ABSTRACT

The Welcoming and Assessment Module (Módulo de Acolhimento e Avaliação) is the first contact of the candidate for the More Doctors Program with the Brazilian health system and composes one of the formative cycles of the More Doctors for Brazil Project, the provision of physicians in priority areas of the Unified Health System (SUS). It is a selective training for Brazilian physicians graduated abroad and for foreigners who wish to participate in the More Doctors Program. The organization and success of the Welcoming and Assessment Module are essential for the continuity of the subsequent formative cycles, foreseen in the Project. This article describes and analyzes the planning and operationalization of the Welcoming and Assessment Modules taken place in Brazil and in Cuba, from 2014 to 2017, recommending adjustments in the management of education so that health work can be qualified and resolutive and, thus, contribute to the strengthening of primary care in Brazil.

KEYWORDS
More Doctors Program; Primary Health Care; Education; Health education; International cooperation

Introduction

The More Doctors Program (MDP) is structured in three axes of action: the improvement of the infrastructure of basic health units, the expansion of vacancies in undergraduate courses and medical residences and the emergency provision, implemented by the More Doctors for Brazil Project (PMMB). This provision of professionals, under the responsibility of the Ministry of Health (MH) and the Ministry of Education (MEC), is an important part of the MDP, as it seeks to meet the immediate need for health care in priority areas of the Unified Health System (SUS) and provides training stages for participating doctors. It is important to emphasize that the Program can be considered one of the most important policies of work management and health education management developed in the scope of SUS in recent years, aimed at solving problems in the field of human capacities in health, focusing on care model, particularly in the area of medicine, but with a positive impact on the management of Primary Health Care (PHC) and, consequently, improving access to health services and addressing health inequity situations, as the Program also emerged with the intention of solving problems of care gaps.

The management of the MDP in the MEC is the responsibility of the Higher Education Department (SESu), through the Board of Directors for the Health Education Development (DDES), which has the task of welcoming, monitoring and developing important aspects of teaching-service integration provided by the MDP legislation, as detailed by Almeida et al.¹1 Almeida ER, Macedo HM, Silva JC. Gestão federal do Programa Mais Médicos: o papel do Ministério da Educação. Interface (Botucatu) [internet]. 2019 [acesso em 2019 nov 11]; 23(supl1):e180011. Disponível em: https://doi.org/10.1590/Interface.180011.
https://doi.org/10.1590/Interface.180011... when referring to the role of this Ministry in the Program.

The training stages planned to take place within the scope of the Project encompass several pedagogical actions, obligatorily offered to the participating doctors as a condition for their permanence in the Program²2 Brasil. Lei nº 12.871, de 22 de outubro de 2013. Institui o Programa Mais Médicos, altera as Leis nº 8.745, de 9 de dezembro de 1993, e nº 6.932, de 7 de julho de 1981, e dá outras providências [internet]. Diário Oficial da União. 22 Out 2013. [acesso em 2019 nov 11]. Disponível em: http://www.planalto.gov.br/ccivil_03/_ato2011-2014/2013/lei/l12871.htm.
http://www.planalto.gov.br/ccivil_03/_at... . These steps are contemplated by Law nº 12.871/2013 and Ordinance MEC nº 585, of June 15, 2015, which are guidelines for academic supervision, one of the educational dimensions of the PMMB responsible for strengthening the policy of Permanent Health Education (PHE)³3 Brasil. Ministério da Saúde. Portaria nº 1996, de 20 de agosto de 2007. Dispõe sobre as diretrizes para a implementação da Política Nacional de Educação Permanente em Saúde [internet]. 20 Ago 2007. [acesso em 2019 nov 11]. Disponível em: http://www.saude.mt.gov.br/upload/legislacao/1996-%5B2968-120110-SES-MT%5D.pdf.
http://www.saude.mt.gov.br/upload/legisl... through teaching-service integration. Thus, every doctor participating in the MDP should be regularly and periodically monitored by a supervisor, who performs the guiding role of clinical practice through educational processes. It is not too much to emphasize that supervision has a pedagogical and non-supervisory nature, and occurs within the framework of the PMMB, and its management is under the responsibility of the MEC.

