Implementation and development of a medical course in Parnaíba-Piaui state , Brazil , based on the Project More Doctors for Brazil

The implementation of a medical course in a city in the Brazilian northeastern region to expand and decentralize medical education as a result of the Project More Doctors for Brazil includes the institutionalization process that takes into consideration cultural and organizational aspects that facilitate or hinder the accomplishment of innovative practices. This study analyzed the implementation process according to key categories: pedagogical project, teaching-service integration, teacher development and infrastructure. The results showed facilitating elements and barriers that depend on the movement among the proposal’s instituted forces, instituting forces and the institutionalization process. A strategy for greater feasibility can be found in autonomous movements triggered by subjects who are committed to the objectives of the involved courses and institutions that work towards making legislations and intentions real.


Introduction
In 2011, Decree no.7508 1 was ratified, regulating the law that created the Brazilian National Health System (SUS).It determined organizational concepts, such as health regions and territories, and regulated the relationship among managers in the promotion of universal access to the system's health services.
In this process, care gaps were identified in several Brazilian regions, among states and cities, aggravating the social vulnerability of people who live in those places.Doctors were the most visibly absent profession.This reality was confirmed by the study Medical demographics in Brazil 2 .This study indicated differences in the proportion of doctors per population in regions and cities and their concentration in capitals and larger cities.
This situation justified the implementation, in 2013, of the Project More Doctors for Brazil (PMMB), instituted by Law no.12871, of October 22, 2013 3 .Its Art. 2 explains that, in order to achieve its objectives, the supply of medical courses and medical residency seats should be reorganized.Health regions with a lower proportion of seats and doctors per inhabitant should be prioritized; new parameters should be established for medical education in the country; and primary healthcare doctors should go through improvement.Teaching and service should be integrated, including through international exchange in the affected regions.
In order to do so, PMMB provided for the creation of 11,447 new seats in medical courses until 2017, among which 6,887 should be offered until late 2014 4 .In order to increase the proportion of doctors per 1,000 population, the North and Northeast regions were given priority in the implementation of new courses and opening of seats in the existing courses, given their lowest proportions.
According to Oliveira et al. 5 , when faced by PMMB's recommendations, the existing medical courses, as well as those created in the context of expansion and internalization of new seats, were challenged by the need to revise their curricula, pedagogical strategies and scenarios of practice.The challenge was present in different instances, involving the integration of disciplines and areas of the courses, the incorporation of student-centered teaching and learning methods and the search for a greater integration with social facilities, health services and the community in general.(p.1,355)   In this sense, the implementation of a medical course in a city in the Brazilian Northeast is an institutionalization process that involves political, cultural and organizational aspects that facilitate or hinder the implementation of innovative practices in medical education.
Under this scope, the creation of new medical courses in higher education institutions in decentralized campi based on the 2014 National Curricular Guidelines of medical courses 6 is considered an innovative intervention.It is an attempt to decentralize education and professional retention in the region in order to improve access to health services.
After the implementation of the medical course of Universidade Federal do Piauí (UFPI), Ministro Reis Velloso campus (CMRV), in the city of Parnaíba, barriers and easiness in the ideological plan (professions' culture), institutional culture and proces- ses, relationship among people (teachers, students, technicians and the community) and social imaginary became visible.
In order to understand this process, the objective of this article is to reflect upon its dynamics through three questions: a) How does the proposal of creation of new medical courses is welcomed by the society?b) What is the relationship between the course's implementation and the organization and management of the territory's health network?c) In terms of structure, processes and academic management, do universities enable/support these changes?
These questions provide results that base the article's contribution, i.e., to analyze the existing barriers and easiness in the institutional culture established in the structures, processes, relationships and social imaginary.These barriers and easiness become visible upon the implementation of a policy related to the education and distribution of doctors in Brazil, according to the logic of equal access.

The state context
The state of Piauí is located in the Brazilian Northeast.It has 251,529.2km 2 , amounting to 16.2% of the Northeast region and 2.95% of the national area, being the third largest state in the region.According to the 2010 Census, its resident population was comprised of 3,119,015 inhabitants.Among its 224 cities, the capital is the largest, with 814,439 inhabitants, followed by Parnaíba (145,705), Picos (73,417), Piripiri (61,840) and Floriano (57,707) 7 .
