Práticas integrativas e complementares no Sistema Único de Saúde: desvelando potências e limites* Integrative and complementary practices in the unified health system: unveiling potentials and limitations

Objective: To understand the perception of professionals in the Family Health Strategy and the Family Health Support Center units regarding the use of integrative and complementary practices in the Unified Health System, revealing potentials and limitations. Method: A qualitative and participatory study articulated using a dialogical methodological reference performed in Culture Circles with professionals of a municipality of the South of Brazil. The disclosure was carried out concurrently with the participation of the respondents. Results: Thirty (30) professionals participated. The potentials of integrative and complementary practices for strengthening the healthcare system as a model of differentiated care with a comprehensive, holistic and empowering approach were identified, however an overload of work and the different types of resistance constitute limitations for its consolidation. Conclusion: Integrative and complementary practices are a form of care with potential for transforming individuals, families, communities, professionals and health services, and thus are important resources for strengthening the Unified Health System.


INTRODUCTION
The Unified Health System (SUS -Sistema Único de Saúde) faces many challenges, but it is unquestionable to extend the right to health to the entire population, precisely because it is a system whose management and planning are based on the social needs of the territories (1) .In the context of the care network organization in SUS, Primary Health Care (PHC) constitutes one of the system's inputs to the needs and problems.It performs whole interventions for the person, provides care continuity, creates reference links and works in the context of comprehensiveness for health promotion (2) .In the national territory, PHC is guided based on the Family Health Strategy (FHS) model, which provides a basic team to work with the community, along with the support of the Family Health Support Center (NASF -Núcleo de Apoio à Saúde da Família).
Such systematization was assured through the National Policy of Basic Care (PNAB) until August 2017 (3) .Recently, a new PNAB has been approved, which tends to deregulate the FHS.On the one hand, it confirms that the FHS remains a priority medium for implementing PHC; however, on the other hand it allows construction of teams with other formats, which means to go back to PHC conceptions prior to the SUS.Thus, the planning and follow-up of PHC are under municipal management in the country, allowing spaces for teams to be less and less multiprofessional and interdisciplinary, fragmenting the linking strategy with the community and promoting the development of the private health sector.In addition, this restructuring of PNAB broke out at a time of freezing public investments, especially impacting the lives of the SUS user population (4) .An unstable environment in the health sector and especially in the FHS is becoming increasingly perceptible and intense, which puts the practices constructed along the institutionalization of the SUS at risk with regard to understanding and implementing the expanded and positive concept of health, promoters of autonomy, quality of life and individual and collective health awareness.Thus, it is up to professionals in the area to seek strategies to strengthen the SUS so as to provide humanized and comprehensive care.
In this sense, integrative and complementary practices (ICPs) can be partners, promoting other ways of providing care and recovering different health knowledge practices.Although ICPs originate in remote times and mainly in Eastern culture, they are emerging in the western world.These practices support the comprehensive care of the individual, considering the body-mind-soul triad (5) .In addition, they are systems which promote natural mechanisms for preventing injuries and health recovery through the use of effective and safe technologies which prioritize qualified listening, the therapeutic link and the connection of the human being with the environment and society.ICPs understand the health--disease-care process in an expanded way, with the objective of promoting health and self-care (6) .Based on the reflections presented, the objective of this research was to understand the perception of FHS and NASF professionals regarding the use of ICPs in SUS, revealing potentials and limitations.

Study deSign
This is a qualitative-participatory study articulated using the methodological reference of Paulo Freire (7) .Participatory studies require the participation of those involved in the problems to be addressed and in searching for possible solutions.It is a process in which the researchers and research subjects are included as active subjects who contribute to understanding and transforming the reality in which they are inserted (8) .The Research Itinerary has a liberating pedagogical proposal mediated by dialogue and horizontal relations, being constituted of three dialectical moments: thematic investigation; coding and decoding; and critical unveiling.These stages take place in a space called a Culture Circle, which is characterized by a group of people with some common interest who come together to reflect on their problems, life situations, share experiences, build a deeper perception of reality and elaborate concrete intervention strategies (7)(8)(9) .

