ABSTRACT

Government in the Unified Health System (SUS) is admittedly complex, requiring management teams to understand and develop a set of skills and competencies that help into their routines and in the challenges of public administration. This article presents a continuing education process developed with leadership teams from two health regions in Paraná, with the aim of broadening the participants’ view of the reorganization of the management and implementation of the SUS in the territory, based on interdisciplinarity and interprofessional. This is an experience report developed with teams, carried out in 2019, presented in five sections: the first describes the context in which the experience was developed, elucidating reasons, actors, and where it took place; the second section presents the work proposal, the preparation of the workshops, and the methodological resources used; the third reports the pathway travelled in its operation; the fourth discussions the characteristics of interdisciplinarity that exists in the continuing education process; and the last section presents some considerations. The proposal presents a powerful strategy to promote dialogue between different actors and institutions, and especially in the context of the State’s sanitary and fiscal crisis, to qualify and make reflective the work in the field of health management.

KEYWORDS
Continuing education; Interdisciplinarity; Interprofessional; Public health management.

Introduction

The Unified Health System (SUS) is recognized as a system under construction, permeated by different challenges, and hegemonic and market interests. Nevertheless, it throughout its history, several advances must be recognized, such as the expansion of access to health services and actions, and significant contributions to the improvement of the health status of Brazilians^{11 Santos NR. SUS 30 anos: o início, a caminhada e o rumo. Ciênc. Saúde Colet. 2018; 23(6):1729-36.}.

The management of this system, whose principles are universality, integrality, and equity, is an arduous and very complex task for federal and state entities, but especially for the municipal entity, considering the various responsibilities assumed based on the decentralization process^{22 Silva CR, Carvalho BG, Cordoni Júnior L, et al. Dificuldade de acesso a serviços de média complexidade em municípios de pequeno porte: um estudo de caso. Ciênc. Saúde Colet. 2017; 22(4):1109-20.}

Therefore, participants in the daily SUS management must constantly improve and always search for new alternatives of action, in addition to understanding their attributions, considering that proper management is a powerful strategy for the implementation of health policies. The complexity of the SUS management involves the development of articulation and integration between different health services, users, and workers^{33 Araújo NP, Miranda TOS, Carvalho Garcia CP. O estado da arte sobre a formação do enfermeiro para a gestão em saúde. Rev Enferm Contemp. 2014 [acesso em 2021 ago 15]; 3(2). Disponível em: https://www5.bahiana.edu.br/index.php/enfermagem/article/view/365.
https://www5.bahiana.edu.br/index.php/en...} , aimed at offering care that meets the needs of the population. Associated with this, the manager must, in addition to mastering technical knowledge related to management, also develop political skills, since the consolidation of the SUS occurs in spaces of power disputes, in which contradictions and challenges are present in daily life^{44 Melo MLC, Nascimento MÂA. Treinamento introdutório para enfermeiras dirigentes: possibilidades para gestão do SUS. Rev Bras Enferm. 2003; 56(6):674-7.}

It is noteworthy that the understanding of these two (technical and political) dimensions and their inseparability helps to understand the challenges experienced by managers and their support teams in the performance of their roles^{55 Domingos CD, Mendonça FF, Carvalho BG. Os desafios de ser gestor. In: Carvalho BG, Cordoni Junior L, Nunes EFPA, organizadores. Gestão da saúde em pequenos municípios: o caso do norte do Paraná. Londrina: Eduel; 2018. p. 125-41.}.

Thus, training strategies for management teams are fundamental for the implementation of the SUS principles and guidelines. When such strategies occur through the integration between segments of education and service, based on the development of the Continuing Health Education (EPS) process, the transformations of reality and the sharing of knowledge in collective spaces are potentialized.

