ABSTRACT

Permanent Health Education is a powerful device for transformation of work practices, as well as an inclusive strategy, because it considers the most diverse actors as protagonists of their daily lives. This study intends to report the experience of the State of Mato Grosso do Sul in the process of elaboration of the State Plan for Permanent Health Education (PEEPS) for the 2019-2022 quadrennium, using upward, decentralized and participatory planning with municipalities. The design of this study was developed through the exploratory-descriptive method, based on three (3) formats: an interpretative analysis, of the documentary type, in which the minutes of the Permanent Committees of Teaching-Service Integration (Cies) were consulted; participation in Cies regular meetings; and experiences in some micro and macro-regional workshops during the PEEPS implementation process. The results obtained were considered relevant for the actors involved, such as the survey of issue-problems of work processes in health care with proposals for continued education actions to improve the resolution of health services provided to the population. The experience reported allowed to promote the strengthening of the Permanent Education Policy in Health, through the qualification of professionals with different insertions in the SUS, betting on the construction of the new, in horizontal relations.

KEYWORDS
Education continuing; Teaching care integration services; Unified Health System

Introduction

The Ordinance GM/MS nº 198, dated February 13, 2004¹1 Brasil. Ministério da Saúde. Portaria nº 198/GM, 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. 16 Fev 2004. [acesso em 2018 out 9]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/MatrizesConsolidacao/comum/13150.html.
http://bvsms.saude.gov.br/bvs/saudelegis... , instituted the National Permanent Health Education Policy (PNEPS) as a strategy of the Unified Health System (SUS) for the training and development of workers. It brings as a proposal the articulation of the needs to develop the education of the workers in line with the resolutive capacity of the health services and the comprehensive health care of the population¹1 Brasil. Ministério da Saúde. Portaria nº 198/GM, 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. 16 Fev 2004. [acesso em 2018 out 9]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/MatrizesConsolidacao/comum/13150.html.
http://bvsms.saude.gov.br/bvs/saudelegis... .

The PNEPS, organized by the Ordinance GM/MS nº 1.996/2007, which guides the implementation of this policy, emphasizes the importance of the construction of a Regional Action Plan for Permanent Education in Health, considering the local specificities of each health region²2 Brasil. Ministério da Saúde. Portaria nº 1.996, de 20 de agosto de 2007. Dispõe sobre as diretrizes para a implementação da Política Nacional de Educação Permanente em Saúde. Diário Oficial da União. 22 Ago 2007. [acesso em 2018 out 9]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2007/prt1996_20_08_2007.html.
http://bvsms.saude.gov.br/bvs/saudelegis... .

Considering the Permanent Health Education Policy as a pedagogical strategy and a transformation of work practices, Ordinance nº 3.194 was issued, dated November 28, 2017, which provides for the Program for Strengthening Practices of Permanent Health Education in the Unified Health System (PRO EPS-SUS)³3 Brasil. 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. 14 Dez 2017. [acesso em 2018 out 9]. Disponível em: http://www.cosemsrn.org.br/wp-content/uploads/2017/12/ok-portaria3194.pdf.
http://www.cosemsrn.org.br/wp-content/up... . This measure is due to the need for training of human resources for the SUS, in a collective and challenging construction⁴4 Cavalheiro MTP, Guimarães AL. Formação para o SUS e os desafios da integração ensino serviço. Caderno FNEPAS [internet]. 2011 [acesso em 2018 out 9]; 1(1):1-9. Disponível em: http://www.saude.pa.gov.br/wp-content/uploads/2017/08/13-Formacao-para-o-SUS.pdf.
http://www.saude.pa.gov.br/wp-content/up... .