Scenario
The research was developed between April and July 2017 in two Health Centers (HC) organized according to the FHS model in the South region of Brazil.Participants were professionals from the FHS and NASF.The inclusion criteria were: interest and acceptance to participate by signing the Informed Consent Form (ICF), both genders, to be a professional linked to the FHS or NASF, to be present on the days of investigation, and participate in the discussions, reflections and activities of Culture Circles.Next, the exclusion criteria were: to be away on vacation or to be on leave during the thematic research period.To ensure anonymity, the teams were identified by codename of East and West, and the participants were encoded with ICP names.

data collection
An approach dialogue was held at the study sites to present the proposal and the selection of the participating team according to their interest and availability.After identifying the team, the days and times were scheduled for the thematic investigation.In total, seven Cultural Circles were developed, four with the East team and three with the West, each lasting approximately 60 minutes and organized based on the demands and profiles of each group.Field diaries were used to record the data.In order to improve the quality and reliability of the investigated themes, fully transcribed audio recordings and filming and photographic records were done during the Cultural Circles with the prior consent of the participants.
The debate leader shared the purpose and methodology in the first Culture Circle in both teams, explaining the steps of Paulo Freire's Research Itinerary.Then the thematic investigation began, being mediated by a mandala formed by elements related to ICPs and triggering issues, which were discussed in the Circles, with 50 themes being highlighted in the East team and 49 in the West.
In the second Culture Circle, the researcher took the previously produced posters and another with the written organization of all the generating themes for the group to revisit, read, reflect and begin the stages of codification, decoding and critical unveiling.The East team codified three themes: I) Strengthening of the SUS; II) Harm reduction; and III) Comprehensiveness.The West team also codified three generating themes: I) Work overload in SUS; II) Health promotion; and III) Times of resistance.At the end of the codification, the participants identified the priority order for discussing the themes, taking into account the next two Culture Circles.
The third Circle with the East team was mediated by three videos available on YouTube: I) What is Harm Reduction?; II) Comprehensiveness -Desire and reality; and III) Integrative Practices in SUS: A Successful Experience!After watching the videos, reflections and discussions were carried out on the work process in the FHS, the potentials and limitations, aligning the decoding on harm reduction and comprehensiveness and revealing strategies of action for the local reality.The third Circle with the West team began with the help of three videos also available on YouTube, namely: I) SUS -The Unified Health System (Sistema Único de Saúde); II) Comprehensiveness; and III) Integrative Practices in SUS: A Successful Experience!After viewing these, the participants were given sheets and pens so they could write down their reflections, which were then shared with the large group in a continuous process of action-reflection-action on reality, decoding and revealing the work overload in SUS and the resistance times, reflecting the daily life of doing in healthcare.
In the fourth Culture Circle with the East team, the debate leader built a mandala on the table with images and phrases about the SUS, highlighting potentials and limitations of the socio-political-economic context, inserting ICPs and the initial chapter titled "First Words" from Paulo Freire's Pedagogy of Hope book, in addition to an editorial named "Against the collapse of the SUS", published in the Revista Radis Comunicação e Saúde (9) .This aroused the curiosity of the participants and enabled a meeting permeated by deep reflections, empowering the professionals to discuss and fight for the SUS, nourishing the spaces of social control and promoting the awakening of critical awareness about the reality for strengthening the SUS.In the West team, the fourth Circle did not take place due to the work process in the HC, so that the health promotion coded theme was not decoded and unveiled.

data analySiS and proceSSing
The unveiling of the themes occurred simultaneously with the thematic investigation from the methodology of Paulo Freire, which provides for the analytical process (7) .This stage, traditionally called data analysis, in the Freirean Research Itinerary is an ongoing process and is carried out with the participation of all the participants who make up the Culture Circles through cautious reading, reflection and interpretation of emerging themes (9)(10)(11) .

ethical aSpectS
The research followed the ethical precepts of Resolution no.466/12 of the National Health Council and was approved by the Research Ethics Committee of the Universidade Federal de Santa Catarina with opinion no.1.828.562 of November 21, 2016.