In terms of availability of medical schools, three of them are private and offer 361 annual seats.One of these schools is located in the city of Parnaíba.There are also two public schools: Universidade Estadual do Piauí (UESPI), with 50 annual seats; and UFPI, with 80 annual seats in Ministro Petrônio Portela campus, in Teresina, 80 in CMRV, in Parnaíba, starting in 2018, and 60 in Helvídio Nunes de Barros campus, in Picos 8 .

The regional context: the northern part of the state and the development territories
Based on Decree no.7508/2011 1 , Piauí implemented development territories, i.e., government action planning units aimed at promoting the state's sustainable development, reducing inequalities and improving its population's quality of life.
Under the Master Regionalization Plan of Health of the state of Piauí 9 , the equivalent expression to "development territory," which is a similar concept to "health region," is conceived as a territorial area inserted into continuous geographical spaces.It is based on the existence of cultural, economic and social identities, and networks in the communication, infrastructure, transportation and health areas.
In these regions, actions and services must be organized in order to meet the demands of the population of the cities connected to them, ensuring access, equality and comprehensive care to local health.The development of primary care, and partially of medium-complexity care, as well as primary health surveillance actions, should be ensured.In the state of Piauí, 11 health regions were identified, corresponding to 11 development territories.Due to the city's conditions, Parnaíba is increasingly becoming an important health reference to the population of other health regions in Piauí, as well as of other states, such as Ceará and Maranhão, its neighbors.Based on Law 13651, of April 11, 2018 10 , Universidade Federal do Delta do Parnaíba (UFDPar) was created, after its separation from UFPI.It will be integrated by Parnaíba's campus with the automatic transfer of courses of all levels and of enrolled students, as well as job roles, both taken and vacant, of UFPI's staff, allocated in this campus.
The course began its activities on September 19, 2014.It was focused on a human, critical and reflective education of general doctors who are able to work based on ethical principles in the health-disease process in different levels of care.They should foster health promotion, prevention, recovery and rehab actions towards a comprehensive care with social responsibility and commitment with citizenship, as promoters of a comprehensive health for human beings.
In general terms, the course is full time, with a workload of 7,650 hours/activities.It is organized in sequential and transversal modules aimed at integrating the content, articulating theory and practice in learning scenarios in health services.
It currently has 148 active students and 54 permanent teachers.A total of 11 teachers were appointed on November 2017.

The analysis context
The analysis context are the conditions in which reflections on the course implementation process emerge due to PMMB's proposal.On the one hand, the courses should have specific conditions that would be followed up by the Brazilian Ministry of Health and the Ministry of Education (MEC).On the other hand, the local dynamics in which the researcher/analyst is inserted influences the proposal's feasibility.Therefore, in order to monitor the implementation and offer of authorized courses, MEC's Department for the Regulation and Supervision of Higher Education (SERES) Interface (Botucatu) https://doi.org/10.1590/Interface.1800125/15 instituted the Special Commission for the Assessment of Medical Schools (CEAEM).CEAEM was responsible for conducting in loco follow-up and assessments during the implementation projects, with at least one visit per semester.
It was based on the 2014 National Curricular Guidelines of medical courses and on the required conditions, obliging the municipal management to collaborate with the course implementation.In order to provide the necessary diagnosis and interventions of the situation, CEAEM uses a document that covers four dimensions to be met as a script: human and financial resources, infrastructure, pedagogical project, relationship between teaching and service.Each of these dimensions has several items that should be met.
Regarding human and financial resources, the allocation and distribution of resources and staff, teacher seat occupancy plan through examination, technical and administrative resources and the existence of other health courses to share equipment and lab practice spaces are analyzed.
In the infrastructure dimension, physical buildings should be in adequate conditions, with administrative facilities, teachers room, educational environments, laboratories, library and support infrastructure.
As to the pedagogical project, the document shows target images to each item, which should be assessed in three levels of compliance.The following should be emphasized: graduate profile, course's pedagogical orientation, social commitment and responsibility, pedagogical project's collective construction, articulation between academia and SUS, undergraduate and postgraduate medical education inserted in the community, essential competencies and skills, academic education connected with SUS, student-centered pedagogical project, integration and interdisciplinarity, focus on the development of competencies, student assessment excellence, commitment with quality management, two-year community-centered residency, use of information technology resources and teacher preparation to act as facilitator in the teaching and learning process.
