ABSTRACT

Eye healthcare interventions and prevention of blindness at school have been developed since the last century in Brazil, following changes in models of care and health at school. This is a qualitative research of documentary analysis that aimed to analyze the normative documents on the subject of eye health in schools in Brazil, especially within the scope of the School Health Program (PSE) and the historical trajectory of eye healthcare policies. For data treatment, content analysis was adopted, and the corpus of the study consisted of 48 normative acts. Among the normative acts, it was possible to identify Presidential Decrees, Public Consultations, Ministerial Decrees, and Interministerial Decrees. It became evident that a comprehensive and coordinated eye healthcare is still a challenge for the Unified Health System (SUS) due to the interruption of initiatives that guarantee access to healthcare and the little incentive to carry out these practices in detriment of other PSE actions. It was also found that the debate on eye healthcare actions in the school environment dates back to the National Policy of Care in Ophthalmology, revealing a pioneering work on the subject in Primary Health Care.

KEYWORDS
Eye health; School health services; Primary Health Care; Unified Health System; Public policy

Introduction

Of the five human senses, vision is the most dominant and plays a crucial role in all aspects of life. Worldwide, at least 2.2 billion people are visually impaired, and about half of these cases could have been prevented or have not been properly addressed. Interventions to reduce the risk of acquiring a visual condition or disability and reduce its impact are various in the fields of promotion, prevention, treatment, and rehabilitation¹1 World Health Organization. World report on vision. Geneva: World Health Organization; 2019..

In this context, interventions to improve students’ health in school environments²2 Langford R, Bonell C, Jones H, et al. The World Health Organization’s Health Promoting Schools framework: a Cochrane systematic review and meta-analysis. BMC public health. 2015 [acesso em 2020 maio 20]; 15(1):130-137. Disponível em: https://bmcpubli-chealth.biomedcentral.com/articles/10.1186/s12889-015-1360-y.
https://bmcpubli-chealth.biomedcentral.c... are used to provide vision-related services and have the potential for cost-effective solutions³3 International Agency for the Prevention of Blindness. Standard school eye health guidelines for low and middle-income countries. London: International Agency for the Prevention of Blindness; 2018. [acesso em 2020 maio 20]. Disponível em: https://www.iapb.org/wp-content/uploads/Guidelines-School-Eye-Health-Programmes-English-Final.pdf.
https://www.iapb.org/wp-content/uploads/... ,⁴4 Burnett A, Yashadhana A, Lee L, et al. Interventions to improve school-based eye-care services in low- and middle-income countries: a systematic review. Bull World Health Organ. 2018 [acesso em 2020 maio 20]; 96(10):682-694D. Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6238998/.
https://www.ncbi.nlm.nih.gov/pmc/article... ,⁵5 Global Partnership for Education. School Health Integrated Programming. Guidelines for School-based Eye Health Programs. Washington, DC: GPE; 2017. [acesso em 2020 maio 20]. Disponível em: https://www.globalpartnership.org/sites/default/files/2017-09-ship-guidelines-vision-screening.pdf.
https://www.globalpartnership.org/sites/... . Initiatives in these environments are anchored by the convergence of education and health systems and have been implemented in low-and middle-income countries for at least 20 years³3 International Agency for the Prevention of Blindness. Standard school eye health guidelines for low and middle-income countries. London: International Agency for the Prevention of Blindness; 2018. [acesso em 2020 maio 20]. Disponível em: https://www.iapb.org/wp-content/uploads/Guidelines-School-Eye-Health-Programmes-English-Final.pdf.
https://www.iapb.org/wp-content/uploads/... .

In Brazil, eye health interventions and prevention of blindness in schools have been developed since the last century through regional initiatives, plans, projects and campaigns. A common characteristic of these interventions was the preventive nature of these campaigns far from the current model of health promotion in the school space²2 Langford R, Bonell C, Jones H, et al. The World Health Organization’s Health Promoting Schools framework: a Cochrane systematic review and meta-analysis. BMC public health. 2015 [acesso em 2020 maio 20]; 15(1):130-137. Disponível em: https://bmcpubli-chealth.biomedcentral.com/articles/10.1186/s12889-015-1360-y.
https://bmcpubli-chealth.biomedcentral.c... ,⁶6 Kara-José N, Rodrigues MLV. Saúde Ocular e prevenção da cegueira. Rio de Janeiro: Cultura Médica; 2009.,⁷7 Becker TOF, Cortela DCB, Miura H, et al. Avaliação da acuidade visual em escolares do ensino fundamental. Rev. bras. oftalmol. 2019 [acesso em 2020 maio 20]; 78(1):37-41. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-72802019000100037&lng=en.
http://www.scielo.br/scielo.php?script=s... .

In 2007, the theme was involved in the genesis of the School Health Program (PSE), according to Decree No. 6,286 of December 5, 2007. This refers to an interministerial program aiming to contribute to the integral formation of students in the public elementary education network⁸8 Brasil. Presidência da República. Decreto nº 6.286, de 5 de dezembro de 2007. Institui o Programa Saúde na Escola - PSE, e dá outras providências. Diário Oficial da União. 5 Dez 2007., and eye health is one of the 12 actions of the PSE⁹9 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Cadernos temáticos do PSE: Saúde Ocular. Brasília, DF: Ministério da Saúde; 2016. [acesso em 2020 maio 20]. Disponível em: http://189.28.128.100/dab/docs/portaldab/documentos/caderno_saude_ocular.pdf.
http://189.28.128.100/dab/docs/portaldab... .