The EPS considers the social relevance of the teaching-learning process. It is based on the world of work, so that the worker acts as a protagonist, thus being a method to re-signify knowledge and professional practice. This methodology adds technical and scientific knowledge, ethical dimensions of life, work, human beings, health, education, and relationships, thus favoring the meaningful and transformative learning of professional practices in daily work^{66 Ceccim RB, Ferla AA. Educação Permanente em Saúde. In: Pereira IB, Lima JCF, organizadores. Dicionário da Educação Profissional em Saúde. 2. ed. Rio de Janeiro: Fiocruz; 2008. p. 162-168. [acesso em 2018 jun 1]. Disponível em: https://www.epsjv.fiocruz.br/sites/default/files/l43.pdf.
https://www.epsjv.fiocruz.br/sites/defau... ,77 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 e dá outras providências. Diário Oficial da União. Brasília. 22 Ago 2007.}.

EPS experiences are common among work teams in the care context ^8-10. However, in the field of management, such strategies are still timid. Thus, this experience focused on developing EPE strategies with the SUS management teams, starting from an interdisciplinary perspective, since management functions require and need an articulation of different disciplinary fields (geography, political science, public administration, accounting, sociology, anthropology, epidemiology, biology, health law, among others).

Interdisciplinarity is understood here as a convergence between the disciplines involved, triggering a real rapport between them, and the establishment of a channel of exchanges between the fields related to one or more functions to be performed jointly^{1111 Furtado JP. Arranjos institucionais e gestão da clínica: princípios de interdisciplinaridade e interprofissionalidade. CBSM. 2011 [acesso em 2021 jun 25]; 1(1):178-89. Disponível em: https://periodicos.ufsc.br/index.php/cbsm/article/view/68439.
https://periodicos.ufsc.br/index.php/cbs... ,1212 Velloso MP, Guimarães MBL, Cruz CRR, et al. Interdisciplinaridade e formação na área de saúde coletiva. Trab. Educ. Saúde. 2016; 14(1):257-71.}.

Thus, this study case aims to present the EPS process with management teams from the perspective of interdisciplinarity as a strategy to broaden its view to reorganize the SUS management and implementation.

The description of the case is organized into five sections: the first one describes the context in which it was developed, elucidating the reasons, the actors, and the location in which it occurred; the second presents the development of the work proposal; the third, in turn, reports how its operation took place; the fourth discusses the results through the characteristics of interdisciplinarity in the EPS process; and, finally, the fifth section shows some considerations about the case developed.

Development context

The present EPS process originated to strengthen the teams with regard to health management capacity. Therefore, initially, the workers of the Regional Health (RS) units involved in this process carried out a survey with the managers and members of the municipal management teams, about the main weaknesses and needs in the SUS management. At this stage, it was possible to identify managers with little experience, incipient local management capacity, a lack of definition of teams to work in management in some municipalities, and overload of attributions and activities.

Based on the demands identified and with the purpose of qualifying the teams to perform the various management functions that permeate a complex and robust health system such as the SUS, a conducting group was constituted. This group was led by researchers from the Graduate Program in Collective Health of the State University of Londrina and representatives of the 16th and 17th RS, who started to formulate an EPS process, which involved from the pedagogical conception, workload, and methodology to the elaboration of support notebooks.

These regions are located in the northern macro-region of Paraná and, together, have 38 municipalities, of which more than 80% are small. Small Municipalities are those cities that have less than 20 thousand inhabitants^{1313 Brasil. Ministério do Desenvolvimento Social e Combate à Fome, Secretaria Nacional de Assistência Social. Política Nacional de Assistência Social PNAS/ 2004. Brasília, DF: MDS; 2005.}.

These territories are considered advanced socioeconomically, with medium/high supply of health services^{1414 Região e Redes. Caminhos para a Universalização da Saúde no Brasil. Banco de Indicadores Regionais e Tipologias, 2016. [acesso em 2019 jun 30]. Disponível em: http://www.resbr.net.br.
http://www.resbr.net.br...} . However, the social and economic characteristics, as well as health services, are not homogeneous between the municipalities that make up the two regions.

