact with SUS and permanently rethink its practices: be a living school for SUS. That is, it must be a school that structures its educational processes in view of social reality, with dynamic, concrete, living, and updated contents. Thus, a school whose reference is work and that uses it as a place of problematization and learning.

A study conducted by the National Council of Health Secretaries (Pontes; Coutinho; Santos, 2020PONTES, H. J. C.; COUTINHO, M. L.; SANTOS, M. R. As escolas estaduais de saúde pública: contribuições pedagógicas e político-institucionais para o Sistema Único de Saúde. Brasília, DF: Conass , 2020.) showed that there were, until 2019, 15 state schools of Public Health, linked to the State Health Secretariats (SES). Of this total, 12 are subordinate and integrated into the direct administrative structure of the State and three make up the structures of the indirect administration of governments. According to the study, the 15 state schools of Public Health are responsible for the formulation and/or execution of programs and policies aimed at the qualification of SUS workers and all use the work process as an educational principle.

The oldest State School of Public Health is the one in Minas Gerais, established in 1946 in the context of the reform of Public Health Services and of the consequent need to train technicians with specialized knowledge in the area and qualified to execute health policy. Thus, it was established aiming to qualify personnel for the health career and promote the improvement of those who already worked in it (Machado, 1990MACHADO, E. N. M. Formação de sanitaristas e políticas de saúde pública em Minas Gerais, 1947-1955. 1990. 269 f. Dissertação (Mestrado em Educação) - Faculdade de Educação, Universidade Federal de Minas Gerais, Belo Horizonte, 1990.).

We highlight that, except for the schools of Minas Gerais, Paraná (1958), and Rio Grande do Sul (1962), all the others were established after SUS; therefore, one can infer that the creation of SUS encouraged and boosted the SESs to create schools.

It should be remembered that SUS radically altered the history of Brazilian Public Health with the definition of new principles and guidelines, and, thus, a new organization of the functioning and management of Health Services. Federal Law No. 8,080, which established SUS, defines, in Article 6, item III, that the field of action of SUS includes the organization of human resources training in the health area. In its Article 15, item IX, it says that the Union, the states, the Federal District, and the municipalities will exercise, in their administrative scope, the attributions of participating in the formulation and execution of the policy of training and development of human resources for health. Finally, Article 27, item I, announces that the Human Resources Policy in the health area will be formalized and executed jointly by the different spheres of government, in compliance with the objectives of organizing a system of human resources training at all levels of education, including graduate, and develop programs for permanent improvement of personnel (Brasil, 1990BRASIL. Lei nº 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União: seção 1, Brasília, DF, ano 128, n. 182, p. 1, 20 set. 1990.).

The constitution of SUS boosted a significant expansion of the network of health services and actions in all regions of the country. Consequently, it became necessary a human resources policy that reoriented its actions, to meet the new objectives expressed. In this sense, on February 13, 2004, by Ordinance no. 198, the National Policy of Permanent Health Education (Pneps) was established as the main strategy of SUS to train and develop health workers (Brasil, 2004BRASIL. Ministério da Saúde. Portaria nº 198, de 13 de fevereiro de 2004. Institui a Política Nacional de Educação Permanente em Saúde como estratégia do Sistema Único de Saúde para a formação e o desenvolvimento de trabalhadores para o setor e dá outras providências. Diário Oficial da União: seção 1, Brasília, DF, ano 141, n. 32, p. 37-41, 16 fev. 2004.).

Pneps considers the importance of integration between health education, health actions and services, and local reality in the organization and provision of workers’ qualifications. Therefore, this is about learning at work, and incorporating this knowledge into the daily work. The training process is based on the need for people’s health and aims to transform professional and work organization practices (Brasil, 2004BRASIL. Ministério da Saúde. Portaria nº 198, de 13 de fevereiro de 2004. Institui a Política Nacional de Educação Permanente em Saúde como estratégia do Sistema Único de Saúde para a formação e o desenvolvimento de trabalhadores para o setor e dá outras providências. Diário Oficial da União: seção 1, Brasília, DF, ano 141, n. 32, p. 37-41, 16 fev. 2004.). Thus, the area of human resources in health assumes, from the Constitution of SUS and Pneps, new and expanded functions and responsibilities.

Based on the assumption that SUS assumes the schools of public health as strategic spaces for the qualification of its workforce, and that these integrate the structure of SESs, this article analyzes the contributions of the state schools of Public Health to the qualification of the work performed in the SUS services, according to the perception of their directors and professors. It starts from the understanding that educating is a form of intervention in the world, and that, therefore, requires commitment. Therefore, it is not a neutral or indifferent action, but a historical act (Freire, 2019FREIRE, P. Pedagogia da autonomia: saberes necessários à prática educativa. São Paulo: Paz e Terra, 2019.).