Although not officially considered part of these stages of training, MDP has developed and refined, for almost four years, strategies to carry out the formative selection of doctors, following the recruitment that occurred through public notices or from the cooperation agreement between Brazil and Cuba. This first moment of contact with the MDP candidate doctor was called the Welcoming and Assessment Module (MAAv), which was attended by foreign doctors and Brazilian doctors abroad who wanted to participate in the MDP.

Under the rules of the Program, a doctor graduated in foreign institutions who does not have a revalidated diploma and who is a candidate for MDP will only join it after approval at MAAv, which became the first formative moment of the exchange doctor at PMMB in order to integrate him/her to generalist role in primary care in the context of SUS⁴4 Brasil. Ministério da Sáude; Ministério da Educação. Portaria Interministerial nº 1, de 21 de janeiro de 2014. Dispõe sobre o Modulo de Acolhimento e Avaliação de Médicos Intercambistas [internet]. 21 Jan 2014. [acesso em 2019 nov 11]. Disponível em: http://www.lexmagister.com.br/legis_25242833_PORTARIA_CONJUNTA_N_1_DE_21_DE_JANEIRO_DE_2014.aspx.
http://www.lexmagister.com.br/legis_2524... .

In the MDP, the MAAv was supported, first of all, by the Interministerial Ordinance nº 1, of 21 January 2014⁴4 Brasil. Ministério da Sáude; Ministério da Educação. Portaria Interministerial nº 1, de 21 de janeiro de 2014. Dispõe sobre o Modulo de Acolhimento e Avaliação de Médicos Intercambistas [internet]. 21 Jan 2014. [acesso em 2019 nov 11]. Disponível em: http://www.lexmagister.com.br/legis_25242833_PORTARIA_CONJUNTA_N_1_DE_21_DE_JANEIRO_DE_2014.aspx.
http://www.lexmagister.com.br/legis_2524... , and, from 2015, by the Ordinance nº 315. Its objectives in the latter legislation were expanded and became:

This welcoming of the MDP is structured to take place in 160 hours, distributed among pedagogical experiences – essential in the territory where the professional will be inserted –, knowledge of the Brazilian health system and Portuguese language. Thus, 40 hours are intended for an experience in the health network in the state/municipality in which the professional will be crowded; and to the MAAv, 120 hours of normally uninterrupted workload. The Module is organized with study routines from Monday to Saturday, full-time, during three weeks, in general, in a schedule that intercalates the health area with the Portuguese language.

Regarding the contents, the MAAv covers the following thematic axes⁵5 Brasil. Ministério da Sáude; Ministério da Educação. Portaria Conjunta nº 31, de 5 de junho de 2015. Dispõe sobre o Módulo de Acolhimento e Avaliação do Projeto Mais Médicos para o Brasil [internet]. 5 Jun 2015. [acesso em 2019 nov 11]. Disponível em: http://www.lex.com.br/legis_26867022_PORTARIA_CONJUNTA_N_31_DE_5_DE_JUNHO_DE_2015.aspx.
http://www.lex.com.br/legis_26867022_POR... : I – Portuguese Language Axis; II – Health Skills Axis, which may address, among other themes: Collective Health, Medical Practice in Primary Care, Access to Health Information, Comprehensive Care and Medical Ethics. The legislation provides that other arrangements may be inserted or excluded, after evaluation of timeliness and convenience, provided that such changes are approved by the national coordination of MDP, which is composed of the MH and the MEC.