Providing that permanent education is learning at work, where learning and teaching are incorporated into the daily life of organizations and work, it is considered that this formation and development encompass aspects of production of subjectivity, technical skills and knowledge of SUS⁵5 Alves ED. Política de Educação e desenvolvimento para o SUS - Caminhos para a Educação Permanente em Saúde. Rev. Eletrônica Gestão & Saúde. 2010 [acesso em 2018 out 9]; 1(1):42-47. Disponível em: http://periodicos.unb.br/index.php/rgs/article/view/24267/17335.
http://periodicos.unb.br/index.php/rgs/a... . More important than this is that when one reflects about reality, one learns reality⁶6 Nicoletto SCS, Bueno VLRC, Nunes EFPA, et al. Desafios na implantação, desenvolvimento e sustentabilidade da Política de Educação Permanente em Saúde no Paraná, Brasil. Saúde soc. 2013 [acesso em 2018 out 9]; 22:1094-1105. Disponível em: https://www.scielosp.org/article/ssm/content/raw/?resource_ssm_path=/media/assets/sausoc/v22n4/12.pdf.
https://www.scielosp.org/article/ssm/con... , because stimulating the debate and practices related to lifelong education promotes the interaction between education, health and the work process⁷7 Pizzinato A, Gustavo AS, Santos BRL, et al. A integração ensino-serviço como estratégia na formação profissional para o SUS. Rev. bras. Educ. méd. 2012 [acesso em 2018 out 9]; 36(1):170-177. Disponível em: http://www.scielo.br/pdf/rbem/v36n1s2/a25v36n1s2.pdf.
http://www.scielo.br/pdf/rbem/v36n1s2/a2... .

This paper proposes to report the experience of the state of Mato Grosso do Sul in the process of elaborating the State Plan for Permanent Health Education (PEEPS) for the 2019-2022 quadrennium, using upward, decentralized and participatory planning with municipalities. This process was supported by the Committees of Teaching-Service Integration (Cies) and Technical Group of several segments of the SUS, with the conduction of the Superintendency of Labor Management and Health Education of the State Health Secretariat of Mato Grosso do Sul.

Material and methods

This is an experience report linked to the elaboration of the PEEPS of Mato Grosso do Sul, 2018-2019 biennium. This work considered the Regionalization Master Plan, which divides the state of Mato Grosso do Sul into 11 Micro-regions of Health (Aquidauana, Campo Grande, Corumbá, Coxim, Dourados, Jardim, Naviraí, Nova Andradina Paranaíba, Ponta Porã and Três Lagoas), which, in turn, are organized in four Macro-regions of Health (Campo Grande, Dourados, Três Lagoas and Corumbá).

MAP

The exploratory-descriptive design was followed, which occurred in three ways:

The work dynamics occurred during the last five months, as follows:

Initially, the municipal health secretaries were sensitized at the regular meetings of the CIB (Bipartite Interagency Committee), during the three months prior to the workshops. Each municipality should indicate two professionals already active in permanent education or other professionals who composed the technical staff of each municipal secretariat. Initially, a partnership was established with the Council of Municipal Health Secretaries of Mato Grosso do Sul (Cosems), where an e-mail was sent to, requesting that the 79 health managers make such an indication. The PEEPS was also presented to the State Health Council and the CIB.

In the first return, only 34 municipalities made this indication, causing a concern to emphasize and sensitize them to indicate such professionals. Application messages were, then, used directly to each Municipal Health Secretary, when quicker responses were obtained, and there were, still, seven municipalities without professionals, less than 10% of the 79 municipalities in the state.

A Technical Group (TG) was constituted at Cies formed by members representing management, education and work segments, being assigned the attributions of coordination, execution and monitoring of the process of construction of the PEEPS.

In this context, it is important to emphasize that there is an integration between the three levels of management, being that, of the three parts, each one is responsible for this upward construction and within the local reality, where municipal managers are responsible for proposing and agreeing, the state for articulating the participation of this construction, and the Federal Government for increasing it with financial resources⁸8 Andrade SR, Meirelles BHS, Lanzoni GMM. Educação Permanente em Saúde: atribuições e deliberações à luz da Política Nacional e do Pacto de Gestão. O Mundo da saúde. 2011 [acesso em 2018 out 9]; 35(4):373-381. Disponível em: http://bvsms.saude.gov.br/bvs/artigos/educacao_permanente_saude_atribuicoes_deliberaco_pacto_gestao.pdf.
http://bvsms.saude.gov.br/bvs/artigos/ed... .