The course implementation taking these dimensions into consideration enabled the process analysis, assessing to what extent the desired target image was met.
Another essential element is the analyst's role in the analysis context.In the reported experience, the analyst/researcher has a multiple point of view.They experience situations related to their role in the bureaucratic and organizational structure, dealing with regulatory and formal issues; in the political dimension, articulating care management and networks with scenarios of practice; and in the pedagogical dimension, faced with the challenge of preparing teachers to new teaching and learning modalities and with the responsibility for implementing the integrated curriculum.

Methodology
The questions that guide the reflections on the implementation process are related to understanding the concept of institutional culture.
Initially, by analyzing culture based on literary art, Bourdieu 11 attributes the strategic meaning of a power field to it.This power field sets rules and regulations, and enforces an aesthetic standard that guides artistic productions in each historical context.Other more specific authors in this field, such as Geertz 12 , adapt the concept of culture as an interpretative science in search for meanings.Institutional universities responsible for producing and disseminating knowledge, and preparing human resources are organizations that work under rules and regulations (explicit or not).They conform to an organizational culture that is resignified by their own dynamics, producing effects in their processes and products.
According to Pedrosa 13 , the effects that result from interventions of this kind surpass changes in the organization's structure and operation.They influence the instituted culture that shapes and guides the existing actions.Since it provides new references for the developed practices, the intervention gives rise to conflicts between agents and organizations.These conflicts can question orders issued by the bureaucratic hierarchy and destabilize the regulating power, due to uncertainties about the future, which cause discomfort and estrangement with the instituted power, rules and regulations.
In this perspective, in order to reflect upon the experience reported herein, the institutional analysis is added as reference.According to Lourau 14 , this analysis is a dialectical movement among the instituted forces, the instituting forces and the institutionalization process.
The following were analyzed: official documents related to the implementation authorization, recommendations made after CEAEM's assessment visits, seminar reports, meetings, memories of meetings of the course's Structuring Faculty Center (NDE), researcher's notes and results of researches conducted about the course 15 .
In the implementation of innovative proposals, it is possible to identify moments in the process that, according to Lourau 14 , contemplate universality aspects.They are: the preestablished justification, rules, regulations and conditions to the implementation related to the total number of implemented courses in Brazil; the particularity moment related to different contexts presented by each institution as structural, functional and mission effectiveness conditions; the singularity moment or aspects resulting from local strategies and movement that build tools for the success or failure of the implementation of what is suggested.
In this article, individual movements resulting from the analyzed course's specificity were considered more relevant.
The analysis was divided in two steps.In the first step, after systematically reading the documents and notes, three analysis categories were identified.These categories describe the instituted and instituting aspects that arise from the contact with the organizational reality and the existing academic management systems; and the strategies and movements resulting from the attempt to making the documents and guidelines of the necessary innovations to medical education feasible in the daily routine.
In the second step, considering the institutionalization process represents the construction and use of the necessary tools and strategies to implement proposals that aim at promoting changes in the institutional dynamics, facilitating movements and barriers were identified. This

Results
In the first step, four analysis categories were identified.They represent essential elements in the process: course's pedagogical project, teaching-service integration, teacher development and infrastructure.In each category, subcategories were identified.They are described on Chart 1. Regarding the pedagogical project category, its subcategories represent tools that explicit and reveal existing conflicts and divergence in the idealized, potential and experienced path.Consequently, they mark instituted and instituting characteristics, and movements resulting from the institutionalization process.
Therefore, the pedagogical project that was submitted to the Office of the Vice-Provost for Education's Assessment Committee and to UFPI's Teaching, Research and Extension Council shows, in its universal characteristics, a modular curricular matrix with sequential and transversal integrated modules and a two-year residency.In compliance with all indicated recommendations and innovations, 30% of its workload is focused on primary care, and urgency and emergency in SUS 13 .However, the process' particularity, such as regulatory requirements to open the course and deadlines to be met in the organization's dynamics, contributed to its construction without the participation of teachers and students who would experience, in their daily routine, the teaching and learning process.
The discussions led by work groups related to the implementation of new courses and adaptation of the consolidated course according to the 2014 National Curricular Guidelines and PMM Law's recommendations included issues related to the innovations suggested to medical education.They were focused on infrastructure, number of teachers, size of classes and maintenance costs.The dialoged construction process of the Course's Pedagogical Project was left in the background.