As the modules, between August 2014 and March 2017, they were intended for doctors from foreign institutions, since some were Brazilians graduated abroad, while others were from the cooperation agreement Brazil-Cuba, there was distinction in Portuguese language content. For Brazilians graduated abroad, the Portuguese area had a smaller workload and involved differentiated competences from the courses offered to foreigners, known as exchange students. For the latter, the Portuguese area involved Portuguese as a Foreign Language (PLE) and, in this case, the required skills followed the guidelines of the Certificate of Proficiency in Portuguese for Foreigners (Celpe-Bras)⁶6 Brasil. Ministério da Educação. Portaria nº 1.350, de 25 de novembro de 2010 - Dispõe sobre o Exame para Certificação de Proficiência em Língua Portuguesa para Estrangeiros - Celpe-Bras [internet]. Diário Oficial da União. 26 Nov 2010 [acesso em 2019 nov 11]. Disponível em: http://download.inep.gov.br/download/celpebras/2010/portaria_n1350_25112010_celpeBras_transferencia_de_responsabilidade_MEC-INEP.pdf.
http://download.inep.gov.br/download/cel... , by choice and guidance of the coordinators who worked in the Modules in the first three years of MDP.

In the health area, the competencies required from the candidates, contained in Ordinance 31/2015, have as specific objectives to bring the exchange student doctor to know the social, demographic, economic and epidemiological context of Brazil; know the SUS and its legislation, implementation and articulation with other social policies in Brazil; understand the work process of the Family Health Strategy (FHS) and identify the specificities in the management of the most prevalent health problems in Brazil, according to the Clinical Protocols of the Ministry of Health; know the main information systems related to primary care of SUS; know the legal aspects and regulation of medical practice in Brazil; and enable the exchange with professionals of primary care of the SUS.

Questions related to students' attendance and criteria for approval are also standardized, through the application of in-person written tests. The MAAv was eliminatory; and to the candidates, there was the minimum approval requirement in both areas: health and Portuguese, being offered the recovery resource, if obtained approval in only one.

It is important to highlight the sites where the MAAv occurred in the period mentioned above. For Brazilians graduated abroad, the Modules were offered mainly in Brasília, FD; for the Cuban exchange students, there was a change in the place of offer: first it was offered in Brasilia, FD, interspersed with some experiences in Cuba. However, after October 2016, the selective training of these candidates became exclusively in Cuba, requiring other possibilities for planning and adjustments in the process.

From the logistic point of view, the Modules that occurred in the analyzed period involved a significant amount of financial resources for the travel, accommodation and feeding of the candidates; displacement, accommodation and feeding of teachers and coordinators of the MH and MEC, when not performed in the Brazilian capital; payment of time/class to teachers; elaboration and reproduction of student evaluations, among others. In addition, at the same time as the Module, there was the document management process carried out by the Ministry of Health, which included the issuance of an Individual Taxpayer Registry (CPF) by the Federal Revenue Service, a permanence visa by the Federal Police and the opening of an account at Banco do Brasil to receive the benefit, among other important actions, as a way to take advantage of the presence of the doctors candidates for the Program. In other words, the MAAv required a great physical and people management structure – by the Brazilian government and the Pan American Health Organization (Paho) – extremely necessary for the process to be fair and transparent.

With this brief introduction, it can be inferred that MAAv became, from 2014 to 2017, potential, an important aspect of the MDP that would allow to improve the educational proposal proposed by the Program. However, despite the fact that the Program has been extensively studied and analyzed since its inception in 2013, little literature is found that allows us to understand or elucidate what was built within this welcoming, which justifies this study. Furthermore, although the MDP is still active, the arrival of Cuban professionals, due to the peculiarity and numerical superiority, required the Program managers to create specific strategies that would meet the health care needs of the Country and, at the same time, that would prepare these professionals to work in Brazilian territory. In addition, some of these strategies must have been reviewed after 14 November 2018, when the cooperation agreement between the two countries was terminated.