RESULTS
Thirty (30) health professionals participated in this study, 18 in the East team and 12 in the West.Of these, three physicians, three nurses, one dental surgeon, one dental health assistant, eight community health agents, one physical education professional and one psychologist, plus five residents (two physicians, one nurse, one physical education professional and a social worker) and seven academics (five medicine and two nursing).Regarding gender, 18 professionals were female and 12 were male.
The Culture Circles were motivated by ICPs and health promotion, the research objects, but they moved into other dimensions encompassing a wider range of knowledge, actions and awakenings for the awareness of the human being, the citizen and the professional.Experiences of moments of love, dreams, ingenuity and moments of reflexive dialogues about reality and the economic, social, political and cultural context took place.
Fifty (50) generating themes were listed in the East team, and three of these were selected for coding, while the others were included in these codifications.The three generating themes were decoded and unveiled.The West team followed the same logic, where three of the 49 generating themes which emerged were chosen to be coded, and two were decoded and unveiled at the end of the Circles.

potentialS of icpS to Strengthen the SuS
Starting from the first Circle, the East and West teams held critical and close discussions on the work process, exercising the coming and going of theory and practice, solidifying the process of action-reflection-action.Some moments were permeated by a search for positive elements, identifying the potentials of ICPs to strengthen the SUS as a differentiated and necessary care model, which needs to be disseminated in the health sector, especially in the scope of PHC, according to the statements: The city hall has the ICP committee, this is a breakthrough, to have a group of people studying and training other professionals to act in ICP, as well as providing some materials such as seeds, needles, auriculotherapy plates (Acupuncture).
We have to approach our reality, of what we experience, because we can spend some time doing auriculotherapy, for example (Homeopathy).
Participants are critically aware of what is needed and what is already being done to increase care through ICPs, emphasizing the importance of organizing time in the work process and professional training.
In the connections of the Circles, it was noticed that the implementation of the national ICP policy enabled new Integrative and complementary practices in the Unified Health System: unveiling potentials and limitations Rev Esc Enferm USP • 2019;53:e03506 paths for care, strengthening the multiprofessional actions within the scope of the SUS and in partnership with the local community, promoting self-care and autonomy for a greater awareness of health and life.

In order to work with ICPs, you don't even need to be a health professional, you can be people in the community, and this encourages self-care and autonomy. All can be curative agents and act to strengthen SUS (Reiki).
A facility with respect to ICPs is that it is not only the doctors acting, the SUS opened possibilities for other professionals to act in this area (Yoga).
In the midst of the reflections strategies for change, of doing things differently, of strengthening the SUS were constantly thought, which promoted an emergence of hope in the teams, which unveiled the integration of another professional to form the NASF, the naturologist, as an important agent for consolidating ICPs in the PHC, according to: The presence of a naturologist would be very important, not to take all the ICP, but to give support to the team, to be inside the NASF (Circular Dance).

It would be great to have a naturologist in the NASF, because they are a professional who does several ICPs, has specific training in this area and could have a space composing the team (Music Therapy).
Thus, the research showed that there is potential to strengthen the SUS in ICPs, as they promote the empowerment of professionals, the autonomy and awareness of users/ families and new care/healing alternatives, transforming and humanizing the health system.

Work overload and reSiStance: limitationS for conSolidating icpS in SuS
Although there was an important movement related to ICPs in both teams, the context sparked reflections which limited consolidating these practices and consequently strengthening the SUS, namely the workload and the different types of resistance that permeate PHC.The hegemonic model with allopathic interventions and health training that is focused on the pathological aspects with limited approaches in the field of health promotion and disease prevention was highlighted as a limiting factor for implementing a new health culture aligned to ICPs, as evidenced by the following statements: (...) it's a teaching error, most health colleges do not address ICPs.Work overload is a difficult factor, lack of physical space (...) (Acupuncture).