Results and discussion

Three authors considered important provocateurs for the reflections on the theme of Permanent Health Education (PHE) will be brought to the text. They are: Emerson Merhy⁹9 Merhy E. EPS em movimento - Emerson Merhy [vídeo]. 5 nov 2014. [15:52min.]. [acesso em 2018 out 9]. Disponível em: https://www.youtube.com/watch?v=o-nApG0Wgks.
https://www.youtube.com/watch?v=o-nApG0W... , Laura Macruz Feuerwerker¹⁰10 Feuerwerker LM. EPS em movimento - Laura Macruz Feuerwerker [vídeo]. 17 out 2014. [10:31 min.]. [acesso em 2018 out 9]. Disponível em: https://www.youtube.com/watch?v=x791Rw9_B8k.
https://www.youtube.com/watch?v=x791Rw9_... and Ricardo Burg Ceccim¹¹11 Ceccim R. EPS em movimento - Palavras de Ricardo Ceccim [vídeo]. 10 out 2014. [13:53 min.]. [acesso em 2018 out 9]. Disponível em: www.youtube.com/watch?v=y3IaODHOZfE.
www.youtube.com/watch?v=y3IaODHOZfE... .

Emerson Merhy⁹9 Merhy E. EPS em movimento - Emerson Merhy [vídeo]. 5 nov 2014. [15:52min.]. [acesso em 2018 out 9]. Disponível em: https://www.youtube.com/watch?v=o-nApG0Wgks.
https://www.youtube.com/watch?v=o-nApG0W... invites us to think of PHE as a systematic practice of life in which the needs that health work produce for health workers are posed. Considering that the field of health work is quite complex, since it is the meeting space with the other that is not defined, it is not under the control of both parties. This field creates a lot of tension for all the actors involved and, therefore, must be problematized and reflected with the collective of health workers in the same field. From this, it becomes a knowledge building space.

The author speaks of the existing immobility in this field and which paralyzes health workers. However, new world contexts can produce mobility. Health institutions are, often, ruled, and health workers can invent new and other spaces, which he calls mobile spaces. The field of work is fertile for learning, and PHE is one of the strategies to potentiate changes and withdraw people from immobility.

Emerson Merhy⁹9 Merhy E. EPS em movimento - Emerson Merhy [vídeo]. 5 nov 2014. [15:52min.]. [acesso em 2018 out 9]. Disponível em: https://www.youtube.com/watch?v=o-nApG0Wgks.
https://www.youtube.com/watch?v=o-nApG0W... points out that the world of work is a school and everyone is apprentices.

Laura Macruz Feuerwerker¹⁰10 Feuerwerker LM. EPS em movimento - Laura Macruz Feuerwerker [vídeo]. 17 out 2014. [10:31 min.]. [acesso em 2018 out 9]. Disponível em: https://www.youtube.com/watch?v=x791Rw9_B8k.
https://www.youtube.com/watch?v=x791Rw9_... reinforces that health work is produced through the meeting. These meetings take place among various actors, who are the managers, the workers and the users. Often, some of the actors do not consider others as subjects in the process, then, a relationship occurs that subjugate the others, that is, considers the other as an empty box. This form of meeting, or rather, of not meeting, does not potentiate the parties.

Therefore, PHE, in the notion of the author, is a strategy of thinking and learning collectively, in the possibility of problematizing, reflecting, listening to the other, but in the meeting between actors considered as subjects. One learns when one is already mobilized, implied on the daily work.