The conducting group was formed by representatives of the educational institution and professionals with practical experience in the management of health services in the mentioned regions, highlighting the following roles: nurses, pharmacists, administrators, and public managers, which generated an interprofessional and interdisciplinary perspective to the process.

In addition to involving different professions/roles, the constitution of the conducting group allowed for the integration of teaching and service, which is so important in the process of implementation of the SUS, provided by the characteristic of the research group in building partnerships with other actors. In this process, the articulation took place in the RS.

It is noteworthy that this experience is part of a larger project, which aims to investigate the cooperation strategies for the regionalization in health regions in Paraná, which was evaluated by the Research Ethics Committee of the institution to which the researchers are linked and approved by opinion N. 3.120.681.

Case development

The EPS process took place from April to December 2019, through six workshops, in response to the needs presented by the managers and members of the municipal management teams. It is noteworthy that, in order to guarantee the certification to the participants, this process was registered as continuing education course, aimed at discussing and supporting the development of macro management roles.

The first workshop was entitled ‘Ser gestor e Regionalização’ (‘Being a manager and Regionalization’); the second was entitled ‘Processo de Planejamento no SUS’ (‘Planning Process at SUS’); the third was called ‘Instrumentos de Gestão do SUS’ (‘SUS Management Instruments’); the fourth workshop promoted the discussion on health financing, with the title ‘Gestão Orçamentária e Financeira’ (‘Budget and Financial Management’); the title of the fifth workshop was ‘Controle Social’ (‘Social Control’); finally, the sixth workshop was called ‘Gestão do Trabalho e Educação em Saúde’ (‘Labor Management and Health Education’).

The total workload of this EPS process was 50 hours; of which 32 hours were in-person meetings and 18 hours were reserved for moments of practical activities. To perform these activities, the participants were divided into small groups, and were assigned tasks to be performed in their work environments. The purpose was to approximate theory and practice in the daily lives of the participants, in order to clarify their doubts and qualify their work process. The practical activities were developed between the intervals of the workshops. The syntheses of the results achieved were presented at the beginning of each new meeting. Table 1 summarizes the meetings, duration, objectives, methodologies, and practical.atividades de dispersão.

In order to prepare and carry out the workshops, the members of the conducting group sought to learn from different fields of knowledge based on notebooks used during the meetings, and in response to the complexities of the themes to be worked on.

The notebooks were prepared from the methodological perspective of EPS, based on the needs reported by the participants in the process. The contents consisted of case studies with problem situations and guiding questions for group debates and reflections. They also had scientific texts that helped them to understand the topics discussed during the workshops.

Also, as mentioned in table 1, during the workshops, active methodologies were used, with the construction of a teaching-learning process, based on the problematization of reality and the protagonism of the participants, in search for the construction/re-signification of knowledge from multiple perspectives and knowledge.

Operationalization of the process

One hundred and fifteen people participated in this case, 65 from the 16th RS and 50 from the 17th RS. The participants were municipal health secretaries, members of the management teams of the municipalities, workers of the RS, workers of the public health consortia and supporters of the Council of Municipal Health Secretariats of Paraná (COSEMS-PR) of both regions. The subjects were informed about the purpose of the process and signed the Free and Informed Consent Form according to the rules of Resolution N. 466/2012^{1515 Brasil. Ministério da Saúde. Resolução nº 466/2012 do Conselho Nacional de Saúde. Pesquisas em seres humanos e atualiza a resolução 196. Diário Oficial da União. 14 Jun 2012.}.

The workshops were mediated by the conductive group consisting of professors, graduate students, and workers from RS. In the financing workshop, the conducting group had the complementary support of technical advisors with expertise in the subject. On this occasion, other municipal actors working in the areas of budget planning and management also participated in the workshop, with the health management teams.

During the meetings, it was possible to structure and ensure dialogic spaces, in which all those involved had the opportunity to exchange doubts, experiences, and knowledge, constituting horizontal relations with solidarity.