As one of the Primary Health Care (PHC) programs, it is dedicated to processes involving health promotion and disease prevention in the territory and acts as a gateway to more complex health services. Health and education professionals are encouraged to work intersectoriality according to the PSE implementation guideline; in turn, eye health practices developed in schools should consider the articulation between the services of both sectors⁸8 Brasil. Presidência da República. Decreto nº 6.286, de 5 de dezembro de 2007. Institui o Programa Saúde na Escola - PSE, e dá outras providências. Diário Oficial da União. 5 Dez 2007.,⁹9 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Cadernos temáticos do PSE: Saúde Ocular. Brasília, DF: Ministério da Saúde; 2016. [acesso em 2020 maio 20]. Disponível em: http://189.28.128.100/dab/docs/portaldab/documentos/caderno_saude_ocular.pdf.
http://189.28.128.100/dab/docs/portaldab... ,¹⁰10 Vieira LS, Belisário SA. Intersetorialidade na promoção da saúde escolar: um estudo do Programa Saúde na Escola. Saúde debate. 2018 [acesso em 2020 maio 20]; 42(esp4):120-133. Disponível em: https://www.scielosp.org/article/sdeb/2018.v42nspe4/120-133/#.
https://www.scielosp.org/article/sdeb/20... .

The PSE represents a landmark in the development of initiatives to promote eye health and prevent blindness in the context of the school community and PHC, despite being part of the operational structure of the Health Care Network of the Brazilian Unified Health System (SUS)⁸8 Brasil. Presidência da República. Decreto nº 6.286, de 5 de dezembro de 2007. Institui o Programa Saúde na Escola - PSE, e dá outras providências. Diário Oficial da União. 5 Dez 2007.,⁹9 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Cadernos temáticos do PSE: Saúde Ocular. Brasília, DF: Ministério da Saúde; 2016. [acesso em 2020 maio 20]. Disponível em: http://189.28.128.100/dab/docs/portaldab/documentos/caderno_saude_ocular.pdf.
http://189.28.128.100/dab/docs/portaldab... .

Over its 15 years of existence, the PSE has gathered a series of norms addressing several issues, including eye health. However, it is worth investigating how eye health is presented in these regulations, its insertion in the PSE, and the situation of it in the State instruments.

Thus, this study aims to analyze the normative documents involving the theme of eye health in school facilities in Brazil, especially in the scope of the PSE, and the historical trajectory of eye health policies.

Material e methods

This is a qualitative documentary research that had as data source policies, decrees, and other regulations published on eye health issues in the Brazilian school facilities and in the federal public administration.

No time frame was established to avoid restricting correlated normative acts and of interest prior to the eye health actions recommended by the health and education ministries and, thus, to include this information on the historical context of implantation and implementation of eye health, and in the context of the PSE.

Its technical reference is documentary research, characterized by the search for information in documents that have not received any analytical treatment, that is, primary sources. These are original data from which the researcher has a direct contact with the facts to be analyzed¹¹11 Marconi MA, Lakatos EM. Fundamentos da metodologia científica. 6. ed. São Paulo: Atlas; 2008.. Official documents are generally a reliable source of data, especially in the analysis of the contexts of political acts and their scope¹²12 Sá-Silva JR, Almeida CD, Guindani JF. Pesquisa documental: pistas teóricas e metodológicas. Rev Bras Hist Ciênc Soc. 2009 [acesso em 2020 maio 20]; 1(1). Disponível em: https://periodicos.furg.br/rbhcs/article/view/10351/0.
https://periodicos.furg.br/rbhcs/article... .

Therefore, normative acts were sought in the electronic platforms for legislation research, namely: Portal da Legislação Brasileira (Brazilian Legislation Gateway)¹³13 Brasil. Presidência da República. Portal da Legislação. Brasília, DF: Presidência da República; 2020. [acesso em 2020 maio 17]. Disponível em: http://www4.planalto.gov.br/legislacao/.
http://www4.planalto.gov.br/legislacao/... and Saúde Legis (search system for SUS normative acts at the federal level)¹⁴14 Brasil. Ministério da Saúde. Saúde Legis. Brasília, DF: MS; 2020 [acesso em 2020 maio 16]. Disponível em: https://saudelegis.saude.gov.br/saudelegis/.
https://saudelegis.saude.gov.br/saudeleg... . The searches occurred on May 16 and 17, 2020, using the following keywords: ‘School Health Program,’ ‘Health at School,’ ‘Eye Health,’ and ‘Ophthalmology’.