This article resulted from the thesis developed in the Graduate Program in Management, Labor, Education, and Health of the Federal University of Rio Grande do Norte, which analyzed the contributions of state schools of Public Health to the implementation and strengthening of SUS.

Methodological procedures

The methodological procedures used were based on the qualitative and exploratory approach, according to the perspective of Minayo (2012MINAYO, M. C. S. et al. Pesquisa social: teoria, método e criatividade. Petrópolis: Vozes, 2012.), and aimed to reveal the universe of meanings, values, beliefs, and conceptions of the research subjects on the state schools of Public Health.

To select the schools, the following criteria were initially used: to integrate the structure of the direct administration of the state government; and to develop technical and graduate education. The state schools of Public Health that are constituted as agencies of indirect administration have their own characteristics, such as greater budgetary and financial autonomy, which differentiates them in this aspect from the others (Pontes; Coutinho; Santos, 2020PONTES, H. J. C.; COUTINHO, M. L.; SANTOS, M. R. As escolas estaduais de saúde pública: contribuições pedagógicas e político-institucionais para o Sistema Único de Saúde. Brasília, DF: Conass , 2020.). For this reason, it was decided to work with schools that are part of the direct administration structure. After the aforementioned criteria, two others were incorporated: seniority and geographical distribution. The latter was intended to encompass the regional diversity of a country with continental dimensions such as Brazil. The oldest schools by region were prioritized. Finally, some schools were selected for the study:

The interviews were conducted from June to November 2021, with actors whose technical and political roles are decisive for the functioning and performance of the schools: directors and professors of the selected schools and state health secretaries. Due to the limits imposed by the Covid-19 pandemic, the online interview resource was used; for its feasibility, the Google Meet platform was used. The interviewees were informed about all the procedures to which they would be submitted, as well as about the purpose of the research; the interviews were recorded (audio and video) and later transcribed, and had an average duration of 50 minutes. In all interviews, the interviewees were by themselves and the camera was permanently on. One must consider that the Covid-19 pandemic was a limiting factor for conducting the interviews.

The interviewees’ statements were analyzed according to the content analysis framework of Bardin (2016BARDIN, L. Análise de conteúdo. São Paulo: Edições 70, 2016.) and following the path below: pre-analysis of the material; exploration of the material (coding); and treatment of the results (categorization, inferences, and interpretations). Three categories emerged as catalysts for the discussions of the interviewees: contributions; relevance; and difficulties and challenges. These categories were constituted from the specific objectives of the research and the answers that emerged from the interviews.

The research that supported this article followed the guidelines of Resolution no. 466 of 2012, of the National Health Council, which guides research involving human beings, and was approved by the Research Ethics Committee of the Onofre Lopes University Hospital from the Federal University of Rio Grande do Norte, on February 4, 2021, under Opinion no. 4,523,802.

Results and discussion

Understanding the state schools of public health as strategic spaces to enable the policy of permanent education, we sought to know the perception of the state health secretaries, their professors, and their directors on the contributions of these schools to health services.

Among the contributions pointed out, the role of schools in the qualification of professionals who assume positions in the management of SUS and in technical support to municipalities stands out, as shown in the statements highlighted below:

The contribution of the State School of Public Health in improving the qualification of municipal health management was also emphasized.

Similarly, the important role of schools in the emergency qualification of health workers during the pandemic was observed.

The relationship between the actions developed by the schools and what is recommended in the state health plans was another highlight.

In addition, the interviews also highlighted the importance of the work the schools develop in the Bipartite Management Commissions (CIBs) - SUS agreement instances - and in the Education-Service Integration Commissions (CIES).

It was evident, in the analysis of all the interviews, that the interviewees recognize that the state schools of Public Health are schools of SUS and for SUS, and that they dialogue with what is recommended in the principles and guidelines of the system. The analysis also allows us to affirm that the health secretaries and directors of the state schools of Public Health understood the work of schools as fundamental to strengthen and qualify the SUS workforce, even with the few resources that are available.