At the end of the workshop cycle, the participants carried out their evaluation regarding the EPS strategy and mentioned the need for continuity and multiplication of content in their municipalities. As part of the evaluation, the participants were motivated to reflect, through a dynamics, on what the course provided, and, from this, what they could offer to their workmates and the population of their municipality, in addition to other ideas that emerge in the group meetings.

With the evaluation, the conducting group could not only improve the process of developing the EPS work, but also favored the systematization of the case study.

The interdisciplinarity in the EPS development process

From the perspective of interdisciplinarity, the EPS process enables the development of responses to demands in the field of management and public health. This is because interdisciplinarity presents itself as an alternative to the mitigation of complexity of managing a health system.

It is noteworthy that the term interdisciplinarity refers to the integration of knowledge, while interprofessionality refers to the integration of practices^{1111 Furtado JP. Arranjos institucionais e gestão da clínica: princípios de interdisciplinaridade e interprofissionalidade. CBSM. 2011 [acesso em 2021 jun 25]; 1(1):178-89. Disponível em: https://periodicos.ufsc.br/index.php/cbsm/article/view/68439.
https://periodicos.ufsc.br/index.php/cbs...} , through the intentional and collaborative articulation between different professions^{1616 Costa MV, Patrício KP, Câmara AMCS, et al. Pró-Saúde e PET-Saúde como espaços de educação interprofissional. Interface (Botucatu). 2015; 19(supl1):709-20.}. It should be noted that, although the concepts are different, they complement each other in the EPS process.

One of the characteristics of interdisciplinarity is precisely to allow the subjects to have the ability to expand their worldviews, since it establishes a scenario that leads to constant exchanges, interactions between disciplines and between different fields of action, within the same purpose^{1717 Vilela EM, Mendes IJM. Interdisciplinaridade e saúde: estudo bibliográfico. Rev. Latino-Am. Enfermagem. 2003; 11(4):525-31.,1818 Peduzzi M, Norman IJ, Germani ACCG, et al. Educação interprofissional: formação de profissionais de saúde para o trabalho em equipe com foco nos usuários. Rev. Esc. Enferm. USP. 2013; 47(4):977-83.}

Other authors highlight that interdisciplinary projects allow a closer relationship between educators (facilitators) and students (management team), consolidating a relationship of reciprocity and sharing of objectives through dialogic means^{1212 Velloso MP, Guimarães MBL, Cruz CRR, et al. Interdisciplinaridade e formação na área de saúde coletiva. Trab. Educ. Saúde. 2016; 14(1):257-71.}

This aspect was also observed in the experience developed when approaching diverse types of knowledge between multiple professional categories that make up the management teams, resulting in the construction of new and broad knowledge about the problems faced by these professionals in the daily SUS management. In this case, it was clear that interdisciplinarity and interprofessionality complemented each other and allowed the participants to further expand their analytical capacity.

Table 2 presents a systematization of the characteristics present during the EPS experience that are consistent with interdisciplinarity.

One of the first characteristics that deserve to be highlighted was the respect for local demands, which was set up as a starting point for the process. According to Fazenda^{1919 Fazenda ICA. A integração e interdisciplinaridade no ensino brasileiro: efetividade ou ideologia? 6. ed. São Paulo: Edições Loyola Jesuítas; 2011.}, sensitivity to the needs of the context is fundamental for the consolidation of interdisciplinary actions. Freire^{2020 Freire P. Pedagogia da autonomia: saberes necessários à prática educativa. 53. ed. Rio de Janeiro: Paz e Terra; 2016.} also pointed to the need of grasping reality, to the extent that such understanding enables the knowledge of the different dimensions that characterize the context, which can even make the practice of this reality safer.

In addition, when considering the local need, there is also evidence of respect for the subjects. Taking advantage of the experience of managers and teams to discuss problems present in their daily lives is a way of valuing these workers.