Content analysis was used for data organization and analysis, considering the pre-analysis stages, which includes floating reading, constitution of the corpus, and formulation of assumptions; exploration of the material, expressed through codification and categorization; and treatment of the results, based on the interpretation raised¹⁵15 Cavalcante RB, Calixto P, Pinheiro MMK. Análise de Conteúdo: considerações gerais, relações com a pergunta de pesquisa, possibilidades e limitações do método. I&S. 2014 [acesso em 2020 maio 30]; 24(1). Disponível em: https://periodicos.ufpb.br/ojs2/index.php/ies/article/view/10000.
https://periodicos.ufpb.br/ojs2/index.ph... .

The normative acts were accessed from the certified versions in the Union Official Gazette, including norms related to the PSE regulations and to eye health in the PHC scope. The exclusion criteria were the acts whose original correspondence in the Union Official Gazette was not found, regulations of activities in hospitals, of accreditation of hospital units, of medicalization and medical-surgical procedures as well as the approval of adherence not related to the PSE.

After accessing the official publications, the normative acts were downloaded and organized in a Microsoft Excel® spreadsheet according to the extraction of the publication number, its origin, the typology, the date of publication, the menu and the information on the validity of the respective regulation. Then, we proceeded to the pre-analysis followed by the exploration of the material, which was organized and categorized according to the subject of the menu and the body of the publication, to finally be analyzed according to the history of school health policies in Brazil.

This study is part of a research on the evaluability of the eye health action of the PSE duly approved by the Research Ethics Committee of the Oswaldo Cruz Foundation – FIOCRUZ Brasília, under opinion number 3.858.465 and CAAE number 28560320.0.0000.8027, on February 27, 2020.

Results e discussion

In total, the searches returned 258 normative acts. Of these, 48 made up the corpus of the study, 36 were identified as duplicates, and 174 were excluded (table 1).

Among the normative acts, it was possible to identify presidential decrees, public consultations, ministerial ordinances, and interministerial ordinances between the Ministries of Health and Education.

Although the search did not return any consolidation ordinances, it is important to consider them in the present discussions. These are the SUS’s ordinary legislation, whose objective is to regulate the administrative and judicial practices of public health policies, as well as having the Brazilian Constitution as a trustee of these administrative processes. The number of normative acts within the SUS is extensive, a legacy of the management complexity of this system and, at times, may present inconsistencies with the adopted model. Therefore, it was necessary to consolidate them with the support of knowledge and precepts of health law¹⁶16 Bisol J. Desafios da sistematização do direito sanitário: da consolidação normativa ao desenvolvimento teórico e dogmático. Cad Ibero-American Direito Sanit. 2019 [acesso em 2020 maio 30]; 8(3):173-177. Disponível: https://www.cadernos.prodisa.fiocruz. br/index.php/cadernos/article/view/580.
https://www.cadernos.prodisa.fiocruz. br... .

It was possible to identify limitations in the search for normative acts prior to the year 2000, which are relevant for context evaluation. The regulations found in the searches and included in the study are from 2002 to 2019 (figure 1).

Based on the analysis of the normative acts comprised in the corpus, having the theme as a unit of record, the categories listed are: ‘Eye Health’, subcategorized in ‘Eye healthcare initiatives in the PHC’; and ‘Health at School’, subcategorized in ‘Implantation and implementation of PSE in Brazil’; and ‘Eye health actions within the scope of PSE’.

Eye health

In 2002, according to the analyzed norms, the Ophthalmology Care Networks were created within SUS based on the need to organize care, structure networks, establish flows, and expand access to ophthalmological services. Networks were understood as outpatient and hospital services previously accredited, whose premise remains in force, as described in Ordinance No. 288, May 19, 2008.

The vast majority of eye care services in low- and middle-income countries are provided in secondary or tertiary hospitals located mainly in urban areas, revealing the inequality in access. That brings to light the importance of strengthening the integration of eye care services in PHC and ensuring an effective referral pathway for timely treatment of eye diseases¹1 World Health Organization. World report on vision. Geneva: World Health Organization; 2019..

The establishment of a Brazilian policy on this issue was collectively conceived through the creation of working groups which would elaborate the former Policy of Ocular Health in 2003. However, only in 2008, there was the National Policy of Care in Ophthalmology, which, in the context of PHC, is intended to carry out actions of individual or collective character aimed at health promotion, prevention of visual impairment, and recovery. It was also intended to clinical actions for the control of diseases leading to ophthalmic alterations and diseases that can be done at this level. These actions would take place in the network of basic health services.

Effective health promotion strategies result in behavior changes and foster compliance to treatment regimens. Thus, professionals should guide their actions in the spheres of health education, prevention, and health protection¹⁷17 Williamson S, Seewoodhary R, Dampies L. Effect of poverty on eye health and implications for nursing practice. Nursing Standard. 2016 [acesso em 2020 set 7]; 30(50):42-51. Disponível em: https://journals.rcni.com/nursing-standard/effect-of-poverty-on-eye-health-and-implications-for-nursing-practice-ns.2016.e10014.
https://journals.rcni.com/nursing-standa... – especially in Brazil, where the supply of eye healthcare is centered in a disordered supply of ophthalmologists in the national territory, who are mostly linked to the private service in heterogeneous levels of care¹⁸18 Ottaiano JAA, Ávila MP, Umbelino CC, et al. As condições de saúde ocular no Brasil. São Paulo: CBO; 2019. [acesso em 2020 nov 24]. Disponível em: http://www.cbo.com.br/novo/publicacoes/condicoes_saude_ocular_brasil2019.pdf.
http://www.cbo.com.br/novo/publicacoes/c... .