Regarding this, we highlight that the shortage of human resources and funding was indicated as one of the greatest difficulties in offering quality education that could respond to all the needs of health services. It is known that financial insufficiency is a problem for the functioning of the entire system, but the interviews revealed how much this mishap interferes with the execution of the activities of these schools, often making the functioning of various activities unfeasible, despite Ordinance no. 198 of 2004, which establishes Pneps, defining in its Article 6 that it will be financed with resources from the budget of the Ministry of Health (Brasil, 2004BRASIL. Ministério da Saúde. Portaria nº 198, de 13 de fevereiro de 2004. Institui a Política Nacional de Educação Permanente em Saúde como estratégia do Sistema Único de Saúde para a formação e o desenvolvimento de trabalhadores para o setor e dá outras providências. Diário Oficial da União: seção 1, Brasília, DF, ano 141, n. 32, p. 37-41, 16 fev. 2004.). This difficulty was also highlighted in the results of the research carried out by França (2016FRANÇA, T. Análise da Política de Educação Permanente do SUS (PEPS) implementada pelas Secretarias Estaduais de Saúde (SES). Rio de Janeiro: Universidade do Estado do Rio de Janeiro, 2016. v. 2.), in which the concern with the insufficiency of the necessary resources for the development of the work of schools is emphasized.

Nevertheless, the data reveal that, despite the financial difficulties or those related to the management and qualification of the workforce, there is a commitment by the workers of the state schools of Public Health with the qualification of work in SUS. Thus, it is pertinent to say that, even dealing with a series of challenging limitations, these workers continue to believe and insist that the state schools of Public Health contribute to strengthening SUS.

In their statements, the interviewees stated that the actions of the state schools of Public Health are carried out by workers who believe in the transformative power of education and SUS: “The school today assumes a strategic role within what we intend for health in the state, it has gained a responsibility even greater than its capacity” (S 1).

In this perspective, it is argued that the work of schools is based on the assumption that the transformation of professional practices should be based on critical reflection on the work process developed by teams in the health services network (Cardoso, 2012CARDOSO, I. M. “Rodas de educação permanente” na atenção básica de saúde: analisando contribuições. Saúde e Sociedade, São Paulo, v. 21, p. 18-28, 2012. DOI: 10.1590/S0104-12902012000500002
https://doi.org/10.1590/S0104-1290201200... ). In this sense, the centrality of the worker in the health work process is highlighted. Thus, it is assumed that the understanding of this centrality is the differential aspect of the educational processes conducted by the state schools of Public Health.

Given the above, it is plausible to state that schools seek to base their actions on the proposal of permanent health education, on learning incorporated into daily work, emphasizing the integration between teaching and service and, especially, considering the needs and participation of society. Their training processes seek to be based on people’s health needs and aim to transform professional practices and the organization of the work process. In summary, when based on the proposal of permanent health education, state schools of Public Health develop their work considering the social reality, always dynamic, and their intervention processes having as reference the daily work; after all, they are SUS schools.

Schools of Public Health were created, according to Nunes (2009NUNES, T. C. M. Uma escola viva: “vida de escola”. [S. l.: s. n.], 2009.), with the perspective of being plural, engaged, and committed to change, permanently interacting and rethinking their practices. Also according to the author, public health institutions must structure their intervention processes in view of social reality, be dynamic, and be in permanent movement, since they have work as a reference, which is used as a place of problematization and learning. In this sense, Saviani (1984SAVIANI, D. Escola e democracia. São Paulo: Cortez, 1984.) says that the pedagogical relationship needs to be referenced in social practice and in the historical perspective. The author argues that the dissemination of real, dynamic, concrete, living, and updated content is one of the primary tasks of the educational process.

In this sense, it is pertinent to remember Freire (2019FREIRE, P. Pedagogia da autonomia: saberes necessários à prática educativa. São Paulo: Paz e Terra, 2019.), when he says that educating requires commitment and that education is a form of intervention in the world; therefore, it is never neutral or indifferent. Freire (2019FREIRE, P. Pedagogia da autonomia: saberes necessários à prática educativa. São Paulo: Paz e Terra, 2019.) teaches that education is not an act of depositing knowledge; it needs to be problematizing and raise awareness. For Freire (1980FREIRE, P. Conscientização: teoria e prática da libertação. São Paulo: Cortez & Moraes, 1980., ²⁰¹⁹FREIRE, P. Pedagogia da autonomia: saberes necessários à prática educativa. São Paulo: Paz e Terra, 2019.), awareness means taking ownership of reality, having the conviction that change is possible.

It should be noted that the statements of the professors and directors of the state schools of Public Health and the of state health secretaries made it clear that schools play a relevant role for SUS. However, this role must be understood and valued by a greater number of public managers, so that these spaces can be strengthened. It is believed that, in this way, it will be possible to materialize the state schools of Public Health as a priority, transform ideas into actions, and enhance the work they already do.