Reporting the initial experience of changes in medical education in the University of New Mexico, in the United States, Mennin and Kaufman 16 describe that resistance to changes and innovations are greater when conducted by subjects with traditional points of view and experiences, who feel threatened to lose control over the curriculum and instituted way of teaching.
Based on the same context, in the multicampi medical course of Universidade Federal do Rio Grande do Norte (UFRN), the creation of the Course's Pedagogical Project was guided by an institutionalization committee that promoted public hearings with university representatives, social movements, managers, social control, professional Interface (Botucatu) https://doi.org/10.1590/Interface.1800128/15 bodies and community members.It enabled the creation of "a pedagogical project that is more sensitive to local realities and the population's health needs" 17 (p.1,334).When the proposal of UFPI's course was presented to managers of cities in the region, it was evidenced that the articulation among educational institutions, care system, management and social participation, which are the bases of a permanent health education, is not part of the management agenda.
In the seminar held to present the course to the region's managers, a certain distance between management and the education process was observed.There is a demand for doctors, but there is no definition of the adequate profile according to local needs.
The finding mentioned above strengthens the idea that topics related to educational processes are still restricted to the academic field, in which universities are responsible for education strategies.
This thought triggered the understanding of the social role of the course and of universities as protagonists in the organization of healthcare networks in the territory.It generated movements towards spaces of regional and municipal management.
Initially, the internal discussion with other health courses underwent resistance, since people thought the medical course could consume the scarce resources available to developing activities.
In order to overcome this distance, another movement arose, i.e., discussing with a group built on campus about the implementation of a new federal higher education institution in which the medical course could be the flagship to require the creation of a new university.
When faced with the weak external discussion about the pedagogical project, reflections were focused on the appropriation of the Course's Pedagogical Project by teachers who were being hired.Therefore, conflicts to overcome the way of thinking and acting in a disciplinary way in order to achieve a comprehensive content and practice in the creation of modules as curricular components were identified.
The distance between ideas and their feasibility represented the experience's individuality, i.e., the difficulty of working in an integrated way and of conducting a shared planning of activities.Therefore, the pedagogical intervention was conducted, i.e., an institutional pedagogy that, according to Lourau 14 : "Is the method that consists in commanding, through the analysis of external institutions, the degree of freedom in which the class-group can self-govern its operation and work, and ensure its own regulation through the creation of internal institutions" (p.258).
According to the author, internal institutions are the internal rules of an organization and the group of institutional techniques, such as boards and councils.The external rules of an organization, program and class, instructions, parallel circuits of authority and staff distribution in the administrative bureaucracy are external institutions.
In this sense, the course had a certain degree of freedom, because the external rules (the guiding documents and MEC's rules) favored protagonism in the conduction of the proposal and adaptation of the pedagogical project.
The intervention's objective was to promote moments to rebuild the teachers' disciplinary experiences and thoughts in order to search for interfaces among disciplines.
The intervention was conducted through culture circles, which is a methodology used by Freire 18 that enables to recall previous experience and knowledge of the partici-Interface (Botucatu) https://doi.org/10.1590/Interface.1800129/15 pants.These circles are conducted by a monitor who helps reflect upon the fragmentation of disciplinary content and possibilities of interaction in a modular way.Teaching-service integration was considered by the involved institutional agents the most complex category.It clearly shows the distance between the ways of teaching and the way practice is organized and developed in services and with people.
In terms of universality, there is a strong consensus among several authors that health services should represent the scenarios of teaching and learning practice [19][20][21] .
Although the region's host city, Parnaíba, signed a term of agreement with MEC, healthcare networks, particularly in primary care, were being restructured, with the presence of exchange doctors from PMMB, resulting in new potential scenarios of practice.
In the instituted aim, the Education-Health Public Action Organizational Contract (COAPES) was signed with Parnaíba's city management in late 2016.However, the articulation with other education institutions that had health courses and required services as scenarios of practice was a slow process.This was due to the culture of the professionals who reproduce the corporate and individualized behavior.It prevented a consensus in the creation of the work plan and in its inclusion as part of the contract.
Towards this same direction, the medical course of Universidade Regional de Blumenau, SC, Brazil, developed participatory construction strategies of COAPES.It encouraged the creation of a municipal policy of integration among teaching, service and community 22 .