The promotion of eye health and prevention of eye diseases were reinforced in the context of the PHC and ratified by the creation, in 2008, of the State Care Networks for People with Visual Impairment, consisting of actions in the PHC and in the Visual Rehabilitation Services.

Eye health directed to Brazilian children is addressed in the establishment of this network, also integrating schools in this inclusion process, a debate that succeeded the Guidelines for Eye Health Care in Childhood: Early Detection and Intervention for Prevention of Visual Impairments within SUS, in 2012.

In 2018, a new working group was formed, this time to review the Ophthalmology Care Networks, but it did not foresee the participation of PHC representatives, as occurred in the first group.

This is relevant due to the role of the PHC in reducing barriers to access eye healthcare whether structural, financial or personal. The lack of prominence of this level of care perpetuates the concentration of secondary care in ophthalmology. These, on the other hand, are unable to meet the demands of prevention; at most, they diagnose conditions for which users cannot afford the high cost of treatment¹⁹19 Lima NC, Baptista TWF, Vargas EP. Ensaio sobre ‘cegueiras’: itinerário terapêutico e barreiras de acesso em assistência oftalmológica. Interface (Botucatu). 2017 [acesso em 2020 set 30]; 21(6):615-627. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-32832017000300615&lng=en.
http://www.scielo.br/scielo.php?script=s... ,²⁰20 Condessa AM, Giordani JMA, Neves M, et al. Barreiras e facilitadores à comunicação no atendimento de pessoas com deficiência sensorial na atenção primária à saúde: estudo multinível. Rev. bras. epidemiol. 2020 [acesso em 2020 set 30]; 23:e200074. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1415-790X2020000100460&lng=pt.
http://www.scielo.br/scielo.php?script=s... .

The Family Health Strategy, as part of the Brazilian PHC, has a unique capacity for eye healthcare because its professionals are inserted in the community and experience health-disease processes in various social contexts.

Thus, timely identification of ocular problems and appropriate referral of users to other levels of care are one of the objectives of a comprehensive and coordinated care of PHC in the Ophthalmology Care Network²¹21 Fernandes LA, Franzoi MAH. Prevalência de Baixa Acuidade Visual em Crianças de Uma Escola da Rede Pública de Ensino. Cogitare enferm. 2020 [acesso em 2020 nov 25]; 25:e67144. Disponível em: http://www.revenf.bvs.br/scielo.php?script=sci_arttext&pid=S1414-85362020000100341&lng=pt.
http://www.revenf.bvs.br/scielo.php?scri... .

Eye health care initiatives in PHC

The link between health and education promoted by the Projeto Olhar Brasil (Brazil Eye Project) happened in parallel to the PSE through the Interministerial Ordinance No. 15, 2007, whose objectives were to identify and correct visual problems related to refraction. The project was meant to reduce school dropout rates and facilitate the target population’s access to ophthalmological consultations and to the purchase of eyeglasses (for children from the public elementary school system, from the Programa Brasil Alfabetizado – Brazil Literate Program, and the population aged 60 or more).

Brazilian population has a high rate of eye problems, especially those linked to refractive error – 30% of school children and most adults over 40 years (in 2008) – that are generally solved with the use of glasses (figure 2).

The project initially foresaw a duration of two years, but was extended to four more years. In 2012, it was redefined without establishing a term.

It is noteworthy that, at the beginning there were elements such as a price registration act for the purchase of eyeglasses, as well as incentives for the adhesion of states and municipalities in the North and Northeast regions, which no longer appear as priorities in the normative acts.

Financing was provided by the Medium and High Complexity Block, automatically from the Fund for Strategic Actions and Compensation (FAEC), either for eye care or for the supply of glasses. In addition, the productions were released exclusively in the outpatient systems through specific project codes, present in the SUS Table of Procedures, Medications, Orthotics, Prostheses and Materials.

Brazil Eye Project was an important initiative for the implementation of the National Policy for Ophthalmology Care at the various levels of SUS health services as it engaged education professionals and PHC professionals, and also professionals from specialized care²³23 Dalia ERC, Campos LM, Teixeira LP, et al. Análise da prevalência dos pacientes que necessitam de óculos em um Hospital Oftalmológico em Goiânia, Goiás, Brasil. Projeto Olhar Brasil. Rev. bras.oftalmol. 2017 [acesso em 2020 ago 23]; 76(2):57-60. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-72802017000200057&lng=en.
http://www.scielo.br/scielo.php?script=s... . Despite this, although Ordinance No. 2,299 of 2012 is still in force, in practice, it was discontinued.