Another important contributing aspect is the interprofessionality, which was the constitution of the conducting group. The group, as previously mentioned, consisted of professionals from diverse backgrounds and places of work. This configuration provided the interaction between different knowledge, contributing to the production of new and powerful knowledge for the resolution of a given problem^{1717 Vilela EM, Mendes IJM. Interdisciplinaridade e saúde: estudo bibliográfico. Rev. Latino-Am. Enfermagem. 2003; 11(4):525-31.,1818 Peduzzi M, Norman IJ, Germani ACCG, et al. Educação interprofissional: formação de profissionais de saúde para o trabalho em equipe com foco nos usuários. Rev. Esc. Enferm. USP. 2013; 47(4):977-83.}.

Thus, the experience of bringing educational professionals closer to health services configured the teaching-service integration and potentialized the EPS process, through a collective, integrated, cooperative and agreed work. In addition, the experience allowed for the qualification of individual and collective health care, enabling the improvement of the knowledge of professionals in the academy and the development of skills for health service workers^{2121 Vendruscolo C, Prado ML, Kleba ME. Integração ensino-serviço no âmbito do Programa Nacional de Reorientação da Formação Profissional em Saúde. Ciênc. Saúde Colet. 2016; 21(9):2949-60.,2222 Finkler M, Caetano JC, Ramos FRS. Integração “ensino-serviço” no processo de mudança na formação profissional em Odontologia. Interface - Comun Saúde Educ. 2011; 15(39):1053-70.}, in the terms of the literature.

The methodological option focused on active methods had a key role in the production of reflections, re-significations, and empowerment for action in the management area, both for the participants and for the members of the conducting group. Interdisciplinarity, when invoked for the creation of pedagogical models, tends to stimulate educational processes, whose participants play a leading role in the learning process.

The workshops were predominantly guided by problems that were part of the reality of the management teams. Thus, they played an active role in the construction of the EPS process when considering the creativity and freedom of thought of the participants. This action is strengthened in Freire’s work^{2323 Freire P. Pedagogia do oprimido. 53. ed. Rio de Janeiro: Paz e Terra; 2013.} by affirming that ‘banking’ education, which judges students without knowledge, does not contribute at all to an emancipatory and critical education aimed at social change.

It is also pointed out that EPS has the use of active methods that aim at the reflection of workers on the work process as one of its principles. This reflection should be developed with the greatest possible professional diversity, in order to build strategies that encompass different knowledge and that are closer to the needs of the locus of action^{2424 Jacobovski R, Ferro LF. Educação permanente em saúde e metodologias ativas de ensino: uma revisão sistemática integrativa. Rev Soc Dev. 2021; 10(3):e39910313391.,2525 Ceccim RB, Ferla AA. Educação e saúde: ensino e cidadania como travessia de fronteiras. Trab Educ E Saúde. 2008; 6(3):443-56.}.

The preparation of the pedagogical material involved different areas of knowledge and performance. It should be noted that the management in the health area comprises the command of the system, the activities and the responsibilities exercised by the managers and their teams, which permeate several functions identified by Machado, Lima, and Baptista^{2626 Machado CV, Lima LD, Baptista TWF. Princípios organizativos e instancias de gestão do SUS. In: Oliveira RG, Grabois V, Mendes Junior WV. Qualificação dos gestores no SUS. 2. ed. Rio de Janeiro: EAD; ENSP; 2011. p. 47-72.} as management macro roles of the SUS, that is: formulation of policies/planning; financing; regulation, coordination, control, and evaluation (of the systems/networks and public and private providers) and the direct provision of health services.

Comprehensively, the weaknesses in the SUS management often occur because of the lack of clarity about these roles and the different competencies of the spheres of government. In addition, there are clientelist and corporate practices in appointments of management positions at all levels; insufficient coordination and barriers in interfederative communication; low incorporation of management technologies suitable for the management of complex organizations; as well as the inadequate process of social control, causing tensions and disputes, not always consistent with the competencies and legitimacy between the executive bodies of the SUS and the apparatus of social control^{2727 Paim JS, Teixeira CF. Configuração institucional e gestão do Sistema Único de Saúde: problemas e desafios. Ciênc. Saúde Colet. 2007; 12(supl):1819-29.}.

