Teaching-Service integration within the National Professional Health Education Reorientation Program

This integrative literature review aimed at identifying the characteristics and describing how teaching-service integration is expressed in studies on Pró-Saúde (Charitable institution for social and hospital assistance) published in Brazil in the period 2007-2012. For the search, the term National Professional Health Education Reorientation Program was entered in the following databases: Virtual Health Library (BVS), Google Scholar and the Bank of Theses of the Coordination for the Improvement of Higher Education Personnel (CAPES). Forty-one publications were selected with the following inclusion criteria: scientific papers; theses and dissertations; studies in English, Portuguese or Spanish. The critical review of studies was performed through a comprehensive reading of the texts. Outcomes are presented in two categories: Dialogue and partnership as tools for teaching-service integration and Movements of change in teaching-service through Pró-Saúde. Studies have shown that changes in professional education and practice are possible and necessary, especially when supported by strategies that encourage active participation of subjects and confirm teaching-service integration as opportunity for dialogue, promoted by this inducing policy.


Introduction
Challenges to the construction of the Unified Health System (SUS) led to an intense debate in all occupations of the sector, especially in relation to the urgent need to transform education and health care practices.Both higher education institutions (IES) and services incorporated into their pedagogical thinking the need for planning the teaching-learning process, taking into account the needs of students and professionals, as well as different practical scenarios and the centrality of reality and work problems 1 .
Initiatives that support the reorganization of the System through changes in the education and work of professionals have been strengthened by pressures from the university reform and the political and administrative decentralization of the State 2-4 .Brazilian education and health scholars have been proposing for some years now a partnership between universities and services in order to ensure these advances 5 .This requires both investments in the improvement of professionals and an academic structure supported by the partnership of universities with different sectors of civil society.The challenge is to recognize teaching-service integration as the foundation of a new way of teaching, learning and doing that is effective for all those involved: teachers, students, IES and SUS managers, professionals and the population 6 .
A rapprochement between the Ministry of Education (MEC) and the Ministry of Health (MOH) in the last two decades marked the inter-ministerial cooperation for the training and development of health professionals 7 .Among the developed actions, aiming to encourage and support changes in undergraduate courses and education-work integration, is the National Professional Health Education Reorientation Program (Pró-Saúde), launched in 2005 as one of the first initiatives in this direction.Including initially medical, nursing, and dentistry courses, Pró-Saúde was expanded to other undergraduate health courses in 2007 8 .The strategy meets prerogatives of the National Curricular Guidelines (DCN) which, in line with the Report to UNE-SCO of the International Commission on Education for the Twenty-First Century, propose the references of learning to know, learning to be, learning to do and learning to live together endorsed by the Ministry of Health by providing comprehensive health care associated with professional education general competencies 9,10 .
The Program is guided by the perspective that the reorientation of education should take place simultaneously in different axes (theoretical guidance, practical scenarios and tutoring), each with three specific vectors and a "Picture-Target" (desirable situation).Axes do not have a standard rule, but an example that states the need to include them as structural elements of change towards integration between IES and health services 8 (Chart 1).
Through active interaction, students shall work with real problems, assuming increasing responsibilities as caregivers, adjusted to their degree of autonomy.Therefore, teaching scenarios should be diversified, associating health equipment to the process, both educational and community-based.The use of active teaching-learning methodologies in professional training is valued, challenging students to overcome their difficulties as subjects in the construction of knowledge.Teachers are facilitators and guide the process 8 .
The program can also contribute to the improvement of services, based on Continuing Health Education (EPS) of professionals and scientific production from the establishment of educational practices consistent with the development of a professional profile in tune with the challenges of working in the SUS 11 .
There are few references on the impact of Pró-Saúde since its implementation.However, it is believed that the strategy has significantly contributed and facilitated teaching-service integration 4 .This is due to the innovative training model, which focuses on the production of knowledge from action-reflection-action (praxis) and is based on the commitment to social transformation, as shown by the principles of critical education 12 .
Based on these considerations, a literature review was carried out with the aim of identifying the characteristics of studies and describing how teaching-service integration is expressed in the work produced under Pró-Saúde.