The PSE participants were given priority when joining the Brazil Eye Project and the Projeto Consultórios Itinerantes (Itinerant Consultations Project), another project that deserves attention. The Interministerial Ordinance No. 15 of 2013²⁴24 Brasil. Ministério da Educação. Portaria Interministerial n° 15, de 10 de outubro de 2013. Institui o Projeto Consultórios Itinerantes de Odontologia e de Oftalmologia, no âmbito do Programa Saúde na Escola - PSE e Programa Brasil Alfabetizado - PBA, e dá outras providências. Diário Oficial da União. 10 Out 2013. established the Itinerant Consultations Project of Dentistry and Ophthalmology within the scope of the PSE and the Brazil Literate Program. The itinerant consulting offices were vehicles adapted and equipped for oral and eye healthcare consisting of a truck for the locomotion of the trunks (the ophthalmology trunk had two offices and an eyeglass assembly laboratory).

This project aimed to expand the ophthalmological care providing, through mobile and itinerant ophthalmological offices, consultations in partnership with Federal University Hospitals and Federal Institutions of Higher Education, such as the network of the Brazilian Company of Hospital Services (EBSERH).

These were subject to municipal adhesion approved by ordinance and through the scrutiny of the Department of Specialized and Thematic Care. One of the criteria was the insufficient care network to meet the demand for eye care, for example, in municipalities not accredited for the Brazil Eye Project.

The Itinerant Consultations Project is no longer active. This is evidenced by the ordinance revoking the codes in the Table of Procedures that served the two projects, as well as excluding the adherence of establishments for this purpose, and ending the funding for project procedures²⁵25 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde. Portaria nº 1.660, de 17 de novembro de 2016. Diário Oficial da União. 17 Dez 2016..

Health at school

Prior to the PSE, there were initiatives of dialogue between health and education present in the federal government’s normative acts. The then Ministers of Health and Education recognized school as a suitable space for the creation of healthy habits and citizenship formation, and also a space for health promotion and disease prevention.

The period coincides with the school health model called Health Promoting Schools, the same name of a program created by the World Health Organization (WHO), which identified schools as a privileged spaces for bringing together, for an important period, children and adolescents, as well as a working environment for teachers, other professionals, and community representatives²⁶26 Silva CS. Saúde na Escola: Intersetorialidade e Promoção da Saúde. Rio de Janeiro: Fiocruz; 2019..

Brazil did not establish policies based on the WHO proposal, but brought the health promotion model to the school enviroment²⁷27 Brasil. Ministério da Saúde. Escolas promotoras de saúde: experiência do Brasil. Brasília, DF: Ministério da Saúde; 2007.. This is relevant due to the national background of adopting hygienist activities and school medicine, models prior to this one and summarily guided by the surveillance of diseases and illnesses, and other activities of biomedical nature²⁶26 Silva CS. Saúde na Escola: Intersetorialidade e Promoção da Saúde. Rio de Janeiro: Fiocruz; 2019..

As observed, health at school is not a recent practice. Among the correlated normative acts, located through manual search, one can mention the Interministerial Ordinance No. 1 of 1993, which established a working group to propose the necessary technical standards to improve actions for the promotion, protection, and recovery of students’ health within the scope of SUS.

In addition, there is Ordinance No. 1185 of 1997, which established the Interministerial Executive Group to review and approve the material to be broadcast in the ‘Saúde na Escola’ (Health at School) and ‘Educação para a Saúde’ (Education for Health) programs; and, also, the Interministerial Ordinance No. 1,094 of 1997 which established a set of health and nutrition activities called ‘Health at School’, aimed at Brazilian students, broadcast on TV Escola (School TV). These point out that the discussion of a programs involving health in the school environment was a concern of the public administration²⁸28 Brasil. Ministério da Saúde; Ministério da Educação e Desporto. Portaria Interministerial nº 1, de 17 de agosto de 1993. Diário Oficial da União. 18 Out 1993.,²⁹29 Brasil. Ministério da Saúde. Portaria nº 1.185, de 25 de agosto 1997. Instituir Grupo Executivo Interministerial para apreciar e aprovar o material a ser veiculado no Programa Saúde na Escola e Educação para Saúde, sua periodicidade e cronograma, bem assim, o material de apoio didático. Diário Oficial da União. 26 Out 1997.,³⁰30 Brasil. Ministério da Saúde; Ministério da Educação e Desporto. Portaria Interministerial nº 1.094, de 05 de setembro de 1997. Diário Oficial da União. 8 Set 1997..

It is importance to consider that the year 2006 was marked by the institutionalization of the National Primary Care Policy and the National Health Promotion Policy, introducing deep changes in the organization of the SUS care model, now established in Consolidation Ordinance No. 2 of 2017³¹31 Brasil. Ministério da Saúde. Portaria de Consolidação nº 2, de 28 de setembro de 2017. Diário Oficial da União. 28 Set 2017., which provided a window of opportunity for intersectorial programs in PHC, such as the PSE, a unique model in the history of school health in Brazil²⁶26 Silva CS. Saúde na Escola: Intersetorialidade e Promoção da Saúde. Rio de Janeiro: Fiocruz; 2019..

Implantation and implementation of PSE in Brazil

The PSE was created in December 2007 by Presidential Decree No. 6,286, being implemented the following year with the objective of contributing to the integral formation of students in the public basic education network through actions of prevention, promotion, and health care. It is based on decentralization, territoriality, integrality, and among others, intersectoriality as implementation guideline.

Participation in the PSE was essentially municipality-based, annually, through the signing of a Term of Commitment, with decentralized management involving commitments from the municipal, state, and federal spheres through Intersectorial Working Groups.