Thus, this study intends to bring up for discussion and provoke analysis about the MAAv, occurred in the period between 2014 and 2017, pondering about its role and its importance in relation to other formative stages that doctors went through in the period, from the MEC management point of view on the planning and management process.

As from 2013 to 2018, the Country had the participation of doctors from the Brazil-Cuba cooperation, in strengthening PHC, and this reality was abruptly changed. In this article, some verbs will be presented in the past time when referring to the formative selection of professionals coming from cooperation, known in the technical language of the MH as 'cooperated exchange students'.

Material and methods

In order to perform the analysis in this article, the following methodological strategies were used: starting from the theoretical bases of the pedagogy of problematization for popular education, developed by Paulo Freire⁷7 Freire P. Pedagogia do Oprimido 2. ed. Rio de Janeiro: Paz e Terra; 1970., allied to the PHE guidelines, the experiences of planning and management of MAAv⁸8 Brasil. Ministério da Educação. Relatório Anual de Gestão - RAG 2015. Brasília, DF: Secretaria de Educação Superior; 2015.^,99 Brasil. Ministério da Educação. Relatório Anual de Gestão - RAG 2016. Brasília, DF: Secretaria de Educação Superior; 2016. were analyzed, from August 2014 to March 2017, based on documentary analysis and direct observations. It is a systematization of experiences, reports and construction of documents and processes by public agents working at MEC during the study period.

Considering the understanding of the author about the concept of education and the need for alignment in the format of a pedagogical political project not yet delineated at the time, the theoretical references were based on Paulo Freire and the precepts of the National Policy of Permanent Education in Health, what motivated the group to propose improvements in the process, since the MAAv had been built under a look less progressive in the field of education and that it was going contrary to the one proposed by the PHE policy.

In summary, the methodological strategies used followed three aspects: a) analysis of pedagogical aspects; b) management and planning experiences, in the given period, through document analysis; and c) direct observation in three MAAv occurred in Brazil and four in Cuba, with qualified listening in dialogue with those involved – health and portuguese language teachers.

The documentary analysis of the planning and reporting of the MAAv, as well as the relevant legislation, was performed using the content analysis technique, proposed by Laurence Bardin¹⁰10 Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2009., considering the pre-analysis, exploration and treatment of the results. In addition, qualified listening followed Pêcheux's¹¹11 Pêcheux M. O discurso - estrutura ou acontecimento. Campinas, SP: Pontes; 1990⁽⁵⁷⁾ proposal for discourse analysis, which assumes that

Results and discussion

The MAAv of the MDP occurred during the period analyzed were 16, in Brazil and Cuba, with the participation of approximately 10.500 MDP candidates, as shown in chart 1. The data are approximate because the count considered that some Modules in the official records did not present number of participants actually enrolled, but rather the expected number for that Module.

It should also be considered that the number of participants does not represent the number of MDP members. According to the MEC⁸8 Brasil. Ministério da Educação. Relatório Anual de Gestão - RAG 2015. Brasília, DF: Secretaria de Educação Superior; 2015.^,99 Brasil. Ministério da Educação. Relatório Anual de Gestão - RAG 2016. Brasília, DF: Secretaria de Educação Superior; 2016. records, the percentage of failure in this period was, on average, less than 3% of the candidates, both in the Brazilian and Cuban modules. The specifics of the experience of the two sites are detailed below.

MAAv in Cuba

The entry of doctors from the Brazil-Cuba cooperation was the reason for structuring proposals to carry out the formative selection, following the recruitment of candidates made by the Cuban government. The partnership involved, mainly, Paho, as the intermediary of the cooperation agreement and management of resources transferred by the MH, the MH itself, the MEC, Ministry of Foreign Affairs (MRE), the Ministry of Justice (MJ), among others, and the Cuban government, represented by the Ministry of Public Health. The role of each partner was clearly outlined, and the MAAv for Cubans underwent significant adjustments until it reached the model developed by 2017.