Laura Macruz Feuerwerker¹⁰10 Feuerwerker LM. EPS em movimento - Laura Macruz Feuerwerker [vídeo]. 17 out 2014. [10:31 min.]. [acesso em 2018 out 9]. Disponível em: https://www.youtube.com/watch?v=x791Rw9_B8k.
https://www.youtube.com/watch?v=x791Rw9_... highlights that we are all producers of experiences and are crossed by socio-age, cultural and varied matters, and in this living process of production, the meetings take place. In meetings, one can be an inventor or reproducer of actions, depending on how one is in this process of collective reflection. The health worker constructs a way of being from what he/she collects from lived experiences.

Ricardo Burg Ceccin¹¹11 Ceccim R. EPS em movimento - Palavras de Ricardo Ceccim [vídeo]. 10 out 2014. [13:53 min.]. [acesso em 2018 out 9]. Disponível em: www.youtube.com/watch?v=y3IaODHOZfE.
www.youtube.com/watch?v=y3IaODHOZfE... highlights that PHE is not a traditional worker training strategy. It brings to the collective reflection matters that are involved in the daily work of health. It raises the local questions, contextualizes, and, from this, it is the daily life that feeds the PHE.

Such strategies are more powerful when constituted in networks, making each group, in its local scope, articulate in networks, starring circles, which must be activated.

This way, it can be said that the experience of Mato Grosso do Sul has as one of its objectives to build circles among the micro-regional networks to sustain PHE in the municipalities, thus guaranteeing the effective participation of workers in this process as active and activated subjects.

It is intended that the elaboration of the State Plan for Permanent Education can promote the autonomy, the valorization of the processes, the invention, the creation and the protagonism of the people in their local contexts.

Ricardo Burg Ceccin¹¹11 Ceccim R. EPS em movimento - Palavras de Ricardo Ceccim [vídeo]. 10 out 2014. [13:53 min.]. [acesso em 2018 out 9]. Disponível em: www.youtube.com/watch?v=y3IaODHOZfE.
www.youtube.com/watch?v=y3IaODHOZfE... brings, as well, the importance that PHE has when it aggregates knowledge, our own and others, and brings diversities closer together when it promotes meetings. He also defends the PHE as the possibility of provisional territories as spaces of interaction between the involved actors.

Based on these perspectives it is believed that this is a process that can empower municipal workers of SUS to better develop care actions for themselves and the other, as well as for them to be able to construct, in the transience of their territories, spaces of collective construction.

Highlighting the teachings of Ricardo Ceccim¹¹11 Ceccim R. EPS em movimento - Palavras de Ricardo Ceccim [vídeo]. 10 out 2014. [13:53 min.]. [acesso em 2018 out 9]. Disponível em: www.youtube.com/watch?v=y3IaODHOZfE.
www.youtube.com/watch?v=y3IaODHOZfE... , experience raises local questions, contextualizes them, and, from this, it is the daily life that feeds PHE.

The process for the elaboration of the PEEPS in Mato Grosso do Sul is still in motion. It has been an ascending construction, decentralized by municipalities, micro-regions and macro-regions of health, and has allowed, in each one of its stages, the empowerment of the involved actors, promoting a re-signification of their practices and, in some situations, living transformations in act⁹9 Merhy E. EPS em movimento - Emerson Merhy [vídeo]. 5 nov 2014. [15:52min.]. [acesso em 2018 out 9]. Disponível em: https://www.youtube.com/watch?v=o-nApG0Wgks.
https://www.youtube.com/watch?v=o-nApG0W... .

Some stages have already been developed, and the first one, called the 'Preparatory workshop for the application of the instrument', took place in July 2018 and was supported by the Regional Health Centers, some Universities and Municipal Health Secretariats. The workshop had a workload of eight hours, where learning managers and municipal facilitators had the first contact with the guidelines that guide the construction of PEEPS, as well as appropriated the concept of permanent education. The learning managers were selected by criteria defined by the TG/Cies, taking into account the geographical proximity of the manager by macro-region.