It began with restrictions to a certain number of municipalities in accordance with predetermined criteria, but there was a change in 2013, when all Brazilian municipalities were allowed to join the PSE; and in 2017, it was established a two-year term known as adhesion cycles.

The actions planned within the PSE consider attention, promotion, prevention, and care, comprise various topics of health concern, and should be carried out by intersectoral work between health and education professionals within the school community and territory of PHC. The work process must be guided by intersectoriality, i.e., it is necessary the knowledge interaction between the PHC professionals and education professionals.

From the perspective of program management, intersectoriality must also be practiced by the Intersectorial Working Groups of states and municipalities. This principle is reinforced in the normative acts throughout the program’s regulation, to the point that it is currently the main pillar of PSE³²23 Dalia ERC, Campos LM, Teixeira LP, et al. Análise da prevalência dos pacientes que necessitam de óculos em um Hospital Oftalmológico em Goiânia, Goiás, Brasil. Projeto Olhar Brasil. Rev. bras.oftalmol. 2017 [acesso em 2020 ago 23]; 76(2):57-60. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-72802017000200057&lng=en.
http://www.scielo.br/scielo.php?script=s... .

Through Interministerial Ordinance No. 675, the ministries established the Intersectorial Commission on Education and Health at School (CIESE) with the purpose of setting guidelines for education and health policies at school in line with national education policies and SUS’s objectives, principles, and guidelines. Despite remaining in force in the normative acts, the CIESE is no longer active, at least not as it was in the past³³33 Ferreira IRC, Vosgerau DSR, Moysés SJ, et al. Diplomas Normativos do Programa Saúde na Escola: análise de conteúdo associada à ferramenta ATLAS TI. Ciênc. Saúde Colet. 2012 [acesso em 2020 out 13]; 17(12):3385-3398. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232012001200023&lng=en.
http://www.scielo.br/scielo.php?script=s... . Currently, negotiations are carried out in occasional meetings between the PSE management teams in the Ministries of Health and Education.

The financial incentive allocated to the actions was historically debited from the National Health Fund’s account, while education was mostly responsible for the printing and distribution of graphic materials. However, the budget planning should be done in conjunction with the Education Secretaries through the Intersectorial Working Groups.

The municipalities that have signed up are ratified by ordinance, whose purpose is to define the transfers fund of fund, from the National Health Fund to the Municipal Health Funds, annually, in a single installment. These were part of the Primary Health Care Financing Block, encumbering the Variable Primary Health Care Floor, being initially constituted by an extra portion of the monthly incentive passed on to the Family Health teams; becoming specific values according to the number of students agreed upon as of 2013.

Except in specific situations, these resources are transferred upon adherence and after meeting the goals and standards for implementing the actions. The Ministry of Health can transfer resources according to the administration’s needs and interests as happened with the specific incentives for the School Health Week.

The resources are intended for the implementation of all actions; however, the ministries define the priority ones for their monitoring, which are linked to the payment by performance criteria depending on the activity. According to the ordinances, actions to control the Aedes aegypti mosquito have received prominence over the others. The actions to promote healthy eating and prevent childhood obesity also receive attention through the Crescer Saudável (Growing Healthy) program, an initiative on the agenda of the General Coordination of Food and Nutrition linked to the PSE.

In 2019, a total of BRL 95,556,013.61 was transferred as an incentive for the implementation of the PSE and the Healthy Growing upon joining the 2019/2020 cycle. This comprised a total of 91,000 associated public schools and day care centers, and corresponds to 22,425,160 million students as the main target audience of the actions³⁴34 Brasil. Ministério da Saúde, Secretaria de Atenção Primária à Saúde. Nota técnica - Divulgação dos resultados do monitoramento das ações do Programa Saúde na Escola do primeiro ano do ciclo 2019/2020. Brasília, DF: Secretaria de Atenção Primária à Saúde; 2020. [acesso 2020 ago 5]. Disponível em: http://189.28.128.100/dab/docs/portaldab/documentos/academia/NT17_Monitoramento_PSE_2019.pdf.
http://189.28.128.100/dab/docs/portaldab... .

The actions monitoring started with the Integrated Monitoring System of the Ministry of Education (SIMEC) and then shared it with the Health Information System for Basic Care (SISAB) between 2013 and 2017, when it started to be carried out only by the latter.

In 2019, from SISAB data analysis, it is known that 1,450,634 activities of the PSE actions were carried out in 4,906 municipalities with the participation of 61,413,856 students in one or more actions. The eye health activities corresponded to 2.81% and totaled 40,823 of these activities³⁵35 Shakarchi AF, Collins ME. Referral to community care from school-based eye care programs in the United States. Surv Ophthalmol. 2019 [acesso em 2020 set 7]; 64(6):858-867. Disponível em: https://www.surveyophthalmol.com/article/S0039-6257(18)30224-8/fulltext.
https://www.surveyophthalmol.com/article... .