The first training of doctors from the Cuba-Brazil cooperation agreement took place in Havana in 2013, before the MDP had actually started. The participants were MH and MEC managers, as well as PLE teachers and teaching doctors from Brazilian Higher Education Institutions.

In the interval between 2014 and 2015, most Modules were held in Brazil, generating high costs to bring the candidates to MDP and then send them back to the country of origin, in case of non-approval. This situation changed in 2016, when the strategy consisted of taking from Brazil to Cuba the structure of courses, coordination and teachers of PLE and Health, in order to carry out the whole process in Cuban territory, including the documentary management. In this new phase, the planning foresaw two big poles offering the MAAv: one taking place in the capital, Havana, and another in some province of Cuba, defined from the amount of students and their place of origin. Most occurred at two poles.

In 2016 and 2017, the MAAv took place intensively, with a view to preparing around 8.000 Cuban doctors to work in Brazil from December 2016, considering, above all, the replacement of doctors working in the first three years of the Program, as provided for by the legislation. As a result, there was a need to structure and expand the technical teams of the MH and the MEC; and in this context of arrival of new technicians, the movements aiming at the reformulation of the Module began. In October and December 2016, the MAAv of Cuba had the participation of a representative of the MEC and two of the MH. Because they were the first in this format, there was a need for adjustments and creation of work processes that would allow compliance with the deadlines agreed with the Cuban government. In the 2017 Modules, the number of MEC participants increased and, then, returned to the previous scheme. In this sense, the MEC was refining its modus operandi, starting with the constitution of a work team that started to discuss the education management and to demand more space in the decisions made by the MH teams. This movement continued until there was no more support from DDES/SESu/MEC for such protagonism, which was interrupted, it is believed, by the process of democratic rupture that occurred at the time, with consequent change of leadership positions, which generated neglect and overlap partisan and individual interests to the collective cause.

From the pedagogical point of view, the Modules suffered from the lack of structuring of an effective teacher recruitment and selection process, which would allow interaction and discussion about the teaching-learning processes. The teachers changed with each edition and taught classes from already elaborated materials that were not updated regularly. However, this fragility was more significant in the health area than in Portuguese, since the PLE area had two main coordinators, who recruited the majority of teachers, with the MH endorsement, while the health area did not had coordinators with such profiles. In this sense, the Portuguese area was much more structured and advanced significantly in the period analyzed.

MAAv in Brazil

For reasons of geographical centrality and being the headquarters of the Ministries, the structure for the realization of modules in Brazil was consolidated in Brasilia-FD, from where the approved candidates were forwarded to the places of operation, as they already pass through document management at the same time, as mentioned above. The execution of these was similar to that of Cuba, with the striking difference in the Portuguese area, which becomes Portuguese language and not PLE.

The MH coordinated the logistics and document management, and the MEC, unlike the management of the MAAv in Cuba, assumed the recruitment and selection of teachers, the pedagogical coordination and the application of learning assessments. The workload was the same, only the public presented greater diversity, as it welcomed Brazilians graduated abroad and foreign doctors trained in other countries (individual exchange students). It is important to highlight that the Modules that occurred in Brazil always had the participation of technicians from the Primary Health Department (DAB) of the MH, a fact that was not observed in the modules of Cuba. Such participation would allow doctors to better qualify in current issues of the National Policy of Primary Care, under the management of the DAB, and bring professionals closer to the reality of Brazilian primary care services.

There was precariousness in the planning and management of the MAAv destined for Brazilians graduated abroad, especially, regarding the recruitment and selection of teachers by the MEC. Similar to those in Cuba, there are no teams of teachers that can discuss, interact and propose improvements in the modules, nor management teams in MEC and MH. The teachers also changed with each edition and taught classes from previously prepared materials.