Paim (2020PAIM, M. C. Prefácio. In: PONTES, H. J. C.; COUTINHO, M. L.; SANTOS, M. R. As escolas estaduais de saúde pública: contribuições pedagógicas e político-institucionais para o Sistema Único de Saúde. Brasília, DF: Conass, 2020.) emphasizes that, even with the recognition of managers, health education occupies a peripheral position in the priority agenda. Corroborating this fact, Padilla, Cardoso, and Nunes (2018PADILLA, M.; PINTO, I. C. M.; NUNES, T. C. M. Trabalho e educação em saúde: desafios para a garantia do direito à saúde e acesso universal às ações e serviços no Sistema Único de Saúde. In: OPAS - ORGANIZAÇÃO PAN-AMERICANA DA SAÚDE. Relatório 30 anos de SUS, que SUS para 2030?. Brasília, DF: Opas, 2018. p. 139-158.) say that the greatest challenge lies in the political field, directly linked to governance and the financial insufficiency of Public Administration.

To conclude, we defend the need to show that, within SUS, state schools of Public Health are privileged spaces for the promotion and management of educational processes aimed at the development of health workers. It is up to these spaces to promote actions that welcome and develop the worker’s expertise, motivating them and creating environments to develop creativity, reflections on health practices, and collaboration to improve the services provided by the institution.

The purpose of the research that originated this article had as its starting point the interest of highlighting the role and contributions of state schools of Public Health to SUS. But, beyond this, the interviewees’ statements offered important information for those who work with the management of work and health education in SUS. They are, in fact, statements that warn about problems that are difficult to overcome, but which need to be evaluated and solved. Deepening knowledge about the actions carried out by state schools of Public Health makes it possible to better understand the role played by them in SUS and, at the same time, indicates ways to overcome historical challenges of work management and health education.

When discussing the contributions of state schools of Public Health, this article alludes in a special way to the need to prioritize - with actions, not only with words - the policy of permanent education and the policy of professional qualification aimed at the health worker. These policies aim at valuing the worker in the perspective of improving and strengthening health services.

Final considerations

In this article, from the support provided by interviews with some protagonists responsible for the work in the schools studied, reflections on the contributions of the state schools of Public Health to SUS were made, with emphasis on some activities developed, their social and political relevance, and the difficulties related to the performance of their role in SUS and for SUS. All this came from the perception of a set of protagonists responsible for the work in the schools studied.

The reasons for the problems faced by state schools of Public Health are diverse. For example, since its creation, SUS has suffered from pressures that hinder its implementation, with emphasis on insufficient funding. In this sense, permanent health education (PHE) is hardly prioritized regarding actions directly linked to health care. As the needs are diverse, it is complex to dispute the allocation of resources between a SUS school and a hospital. On the other hand, the health secretaries, directors, and professors of state schools of Public Health assessed that the training developed causes changes in health services. The pressure and the need for immediate responses are always present; and, to face this problem, one must overcome this false dichotomy and understand that health care and training are complementary priorities.

In this sense, one must study the impacts of the educational actions of the state schools of Public Health in the implementation and strengthening of SUS. Ordinance no. 3,194, of November 2017BRASIL. Ministério da Saúde. Portaria nº 3.194, de 28 de novembro de 2017. Dispõe sobre o Programa para o Fortalecimento das Práticas de Educação Permanente em Saúde no Sistema Único de Saúde - PRO EPS-SUS. Diário Oficial da União: seção 1, Brasília, DF, ano 154, n. 229, p. 141, 30 nov. 2017., which established the Program for the Strengthening of Permanent Health Education Practices in SUS (PRO EPS-SUS), also establishes, in Article 11, its Monitoring and Evaluation Commission, a commission that was never constituted.

In conclusion, it is important to say that evaluating the role that state schools of Public Health play in SUS, highlighting their contributions, as well as the need to monitor the impact of their actions, aims to alert the authorities of SUS, so that they direct their gaze to the strengthening of state schools of Public Health, understanding them as strategic spaces for the management of SUS that are committed to its principles and guidelines. However, their role must be understood and valued by a greater number of public managers, so that these spaces can be strengthened. We believe that, thus, it will be possible to materialize the state schools of Public Health as a priority, transform ideas into actions, and enhance the work they already do.

Furthermore, the state schools of Public Health are committed to the principles and guidelines of SUS, fundamental for the maintenance of the PHE policy and essential for the qualification of the health workforce, and therefore they should be understood as a space for the valorization of the health worker. SUS schools develop their work considering the social reality, always dynamic, and their intervention processes have as reference the daily work.

Finally, with the certainty that history is a human action, concretized from the present conditions, but, at the same time, in permanent and eternal movement and transformation, we understand that all work is unfinished; therefore, we point to the need for other studies on the performance of state schools of Public Health and their impacts on SUS.

References

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