Eye health actions within the PSE

The theme of eye health appears as a PSE action since the beginning under the nomenclature ‘ophthalmological evaluation’. Between 2011 and 2017, PSE actions were segregated into Component I – clinical and psychosocial evaluation having the ophthalmological evaluation as a line of action, and the visual acuity screening (Snellen Test) and the identification of students’ visual problems as an ‘activity’; Component II – health promotion and prevention actions, of which the theme was not part; and Component III – permanent education and training of education and health professionals and young people for the PSE, which included the training of health and education professionals to apply the Test.

Conceptually, the nomenclature ‘ophthalmologic evaluation’ did not express the PSE’s objectives clarifying actions that include health promotion, prevention, and healthcare since ophthalmologic evaluation, in a way, alludes to clinical evaluation which is performed by specific professionals, and even within the competence of specialized care and not of PHC, as described in Ordinances No. 288, May 19, 2008, and No. 3,128, December 24, 2008.

Thus, the interpretation of the actions/activities involving eye health has historically been reduced to eye screening and measuring visual acuity, which, as a whole, do not include the comprehensive care envisioned by the PSE⁹9 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Cadernos temáticos do PSE: Saúde Ocular. Brasília, DF: Ministério da Saúde; 2016. [acesso em 2020 maio 20]. Disponível em: http://189.28.128.100/dab/docs/portaldab/documentos/caderno_saude_ocular.pdf.
http://189.28.128.100/dab/docs/portaldab... ,³²32 Brasil. Ministério da Saúde; Ministério da Educação. Caderno do Gestor do PSE. Brasília, DF: Ministério da Saúde; 2015..

Vision screening is very present in a Brazil, but it also happens in other countries. In the United States of America, at least 40 states require vision screening for school-age children. Although vision screening of school-age children is supported by governments in countries such as the United Kingdom, Canada, Australia, South Africa and Eastern Mediterranean countries, it is not mandatory. Lack of legislation leads to ad hoc screening by private clinics, resulting in unmeasured and inconsistent service delivery³⁵35 Shakarchi AF, Collins ME. Referral to community care from school-based eye care programs in the United States. Surv Ophthalmol. 2019 [acesso em 2020 set 7]; 64(6):858-867. Disponível em: https://www.surveyophthalmol.com/article/S0039-6257(18)30224-8/fulltext.
https://www.surveyophthalmol.com/article... ,³⁶36 Metsing I, Hansraj R, Jacobs W, et al. Review of school vision screening guidelines. African Vision and Eye Health. 2018 [acesso em 2020 set 7]; 77(1):1-10. Disponível em: https://avehjournal.org/index.php/aveh/article/view/444/887.
https://avehjournal.org/index.php/aveh/a... .

The Interministerial Ordinance No. 1,055/2017, among other provisions, redefined the rules and criteria for joining the PSE, brought the theme of eye health more into the scope of promotion with the following nomenclature: ‘Promotion of eye health and identification of students with possible signs of impairment’. This is detailed in the Thematic Booklet and is commonly known as the PSE eye health action⁹9 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Cadernos temáticos do PSE: Saúde Ocular. Brasília, DF: Ministério da Saúde; 2016. [acesso em 2020 maio 20]. Disponível em: http://189.28.128.100/dab/docs/portaldab/documentos/caderno_saude_ocular.pdf.
http://189.28.128.100/dab/docs/portaldab... .

The World Health Organization recognizes that schools are privileged environments for health promotion; however, when considering eye health, there is evidence that interventions to promote eye healthcare have received less attention and investment than those for prevention and treatment; and, although these interventions have proven effective in some places, more research is needed¹1 World Health Organization. World report on vision. Geneva: World Health Organization; 2019.,²2 Langford R, Bonell C, Jones H, et al. The World Health Organization’s Health Promoting Schools framework: a Cochrane systematic review and meta-analysis. BMC public health. 2015 [acesso em 2020 maio 20]; 15(1):130-137. Disponível em: https://bmcpubli-chealth.biomedcentral.com/articles/10.1186/s12889-015-1360-y.
https://bmcpubli-chealth.biomedcentral.c... .

According to some references to the issue within the regulations, it is mentioned that eye health was the theme of the School Health Week in 2013, an annual mobilization for intersectorial work in schools through the PSE, as evidenced in Ordinance No. 364 of March 8, 2013. Furthermore, the PSE and consequently its list of actions are considered in the National Policy for Child Health Care, as observed in Ordinance No. 1,130, August 5, 2015.