It is noteworthy that the difficulties of MAAv in Brazil, likewise, were mainly in the health area, given that most of the participating candidates have predominantly hospital-centric medical training¹³13 Romano VF. Tendências de mudanças na formação médica no Brasil: tipologia das escolas. Jadete Barbosa Lampert. Rio de Janeiro: Hucitec; 2002. – obtained in neighboring countries that follow the movement of traditional schools since 1960 –, demanding from teachers a greater commitment to present and bring the Brazilian health system and the focus on PHC to the understanding of all.

Weaknesses and potentialities of MAAv

In the operationalization of the Modules in Brazil and Cuba, weaknesses in the processes were observed, mainly because: a) there are no formal criteria for recruitment and selection of teachers in the Portuguese and health area; b) health contents are not regularly updated; c) there is no interaction between the areas or articulation between the contents taught, which is noticeable by the weak theoretical and methodological integration between health and Portuguese teachers; d) there is a split in the pedagogical process, who elaborates(ed) and organizes(ed) the contents is not who takes over the classroom; e) the elaboration of student evaluations is solely and exclusively the responsibility of the coordinator selected for each Module who, not necessarily, has knowledge and experience for such function; f) there is no course evaluation instituted; and g) classes are given without discussion about the methodology or clarity about the pedagogical intentionality that the situation requires and, mainly, because there was no preparation or teacher training.

Criticism of the Modules carried out until March 2017 generally converges on the lack of structuring of attendance to pedagogical demands, as already pointed out by Faria¹⁴14 Faria MA, Paula DMP, Rocha CMF. Apontamentos sobre o Módulo de Acolhimento e Avaliação do Programa Mais Médicos. Rev bras educ med. 2016; 40(3):332-336. Disponível em: http://www.scielo.br/pdf/rbem/v40n3/1981-5271-rbem-40-3-0332.pdf
http://www.scielo.br/pdf/rbem/v40n3/1981... , when reporting on the experience of monitoring a MAAv in 2013, establishing criticism of the adopted teaching profile, which, at that time, was already precarious, questioning whether

Because this has not happened since the beginning of the Modules, the situation of each teacher presenting pedagogical practices that suited him or her continued.

Despite these problems, the major difficulties identified in the analyzed period may be due to the poor alignment between the MEC and the MH regarding process management. There was a significant difference in the management of the Cuban and Brazilian Modules.

In the Cuban Modules, the MH was formally in charge of logistics, once it was responsible for the institutional relationship and management of financial resources at Paho, which required the involvement of much of the MAAv planning, as a follow-up to negotiations with the Cuban government, definition of calendars, locations of modules, payment of class hours to teachers, travel and accommodation of students and teachers, among others. However, it also assumed other fronts, such as: recruitment and selection of teachers, content organization, choice of coordinators and theoretical-methodological definitions, leaving the MEC the reproduction, application and custody of student evaluations, and the provision of legal support where necessary. Chart 2 presents a summary comparison of the two situations.

In our analysis, these interministerial mismatches are, probably, due to the non-compliance with an aspect of Ordinance nº 31: a pedagogical commission should have been created that would have the deliberative function on all these issues, especially with regard to choices or reformulation of the theoretical and methodological framework of the MAAv, content updating and evaluation processes. The creation of the Commission is foreseen in the referred legislation and should have been appointed by the National Coordination of the PMMB. Any and all changes of the MAAv must be approved by the National Coordination, which ceased to meet after May 2016. It was up to the

The Pedagogical Commission of the PMMB would express the partnership and inter-ministerial responsibilities provided for in MDP legislation and design.