Methodological procedures
A comprehensive literature review was conducted through the following stages: 1) Identification of the subject and question of research; 2) Definition of studies' inclusion and exclusion criteria; 3) Sample selection; 4) Definition of information to be extracted from studies; 5) Inclusion of selected studies; 6) Review and discussion of outcomes 13 .It was guided by the following question: what are the characteristics of works produced under Pró-Saúde and how is teaching-service integration expressed in them?
The following criteria were defined for the inclusion of studies: papers published as scientific articles; theses and dissertations; studies in English, Portuguese or Spanish; period: 2007-2012;  studies full text available online.Studies exclusion criteria were defined as follows: non-systemized bibliographic review papers, letters, reviews, editorials; publications such as books, book chapters, government authorship publications, newsletters, monographs, final term papers, summaries; duplicate studies or studies whose full texts are not available online for analysis.The protocol for conducting the study was validated by a professional with expertise on the subject.
Regarding study search, selection and organization strategies, we used the term National Professional Health Education Reorientation Program to replace a MeSH-or DeCS-derived descriptors, since, in the simulated search, it was noticed that this was sought in the title, abstract and keywords.Given that it is a nationwide research and the fact that Pró-Saúde is a policy exclusive to Brazil, it was considered that objectives would be achieved only from this search structure.Thus, this term was entered in the following databases: a) Virtual Health Library (BVS/BIREME), we proceeded to the free search with string "Search in BVS" using the term without quotation marks; selecting "integrated method", "all indexes" and "all sources".In "language", the following languages were selected: Portuguese, English and Spanish; b) In Google Scholar, the term was inserted with quotation marks, selecting items: any date, pages in Spanish, English and Portuguese, with at least an abstract; c) Bank of Theses of the Coordination for the Improvement of Higher Education Personnel (CAPES), while accessing item "abstracts", the term was inserted without quotation marks under "subject" and "search" button was clicked on.
The 41 studies included were reviewed according to their nature: experience reports, original articles from research with qualitative or quantitative approach, theoretical reflections, documentary research and review papers.An attempt was made to obtain an estimated number of works produced by year and by course.A critical review of studies was carried out with a comprehensive thorough reading of the work.The following items that fed two matrices were extracted (one for papers and one for dissertations) built for data organization and analysis: author, title, journal or institution of origin, year, study approach, objectives, mention to education -service integration.

Outcomes and discussion
Outcomes show that there is a scarcity of publications on Pró-Saúde, given the impact or the expected influence of this program on professional education for the SUS in the Brazilian scenario.Thirty-five papers and six master's degree dissertations were found, and the first publication is from year 2007.
Chart 2 below shows a list of scientific papers found in the period, the journal in which they were published and sorted by increasing year of publication.
Regarding the year of publication, most studies were published in 2012 (11 studies), followed by 2010 (7 studies), 2008 and 2011 (6 studies each), 2009 (3 studies) and 2007 (2 studies).These findings confirm the progressive increase of publications on the subject.The largest number of publications ( 12) appears in the Brazilian Journal of Medical Education (RBEM), the Brazilian Association of Medical Education (ABEM).
As regards the nature of papers, most of them ( 13) are experience reports, followed by qualitative approach-based research ( 7), theoretical reflections ( 6), documentary research (4), review articles (3) and quantitative approach-based research (2).The small number of research papers (9) shows that evaluative processes of inter-ministerial structuring actions, including Pró-Saúde are still incipient and that the largest production focuses on the socialization of experiences.In the Bank of Theses and Dissertations of CAPES, all of the 10 papers identified in the search period were master's degree dissertations deriving from the Great Health Area, and of these, six studies met the search inclusion criteria (Chart 3).
As for the included courses, there were nine articles in dentistry, nine in medicine, four in nursing, one in physical education and 12 with unspecified health areas or included all of them.Regarding dissertations, two were in medicine and one each in nursing, psychology, dentistry and nutrition.These findings highlight dentistry and medicine courses as the most investigated in relation to the subject.
Regarding the year, studies are related to 2009 (1), 2010 (3) and 2011 (2).Five papers use a qualitative approach to research and the remaining one adopts both qualitative and quantitative approach to research.Pró-Saúde is the central subject in only one paper (D5).Four papers are linked to IES located in the Southeast (Estacio de Sá University, Unimontes, ENSP and UFRJ) and two in the South (UFRGS).
A discussion on the main findings, organized by category, is shown below.