It is important to bring the role of the Brazilian National Common Curriculum Base (BNCC) into the debate³⁷37 Brasil. Ministério da Educação. Base Nacional Comum Curricular. MEC, 2017. Brasília, DF: Ministério da Educação; 2017. [acesso em 2020 set 7]. Disponível em: http://basenacionalcomum.mec.gov.br/images/BNCC_EI_EF_110518_versaofinal_site.pdf.
http://basenacionalcomum.mec.gov.br/imag... . Curricular insertion of health and the theme of eye health in school curricula is the first step for the implementation of interventions guided by the WHO’s Health Promoting Schools framework, recommended in current guidelines for eye health promotion programs at school²2 Langford R, Bonell C, Jones H, et al. The World Health Organization’s Health Promoting Schools framework: a Cochrane systematic review and meta-analysis. BMC public health. 2015 [acesso em 2020 maio 20]; 15(1):130-137. Disponível em: https://bmcpubli-chealth.biomedcentral.com/articles/10.1186/s12889-015-1360-y.
https://bmcpubli-chealth.biomedcentral.c... ,³3 International Agency for the Prevention of Blindness. Standard school eye health guidelines for low and middle-income countries. London: International Agency for the Prevention of Blindness; 2018. [acesso em 2020 maio 20]. Disponível em: https://www.iapb.org/wp-content/uploads/Guidelines-School-Eye-Health-Programmes-English-Final.pdf.
https://www.iapb.org/wp-content/uploads/... ,⁴4 Burnett A, Yashadhana A, Lee L, et al. Interventions to improve school-based eye-care services in low- and middle-income countries: a systematic review. Bull World Health Organ. 2018 [acesso em 2020 maio 20]; 96(10):682-694D. Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6238998/.
https://www.ncbi.nlm.nih.gov/pmc/article... ,⁵5 Global Partnership for Education. School Health Integrated Programming. Guidelines for School-based Eye Health Programs. Washington, DC: GPE; 2017. [acesso em 2020 maio 20]. Disponível em: https://www.globalpartnership.org/sites/default/files/2017-09-ship-guidelines-vision-screening.pdf.
https://www.globalpartnership.org/sites/... .

It is known that there are few documents aimed at guiding educational objectives that specifically address the topic of health. Thus, the mention of eye health in the BNCC needs to be detailed to affirm its importance in the classroom³⁷37 Brasil. Ministério da Educação. Base Nacional Comum Curricular. MEC, 2017. Brasília, DF: Ministério da Educação; 2017. [acesso em 2020 set 7]. Disponível em: http://basenacionalcomum.mec.gov.br/images/BNCC_EI_EF_110518_versaofinal_site.pdf.
http://basenacionalcomum.mec.gov.br/imag... ,³⁸38 Monteiro PHN, Bizzo N. A saúde na escola: análise dos documentos de referência nos quarenta anos de obrigatoriedade dos programas de saúde, 1971-2011. Hist Ciênc Saúde – Manguinhos. 2015 [acesso em 2020 ago 23]; 22(2):411-428. Disponível em: https://www.scielo.br/j/hcsm/a/pd6KN8hjtZQ5fcs5Yxkr47L/abstract/?lang=pt.
https://www.scielo.br/j/hcsm/a/pd6KN8hjt... . Eye health is inserted in the science curriculum component, whose specific skills include the discussion of habits necessary for the maintenance of hearing and visual health considering the environmental conditions in terms of sound and light³⁷37 Brasil. Ministério da Educação. Base Nacional Comum Curricular. MEC, 2017. Brasília, DF: Ministério da Educação; 2017. [acesso em 2020 set 7]. Disponível em: http://basenacionalcomum.mec.gov.br/images/BNCC_EI_EF_110518_versaofinal_site.pdf.
http://basenacionalcomum.mec.gov.br/imag... .

Final considerations

The access to eye care in Brazil goes through the school space as a point of attention and part of the PHC. Thus, it became evident that comprehensive and coordinated eye health is still a challenge for SUS given the interruption of initiatives that ensure access to care, such as the Brazil Eye Project and Itinerant Consultations Project, and the little incentive to perform these practices over other actions of the PSE.

It is also worth mentioning that the debate on eye health actions in school environments dates back to the National Policy of Attention in Ophthalmology, suggesting a certain pioneering spirit in the work of PHC.

One of the limitations of this work was due to the search tools, which returned a large volume of normative acts, but missed some important publications for a better understanding of the context. Some normative acts were gathered by manual search and used in the argument. However, despite the weaknesses, these are essential instruments for deepening issues involving health law, especially in universal systems such as SUS.

In addition, the discussions presented here correspond to the analyst’s interpretations, thus, one must consider the present interpretations and recognize the breadth of possible interpretations, including those of the readers.

Legal and technical discussions of eye health rights in PHC are still scarce, judging by the review of normative acts and current literature, suggesting little strategic and planning vision in the scope of PHC and health at school. Also, the current literature does not have reference documents for including eye health into the curricula of Brazilian students, despite the observance of health themes in the curriculum guidelines of basic education.

The theme of eye health in the analyzed regulations was restricted to early detection activities and did not explore the potential of health promotion, as well as reinforcing their role in accessing services and solving these problems. When leaving the reductionist perspective of ophthalmological evaluation, the PSE can become strategic for the implementation of educational activities, eye health promotion and prevention of blindness; in addition, early detection of reversible conditions in the PHC.

So far, the PSE presents itself as the most consolidated school health policy in the SUS, as a result of the uninterrupted work to improve its management in order to change the conception of actions, facilitate the processes of adherence and funding, among others. It was also possible to observe that new processes involving the PSE management and the implementation of the Eye Health action were more present in the years 2013 and 2017, which calls for reflections on why these processes have stood out beyond the normative perspective, and this requires a more refined analysis of the context.

Finally, a thorough analysis of the National Policy for Ophthalmologic Care is recommended, having the consolidation of the Health Care Networks as an objective of SUS, and the PHC as a prism of first access, continuity of care, and coordinated actions.

References

Publication Dates

History