In the period analyzed, there were seven formations in Cuba and nine in Brazil; and, in all, the difficulties were similar. With the dynamics that were being developed in the management of the Modules, there was a clear fission of the educational process that should have been the basis of the formative selection, when decoupling the planning of the pedagogical practice and, from this, the student evaluation. This fission is evident when, for the selected teacher, it is appropriate to mediate the learning with a material already structured in selected contents in planning processes of which he/she was not part of. These clippings were obviously not based on deliberate learning methodologies with intentionality, aiming at the objective that was intended to be achieved, due to lack of knowledge or lack of interest of the managing core. Acting with pedagogical intentionality is to organize the formal educational process in a conscious, planned, creative way and capable of producing a positive effect on the student's learning¹⁵15 Negri PS. Comunicação Didática: A Intencionalidade Pedagógica Como Estratégia de Ensino. Módulo I. Londrina: LABTED/UEL; 2008., according to the desired skills. In the case of MAAv, if the methodological choices existed, these were not aligned with the MEC that, in turn, took the application of the evaluation of students as a logistical-administrative responsibility and therefore, within a strictly traditional and conservative pedagogical perspective, under the concept of 'bank education' described by Paulo Freire⁷7 Freire P. Pedagogia do Oprimido 2. ed. Rio de Janeiro: Paz e Terra; 1970..

Added to these challenges was the lack of continuity/integration of the MAAv with the subsequent stage of the training cycle, which is academic supervision, which is mandatory for all doctors of the MDP, although such articulation is important in MDP design. Currently, the only existing link in the health area between these training is mainly due to the presence of MDP supervisors and tutors as MAAv teachers, which puts in a more demanding position the quality of academic supervision that the doctor has received. The contents of the Reception Modules should be fed back by the supervision, if there were technical capacity and interest of MEC to act in this level of involvement after 2016.

In addition, experience has shown that health care also suffers from the activities that professional doctors – university professors, tutors, supervisors, etc. – exercise. Acting as a MAAv teacher requires availability that Brazilian medical professionals do not usually have, due to their agendas and professional work dynamics. Thus, maintaining a cohesive group or groups was not a possibility, especially when referring to the Modules that took place in Cuba, which required a minimum of 20 days dedicated exclusively to the course.

As potentialities, the advances made in the Portuguese area are emphasized, especially in the group that operates in PLE in the Modules that involved Cuban exchange students. The difference was observed by the more constant presence of the same coordinator, that is, even with scheduling difficulties, the leadership of the processes was between two extremely qualified teachers who were accumulating expertise in this process. Another point that deserves attention is the fact that even though not all teachers in this area were trained in PLE, all had minimal experience as teachers. The PLE group has, therefore, improved over the modules; and by March 2017, they were proposing improvements in student assessment in order to better select doctors approved to come to Brazil. It is not known if the proposals were accepted by the teams that were in the process management until 2018.

The MAAv pedagogical process, in general, was apparently weakened by the absence of teaching-learning specialists in the planning and management of the modules in MH and MEC. However, what was fragile became even more precarious with the changes in post-impeachment government Ministries. From 2014 to 2016, for example, the recruitment and selection criteria for teachers – albeit incipient – in the health area, prioritized doctors with training and teaching experience in Family and Community Medicine (MFC). These criteria were no longer respected after March 2017, when the MH teams, by default of the MEC, began to use undisclosed criteria for choosing teachers, and removed most doctors with training in MFC from the process.

It is noteworthy that, at the end of 2016 and beginning of 2017, there were attempts by MEC and MH, through DAB, to reformulate MAAv. In November and December 2016, the General Coordination for Health Education Management/DDES/MEC and DAB/MH met to plan the reformulation of the Modules, and the construction of a preliminary diagnosis was started, with the help of tutors who had been teachers of the courses. This diagnosis would be the starting point for the update of the training axes for the MAAv, since it has as its characteristic the identification of a situational mark in a collective process. After these face-to-face meetings, a virtual conference took place in January 2017, which was attended by tutors. However, this initiative did not advance because: a) there was already a change in the teams of both institutions after the impeachment, and the interest of the new managers did not match those of the technical teams, leading to the maintenance of a situation without structuring or pedagogical commitment; b) there was an apparent difficulty in performing collective work between sectors in the MH involved in the MDP. There were difficulties of interaction between these sectors, which impaired the participation of DAB in the expected protagonism of this in the definition and/or revision of contents related to the Program; and c) there was difficulty on the part of the MEC team in defending the pedagogical nature of MAAv, as intended in late 2016 and early 2017.