Dialogue and partnership as tools for teaching-service integration
Pró-Saúde is a policy aligned with the changes in education, mobilized by the Law of Guidelines and Bases of National Education (LDB) and the National Curricular Guidelines (DCN).Therefore, although IES participation in such projects is limited (because it lacks approval in public call), teaching-service integration has been central to the curricular restructuring since 2001 and has been mobilizing relevant undergraduate courses.Thus, the evaluation of ongoing projects must be a "laboratory" for other IES, in other words, the importance of this topic is not limited to the scope of IES participating in the Pró-Saúde.
Studies A3, A13, A22, A25 and A29 distinguish potentialities and challenges as to the implementation of inter-ministerial policies that direct Brazilian health education, including Pró-Saúde.This depends on a close relationship between authorities and stakeholders involved in the process: the Ministry of Health, coordinating the National Permanent Health Education Policy (PNEPS) geared to health workers; IES, who are committed to education and knowledge production; state health secretariats, whose mission is to establish the network of care and identify education needs; and municipalities, who are responsible for managing much of this network 3,[14][15][16][17] .
Health professional education is understood as a permanent process brokered by intersectoral relations, with partnerships between educational institutions and services.Papers A4 through A7, A15 and A26 highlight the contribution of actions supported and implemented by the Ministries, such as Pró-Saúde and the Healthcare Work Education Program (PET-Saúde), preparing professionals to perform primary health care 2,18-22 .In this perspective, authors of study A26 propose the establishment of "municipal centers" responsible for the PNEPS, composed of individuals representing different segments involved to foster teams' mobilization 22 .
In study A33, authors indicate that, despite hindrances in relation to the agreements in the decision-making process between educational and service institutions, both place their expectations in Pro-Saúde's ability to equate problems through interinstitutional dialogue 23 .What we see is a consensus on the shared commitment that implies expectations from such intersectoral dialogue.More often than not, works indicate that this intersection, in some cases, may be mediated by instances of management and coordination of actions, demonstrating the commitment of managers, professionals and health users and IES representatives.In study D5, the experience of a Local Management Committee as operational structure shows the potential of a congregation forum of these subjects, with positive effects in the coordination, enabling dialogue 24 .
Other studies (A2, A9, A12, A16, A28, A30, A32, A35) consider that the diversified settings of teaching and care practices enabled by the unfolding of Pró-Saúde promote interdisciplinarity, consolidating primary health care in health [25][26][27][28][29][30][31][32] .An example of the appropriation of communication as a fundamental element of dialogue, which also provides greater ownership of SUS, is TelEduc, an approach tool between teachers, students and professionals of the network, an experience that has proven effective for all parties 27 .Study A16 mentions a successful connection of Pró-Saúde and PET-Saúde actions, before academy and professionals' motivation to investigate, allocating research as a source of col- lective production of health promotion actions in a praxis articulated to reality 28 .In convergent fashion, study A17 addresses the experience of implementing Pró-Saúde, with emphasis on outcomes such as the restructuring of institutional environments, considering service functional dynamics, as well as the review of teaching practices, coordinating the theoretical realm of knowledge with experience.It signals services passivity before the academy as a producer of knowledge, but reiterates teaching-service integration as a twoway street, in which both are potential partners in the appropriation and reproduction of organized actions 33 .Thus, hardships that permeate the lack of effective partnerships appear to be offset by some advances related to teaching-service integration, such as the restructuring of the service settings and the review of teaching practices in universities.
Study A21 identifies hindrances related to teaching-service integration, focusing on professional resistance, both by signaling that training students is not part of the work agenda and fearing that their own weaknesses can be identified.Professionals recognize issues in the physical structure of facilities and people's resistance to students 34 .From this perspective, study A27 registers a case in which the segments involved clashed, motivated by the understanding of health counselors that IES had interests that diverged from the commitment to improving the health conditions of population 6 .
These problems evidence that effective integration depends on the openness of professionals, students and users, and support to the management of processes and consensus on investment.This impression on the mutual recognition of individual possibilities, duties and aspirations is enhanced in studies D1 and D2, which identify that early introduction into primary health care units evidences some problems related to the learning scenario, due to lack of planning between health services and the IES 35,36 .The difficult insertion of medical students in health teams permeates service structuring deficiencies and work overload, and professionals' perception that students hamper communication and constrain patients.Authors (A18) mention difficulties in the restructuring of the Pedagogical Project of the Medicine course, considering the need to insert students in services and bring them closer to the epidemiological profile of the population.They deem that coordination between the political definitions of ministries are insufficient, contributing to a gap between education and health needs.They say that teaching-service integration efforts have always had low sustainability as this depends on the idealistic adherence of teachers and students and, even when institutionalized, it remains vulnerable to local situations 37 .
These studies show movements triggered by Pró-Saúde which converge to a successful strategy to reorient education and thus qualify primary health care.Therefore, diverse settings of teaching and care practices and IES-services integration are key elements.Such movements involve partnership and dialogue between subjects representing the various bodies involved in the proposal, as well as an idealistic acceptance thereof.The challenges of apparent political uncertainty felt by the ministries cause a stir.However, experiences guided by the establishment of Pró-Saúde's management and coordination structures as dialogic space have been crucial to the consolidation of some teaching-service integration movements.
It can be said that training for the SUS from Pró-Saúde promotes education-work integration, based on the axes of theoretical guidance, practical and teaching orientation scenarios and relationships of commitment and dialogue between managers, teachers, professionals and community.However, studies lack more prolific evidence regarding the level of approximation and dialogue among the segments representing bodies involved in the inter-ministerial proposal, in order to show the level of teaching-service integration through advances, confrontations and challenges deriving from this process.