To these weaknesses, one can also add the high turnover, as well as the limitation of some managers regarding the technical capacity and efficiency of municipal management^{2828 Leite FLB. Fusão de municípios: impactos econômicos e políticos da diminuição do número de municípios em Minas Gerais. [dissertação]. Minho: Escola de Economia e Gestão, Universidade do Minho; 2014. 129 p.,2929 Krüger TR, Reis C. Organizações sociais e a gestão dos serviços do SUS. Serviço Soc Soc. 2019; (135):271-89.}.

Given these notes, the performance of the management team in the SUS must be materialized through the recognition and understanding of its roles, since, in this way, it can exercise them productively and coherently to the principles of the SUS and public management^{2626 Machado CV, Lima LD, Baptista TWF. Princípios organizativos e instancias de gestão do SUS. In: Oliveira RG, Grabois V, Mendes Junior WV. Qualificação dos gestores no SUS. 2. ed. Rio de Janeiro: EAD; ENSP; 2011. p. 47-72.,3030 Souza L. Construindo o SUS: a lógica do financiamento e o processo de divisão de responsabilidades entre as esferas de governo. [dissertação]. Campinas: Universidade de Campinas; 2002. 102 p.}.

In this sense, the support material used sought to contemplate these different management roles and establish an articulation between them. It is also noteworthy that conducting practical activities encouraged the sharing of tasks among the participants and allowed for the assimilation of the theoretical contents and their implementation to the daily work practice.

Important results were perceived based on experience, such as the interaction between the participants; the emergence of the feeling of belonging to the management team of professionals working in the municipalities; and the importance of collective and cooperative action between professionals from different areas related to education and health services.

Peduzzi et al.^{1818 Peduzzi M, Norman IJ, Germani ACCG, et al. Educação interprofissional: formação de profissionais de saúde para o trabalho em equipe com foco nos usuários. Rev. Esc. Enferm. USP. 2013; 47(4):977-83.} add that interprofessional practice also contributes to problematize and expand the resolvability of services and the quality of health care, avoiding omissions or duplications of activities, qualifying communication between professionals, recognizing the specific participation of each area of activity and its limits and overlaps, making the role of professionals versatile.

Thus, the EPS study case proved to be an innovative strategy in the reorganization of the management and implementation of the SUS in the regions studied and is also presented as a powerful cooperative strategy in overcoming the challenges present in the field of public health. In addition, it allows us to affirm the importance of the role of science in the face of knowledge gaps in issues inherent to management.

Considerations

The practice of teaching-service integration based on the perspective of interdisciplinarity and interprofessionality, using EPS methodologies, was considered as a positive aspect to overcome the challenges faced in the SUS management and could promote transformations of realities and collaborate to the consolidation of the management of this system.

The dialogic relationship between the participants of the EPS process allowed us to share doubts about management, which were always treated collaboratively, contributing to updating mutual knowledge.

The use of active methodologies during the workshops made the teaching-learning process more dynamic. It is important to emphasize that partnerships between universities, municipal, and state health secretariats, in the current context of health crisis and fiscal austerity, may qualify and make health work reflective and is confirmed as a relevant and motivating practice for both the professionals in the management teams and the academy.

However, the challenge of expanding the implementation of EPS processes in the field of the SUS management persists, in order to qualify and enhance municipal management practices and instrumentalize teams to improve their performance. Such processes should be strengthened, especially in the current context, marked by constant attack against the SUS, either by the gradual reduction of transfers of federal resources, which intensified after the EC95, or by changes both in the policy of primary care organization and financing and by the increase in outsourcing of the workforce in the SUS.

References

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