Reflecting on the prevalence of movements focused on the institutionalization of teaching-service integration spaces, the need for developing actions to break with the technical and uniprofessional culture incorporated in the education processes was observed.
In the medical course of Universidade Federal de Pernambuco (UFPE), Agreste Campus, in the Brazilian city of Caruaru, one of the innovations is a proposal involving articulation between science and art in the education process.This articulation reinforces the social, ethical, educational, psychical and emotional dimensions that are present in the professional practice's daily routine.The result was the creation of the Sensitivity, Skills and Expression Laboratory 22 .
Corroborating with the hypothesis that what is institutionalized not always is permanent, the new mayor, elected in 2017, did not acknowledge the signed COAPES.This happened even though, after the workshop held in Brasília, promoted by the Brazilian Ministry of Health's Division of Health Education Management (DEGES), the municipal management was mobilized and two meetings were conducted to come up with demands from higher education institutions with health courses, which were presented to the management to create the counterpart plan.
Nevertheless, UFPI keeps a standard partnership with state and municipal government entities to conduct curricular and non-curricular internships.This partnership enables negotiations with the current municipal management in Primary Care Units (UBS) during the development of the transversal primary healthcare module.
Meanwhile, neighboring cities showed interest in participating as education scenarios.Additionally, their representation and participation in the Regional Intermanagerial Commission (CIR), particularly in the Teaching-Service Integration Commission (CIES), have favored COAPES' revitalization in the regional scope.
Interface (Botucatu) https://doi.org/10.1590/Interface.18001210/15 In summary, this situation resulted in a new configuration to existing universities and colleges.They started incorporating the sense of social responsibility of courses in the creation of healthcare networks.
In the instituting aim, the movement occurred to ensure the course's participation in the construction of care networks.In order to do so, the course integrated Dirceu Arcoverde Regional Hospital's Management Committee (HEDA) through state government Decree no.16964, of December 30, 2016 23 .The objective was to institute a joint hospital management according to the National Humanization Policy, National Policy for Permanent Health Education of SUS and other policies created under SUS context.It also aimed at articulating, agreeing, following and deliberating on the implementation of actions proposed in COAPES for the operation of HEDA as a scenario of practice in the teaching-service integration.
Another instituting movement was being a member of CIR.CIR gathers managers of all 11 cities in the region.The course's project was presented and discussed in the commission, and municipal managers were interested in developing partnerships to integrate teaching and service in their cities.
Meanwhile, through an articulation with the National Council of State Health Secretaries (CONASS), the Health Department of the State of Piauí (SESAPI) signed a term of cooperation for the development of the care network planning process in all 11 cities in the region.It particularly involved the preparation of the primary care network to manage and follow chronic conditions by implementing flows and counterflows in the entire region with admission according to the risk level.
With this process, the permanent education movement was reactivated.An UBS was set in each city, acting as laboratory for the education of tutors who follow the facilitator process through educational workshops to implement this admission in all UBS and to consolidate a reference and counter-reference.
Regarding an integrated education and work, there are still a lot of barriers to overcome.An instituting and autonomous movement, which was an initiative from teachers and service professionals, was the organization of the 1 st Meeting of Teaching-Service Integration, in 2016.This meeting's report indicates the following issues to be solved: students taking too long to change their thoughts, transition from school to university, content integration, teacher integration, module integration, participation of all, joint thought, dialog and diversities.
Meanwhile, the following possibilities and advances were indicated: autonomy development of students who are more engaged in the process, giving feedback to teachers; student's humanization and preparation to discuss with community health agents (knowledge exchange); new points of view to new doctors; change; meetings to discuss actions; creation of dialog and integration moments; different and active methodologies; interdisciplinarity; work with different personalities; attempt to constantly improve; medical approach recycle; innovation; freedom to create; and greater participation in the process construction.
In the instituted aim, in the teacher development category, the participation of hired teachers in the Teaching Seminar, held by the Office of the Vice-Provost for Undergraduate Education (PREG), was mandatory.However, it was limited to adequately dealing with the academic management system and bringing teachers together.Most of the teachers did not have an education based on concepts and techniques, such as Interface (Botucatu) https://doi.org/10.1590/Interface.18001211/15 lesson plan, teaching topics, assessments, credit system and use of distance-learning tools.