Movements of change in teaching and service from Pró-Saúde
While not as central theme, in some studies, Pró-Saúde appears as device for change in education.This is the case of A24 and A34 reports of experiences that consider that the Program is involved in the success of integrative actions (teaching and service), with a view to training professionals, working towards improving the quality of care 38,39 .From this perspective, other studies (A1, A20, A29) consider this device as a trigger of change through closer ties between learning and professional practice.They point to the need for diverse learning scenarios and implementation of interdisciplinary practices, with Pró-Saúde as a mobilizer.They also emphasize the importance of the Program for the implementation of changes by proposing the use of teaching methods that centralize the learning process 14,40,41 .
This mobilization towards interdisciplinary teaching practices and reality problem-solving teaching methods recognizes one of the priorities of Pró-Saúde, called "practical scenarios".Study A10 analyzes that some medical schools are currently in an extramural movement, in order to provide students with experience in different areas of care and the understanding of building networks.These strategies converge with DCN and Pró-Saúde recommendations 11 , by prioritizing the insertion of students in services, diversifying environments for the development of practical learning and providing opportunities for recognition of the territory of operation 42 .
In A33, authors consider successful partnership experiences between schools and health services at all levels of care, however, they indicate that convergence of all disciplines to practice settings with minimum working hours is not sufficient, but due to the complexity of work required at this level, learning must be structured by the local reality 23 .This orientation is explained by the Ministry of Health who recognizes the need to create opportunities for students of active interaction with the population and health professionals "from the onset of the training process, providing students with work on real problems, assuming increasing responsibilities as caregivers, consistent with their level of autonomy." 11,20.
Studies D3, D4, A11, A14, A19 and A23 are also betting on the teaching-service integration as a possibility for students meeting with practice settings, allowing training methodologies to transcend predominantly epistemological and content-based territories and immerse in the life of users and performance in multi-professional teams and build effective humanization linkages and ties [43][44][45][46][47][48] .Confirming this need, study D6 draws the attention to the superficial rapprochement of courses with health services, limited to some extension and research initiatives 49 .
Study A31 aimed to present, within the proposal developed in Pró-Saúde, the Information and Communication Technologies insertion (ICT) strategy in extramural undergraduate education of a medicine course.Results show effective partnerships between education and service at different government levels, but which need to scale-up consolidation at peripheral levels.Authors acknowledge that part of that process is underway because of the financial resources from Pró-Saúde, PET-Saúde and SUS Open University (Una-SUS), which shows that, in both structural and teaching issues, there is a need to interweave the various initiatives and instances towards teaching-service integration 50 .
The need to enhance partnerships is also evident in the perception of students on curriculum changes of medical education, shown in study A8.Noteworthy in this context is the teaching-service integration as one of education's critical points, and it is shown that this challenge has to do with the low sensitivity of teachers to changes and the inconsistency of services network in relation to the transformation of the care model 51 .
Studies that address teaching-service integration within Pró-Saúde converge on the understanding of this coordination as a possibility to consolidate the Program through a movement of change, which requires the structuring of learning geared to reality and guided by multi-professional work.This movement can be enhanced by raising the awareness of stakeholders and effective partnerships, as well as involving users in the process.It is worth noting that financial resources that promote the Program facilitate its operationalization.
Findings of these studies stir reflection on the educational process as the trigger of movements that involve all subjects, corroborating the awakening of new models and health practices.
It is clear that boundaries between teaching and service are intertwined with each other as power of knowledge and the construction of citizenship by putting individuals or groups face to face 52 .It is natural that such a confrontation generates conflicts, which hinders involvementwhose otherness is indisputable -between knowing and doing, in the dialogic sense, of recognition and understanding of different views and needs.

Final considerations
Studies have shown that possible and necessary changes in professional education are being implemented, especially when supported by strategies that encourage active participation of the subjects involved.Thus, relationships are shown whose superficial threads must be strengthened and anchored in social engagement for the construction of a resolutive and quality SUS.
Pró-Saúde has established itself as an important device for effective teaching-service integration, although permeated by different powers and confrontations.Fundamental to its consolidation as an important part of health education policy is that authorities, especially the overlapping subjects in this process, transcend their individual projects of knowledge/power, emerging in professional and institutional thinking anchored in new ways to produce health, without losing sight of the constitutional prerogative that assigns to the SUS the training of human resources in the field.
Noteworthy is the deficit of original studies that address Pró-Saúde as central subject of research, which signals the need for more scientific production, especially of evaluative nature on this and other inter-ministerial education reorienting devices.

Chart 1 .
Development axes and their Pró-Saúde vectors, as per editions I and II of the Program 7,8 .