This last effort towards the new structure of MAAv, in order to improve the norms and guidelines that guide it, would be a possibility of establishing a link between the entry of the doctor into the Program and his/her continuity in the teaching-service integration. The MAAv update would also go as a means of integrating the various pre-existing knowledge, allowing the constant revision of contents, methodologies and the evaluation format, because it would contain the objectives of the educational action and the linearity necessary to articulate the cycles, as well as the strategies that were intended to be used to achieve what was proposed. It was a matter of organizing the pedagogical intentionality of MAAv, supported by the conceptions of participatory management and the premises of the PHE.

Even with this scenario, in October 2017, MEC launched a public notice, in partnership with the United Nations Educational, Scientific and Cultural Organization (Unesco), to hire a consultant to analyze MAAv and propose solutions. At the end of 2017, MEC formed a group to discuss the MAAv, without the participation of the MH, not having been disclosed the results of these actions. It is interesting to reflect that such initiatives went against the current legislation again, which aimed to institutionalize interministerial actions that would culminate in the reformulations of the Modules.

Final considerations

The MDP has been built and improved, since 2013, under the premise of sharing management, especially interministerial. From the date of its creation until mid-2015, there was a need to create new legislation to improve the design of the Program, as well as to meet the requirements of transparency of processes before the Brazilian control and supervisory bodies. In addition, it still continues even if reduced and under other arrangements, which makes this analysis a first step for future research on the subject.

As part of important formative stages, it is necessary to consider that, despite being foreseen in the MDP design, the academic supervision and the Welcoming Module do not yet have a linear and intentional management, to overcome the current bond between the formation cycles. This is mainly due to the recruitment of health professors among MDP supervisors and tutors, which had already been expressively fragile.

In relation to the organization of pedagogical work, even if there is no longer the MAAv for the cooperated exchange students, it is recommended that, safeguarding the conditions of recruitment and selection, a space for planning and exchange of experiences is guaranteed, so that teachers can formulate more integrated assessment instruments, methodologies and technologies that take into account the recommendations of the National Policy on Permanent Health Education in its Annex II³3 Brasil. Ministério da Saúde. Portaria nº 1996, de 20 de agosto de 2007. Dispõe sobre as diretrizes para a implementação da Política Nacional de Educação Permanente em Saúde [internet]. 20 Ago 2007. [acesso em 2019 nov 11]. Disponível em: http://www.saude.mt.gov.br/upload/legislacao/1996-%5B2968-120110-SES-MT%5D.pdf.
http://www.saude.mt.gov.br/upload/legisl... , in which knowledge is not transmitted, but is built from the doubts and questioning of current practices in the light of contextual problems, it includes the search for training in teamwork, the integration of cognitive dimensions, attitudes and practical skills, prioritizing long-term processes over isolated actions through courses.

Allied to this, it is expected that the teaching team can develop a process of systematization of experience, thus constituting a set of information on what was experienced, especially the social, cultural and political dimensions expressed during the performance of MAAv. It refers singularly to the expressions that give meaning and sense to the participating doctors and teachers, in terms of the different knowledge and ways of thinking about the processes of illness and health promotion, considering the different conceptions of health and medicine that make up the philosophical repertoire of the participants from MAAv.

It was identified that the objectives contained in the institutional planning of both Ministries could not go beyond the molds of a learning process based on traditional teaching, understanding that what could be expected from the pedagogical process built and realized would have to have intentionality and clarity in the theoretical-methodological options.

Despite all these difficulties, it is considered that this formative selection was still the most appropriate for the Program, requiring fundamental adjustments in the management of education so that health work is qualified and resolute and, thus, contributes to the strengthening and the consolidation of PHC in Brazil.

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