In the instituting aim, the course was one of the 2015 InovaSUS award winners, sponsored by the Ministry of Health's Management Department for Work and Education in Health (SGTES), with the support of the Pan American Health Organization (PAHO).It provided a teacher awareness workshop for the use of active methodologies.All the course's teachers and invited teachers from other higher education institutions participated in the workshop.
Other courses, such as of Universidade Estadual de Londrina (UEL) and UFSC, were also granted the 2015 InovaSUS award.They provided education of preceptor teams as a strategy to facilitate the teaching-service integration 22 .
In 2018, Circular Letter no.2/2018/DDES/SESU-MEC was published and sent to the new courses.It is related to the grant of Health Preceptorship Development Program (PRODEPS) scholarships.
This emergency and temporary grant aims at supporting the implementation/ maintenance of residency programs during the period of strengthening relationships among federal universities, professionals and local health services.It aims at implementing sustainable contracting models for the provision of spaces of practice to medical and health courses in general 24 .
This notice objectively articulated the Residency Committee to create the work plan, in which 10 scholarships were claimed for 2018 and 5 for 2019.
As a member of HEDA's Managing Committee, it was possible to approve Medical and Surgical Clinic Residencies in plenary in the State Medical Residency Committee (COREME).MEC paid a visit to authorize Pediatrics, Gynecology and Health and Community Medicine Residencies in partnership with the medical course provided by a private higher education institution.
The participation of resident doctors under teacher supervision in following students in scenarios of service encouraged the search for doctors for teaching and preceptorship education and motivated them to participate in teacher examinations.
Initially, the infrastructure category was out of the course coordination governability's scope.It involved the construction of physical works and equipment that were the responsibility of other sectors of the organizational bureaucracy.Additionally, there were certain requirements in the rules for managing public resources, such as bidding processes, building grant and possession documents, and partnership management types.
However, guided by CEAEM/MEC, the blueprint was redesigned aimed at the need for study rooms for small groups, mentoring actions and an area of interaction.UFPI's architects were able to visit the other university for knowledge and structure adaptation.
The course was being held in a building donated by Parnaíba's municipal government.With the conclusion of the course's building on campus, the real estate was transferred to SESAPI to implement an Integrated Center of Medical Specializations (CIEM).A total of 11 medical specializations are offered.They will provide support to Medical Residency, in which specialized doctor-teachers will meet the demand and develop diagnostic studies on the situation of non-transmitted diseases and aggravations through an interventionist research.Comprehensive care and information on emer-Interface (Botucatu) https://doi.org/10.1590/Interface.18001212/15 ging, re-emerging and neglected diseases will also be provided, involving institutions as Piauí Research Foundation (FAPEPI).

Final remarks
The implementation of a medical course in an innovative way is an enlightening process.It shows weaknesses and opportunities that institutions, such as universities, can present.
In some moments, the institutional culture incorporated in the organization's dynamics is a barrier, particularly due to existing formalities for making decisions and financially managing resources.
It is also resistant to some changes, since there are non-academic interests that interfere in deliberations.Such an example was the non-acceptance, by UFPI's University Council, of the regional inclusion argument that suggested a 10% bonus in the Unified Selection System (Sisu) classification of young people who live in the region, according to the quota policy.
The culture of professions, particularly of the medical profession, shows the construction and reproduction of an imaginary based on the biomedical model's culture.The biomedical's culture is based on the consumption of medical-hospital services and inputs and includes teachers, students, family members and the community itself.
Nevertheless, the instituting force is still there, even though invisible sometimes.However, it is present in the teachers' willingness to learn new ways of teaching; in political articulations between management and academia, in which it is possible to reveal the universities' social role and responsibility; and in the institutionalization of protected spaces and times for dialog and reflection.These aspects contribute to the construction and strengthening of the commitment made by professionals with services, strengthening the sense of protagonism in the reorganization of care networks.
Finally, this strength is consolidated based on dialog and exchange of experiences among courses resulting from PMMB.It strengthens autonomous and instituting movements towards institutionality.Innovative proposals of education of doctors consistent with the current health needs then show feasible conditions.
Autonomous movements are actions aimed at implementing the course as recommended, but with the participation of subjects inserted and committed to the innovative proposal's feasibility.These movements have the power of going from instituted forces to instituting forces and vice-versa, conducting the institutionalization process.

Copyright
This article is distributed under the terms of the Creative Commons Attribution 4.0 International License, BY type (https://creativecommons.org/licenses/by/4.0/deed.en).