After this workshop, in the second stage, 72 municipalities confirmed the participation of their facilitators, these indicated by the health managers, that is, 91% of effective participation of the municipalities in the construction of the PEEPS.

At that stage, the facilitators returned to their municipalities and proceeded to implement the instrument, which was made available by an access link, through the Moodle platform, with the purpose of filling information about the composition of the health workforce in the municipalities, quantifying by category, working time, qualification and occupancy. Experience has shown that informations are lagged and decontextualized from reality. In this sense, the facilitators had more or less difficulty in constructing the database under analysis in the present study.

This action has as objective the knowledge of the health workforce in the state of Mato Grosso do Sul, through a database organized for this purpose.

The workshops have dedicated to work on the themes of the Health Care Networks (RAS) within each local reality, with the effective participation of health workers as well as team members, who were able to portray the potentialities, challenges (critical knots) and coping strategies in order to improve resolutivity in health care.

According to the meetings with the other, produced in the workshops, brought by the work of Merhy and Feuerwerker, is when we potentiate the existing tension spaces and advance to the construction of knowledge.

In this process, still in the second stage, it was necessary to know the health situation of the municipalities to subsidize the elaboration of the State Plan for Permanent Health Education; to immerse in these contexts, in order to know the potentialities and problems that exist in the work processes involving care in health care. This was done through meetings in regional workshops held in the host city of the 11 health micro-regions.

In the third stage of the work, the team carried out workshops with the micro-regional facilitators to process the reports on the meetings arranged. In these spaces, the facilitators were able to talk about their municipal experiences and their affections about this movement. These meetings were conducted by the learning managers. Many remarkable experiences were reported by facilitators and impacted their life and work processes, reaffirming the importance of the construction of PEEPS in the state.

As endorsed by Merhy, the workshops provided the conquest of new and mobile spaces, promoting in those involved a greater motivation in the work process.

The aim in this stage was to condense the data collected in the health micro-regions.

At that moment, the team works in the fourth stage, where the results of the micro-regional meetings are now reflected and analyzed by the learning managers and facilitators in the four macro-regional health. As highlighted by Ceccim, these meetings are not traditional spaces of education, but rather of collective reflection of the daily life, through the contextualization of local questions.

The condensation of the data has been discussed in order to elicit notes, adjustments and evaluation of the process, to formulate, provide and agree on PHE policies.

The fifth stage of this process foresees the consolidation of the data, by macro-regions of health and RAS, where professionals with expertise in the thematic areas should analyze the products of the workshops, in order to qualify the analyses.

This will be a period of meetings with managers, representatives of educational institutions, technical areas of health and health councils, to socialize the results found, as well as for the joint construction of PHE proposals in the RAS.

In the face of all the construction of this process, in the sixth stage envisaged in the project, is being organized, for November 28, 2018, the 'PRO EPS-SUS State Seminar: strengthening permanent health education in Mato Grosso do Sul', with the presentation of the product of the permanent education workshops in the health regions.

It is intended to be a privileged moment for the actors involved, where the presentation of the State Plan for PHE will be made, which can also provide spaces for analysis and evaluation of the process carried out with a larger number of people.

Final considerations

The results obtained, up to this moment, were considered relevant for the actors involved. Which are: survey of matters-problems of work processes in health care, proposing permanent education actions to improve the resolution of health services provided to the population.

The experience reported allowed to promote the strengthening of the Permanent Health Education Policy in the state of Mato Grosso do Sul through the production of 'meetings' between workers and health managers, who could experience a way of doing health with focus on the subject. Actors in different insertions in the SUS, betting on the construction of the new, in horizontal relations, where these products and fruits should be shared with the objective of greater capillarity of PHE in the territories.

Based on this experience, the municipalities are expected to be more mobilized and prepared to promote, in their local contexts, the strengthening of actions by RAS and to bet on the PHE as one of the possibilities of strategy.

References

Publication Dates

History