The biomedical model is present, both in professionals and in the population itself, who sometimes prefer a drug because it has a faster effect (Ayurveda).
We live in times of resistance, the population, the professionals and the system itself (Circular Dance).
In this line of discussion, the resistances and difficulties of overcoming the hegemonic model are especially manifested in the cultural aspects of the population, in the way of thinking, being and living, which differ between one community and another.In some neighborhoods, work is focused on ICPs and differentiated forms of care, but in others there is a predominance of biomedical care which follows the logic of the disease/conduct, making it a challenge to establish other healthcare models.The statements below express these two realities and raise some reasons for such differences.
There is a very big difference within the city itself, between communities, one population does ICP and likes it, another doesn't.Maybe people use it but don't bring it into the consultation, they think that the professionals will not accept it, that they will be repressed (Acupuncture).
The South Island is different, it's just integrative therapy, it's the vibe of the place, everyone likes it, they have their feet on the ground, a connection.They do herbal medicine, there is a vegetable garden (Music Therapy).
It was also revealed that the social, economic and political crises which plague Brazil leads to implementing actions and practices which are retrogressive in all spheres, leaving a gloomy and worrying aspect about the future of PHC and the FHS model.This is a daily concern of the study participants, as revealed by the speeches: The government understands health as spending, not investment (...) (Acupuncture).
The SUS is in a difficult time.The FHS changed its focus (...) (Anthroposophy).

Sometimes I keep thinking that the way we work is not effective, because we can't reach people, get them to have an expanded understanding (Circular Dance).
The political scenario is disheartening.The population is polarized; in fact, it does not know what it thinks anymore.There is a lot of polarization and no one thinks.The SUS today has a small investment and is very poorly managed (Reiki).
Considering the mentioned aspects, there are important impediments to implementing ICPs in PHC and in SUS, mainly a lack of investment and understanding about the significant and transformative role of such practices in the lives of users.
In this dimension, the Culture Circles made it possible to awaken the political and constructive role of the SUS's social control spaces, which are still currently underused.Health councils represent the legitimacy for constructing a universal and quality system, through which the population has space to mobilize and fight in the current situation, as expressed by the participant below:

Now there is a transformation movement, as some people in the community are more engaged, participating in the local health council, because at other times people only came to the council to solve questions of personal interest (Circular Dance).
Based on the aforementioned disclosures, the need to provoke reflections and changes to overcoming resistances and to improve the work in PHC is evident, with visibility for construction movements of the SUS and dissemination of ICPs either by services or by the community.

StrategieS for coping With and Solidifying icpS in SuS
In the midst of the action-reflection-action movement which permeated the Culture Circles, important aspects emerged related to understanding the effective role of PHC and of Family Health in the midst of the current scenario.In order for the FHS to continue, it is necessary to redeem its guiding principles such as territorialization, care continuity, organization based on priority actions and health promotion, in order to develop work which can reach the population within the reality in which they live and work, attributing transformative meanings when doing in health.

It is necessary to know the community. In knowing, I will know which ICPs are part of people's lives (Acupuncture).
If we knew how to use ICPs, that could improve the timing issue.Because we have a heavy load on the system and few investments, we need measures to minimize costs, optimize people service and more access (Reiki).
ICPs, auriculotherapy, and acupuncture may contribute to easing the queues, mainly related to pain and mental suffering, which are the greatest demands of reception (Yoga).
It is essential to know the ascribed population in the FHS, understand the relationships and forms of care existing, essentially within the family and in the popular context.This directs the delivery of care based on local values, making it possible to fully exploit the potential of ICPs for health promotion, disease prevention, cure and rehabilitation.
In becoming aware of the above aspects, health professionals emphasized the importance of inserting ICPs for qualifying and strengthening the SUS.In this way, they reinforce actions which were thought about from the concerns provoked by the Culture Circles.

In addition to reflection, this research stimulated critical thinking. What was interesting about the research is that it made us think about all of this (Acupuncture).
Professionals in all areas are thinking about doing different things, we just need to stop and organize (...).auriculotherapy, teas, circular dance, biodance, tai chi chuan, we could learn and make a group here in the unit (...) (Yoga).
In this sense, paths and strategies exist, enabling the development of ICPs in PHC.For this, it is fundamental to engage the teams and the work process organization, thus promoting comprehensive care.

DISCUSSION
In modern society, productive activities are linked to one or more organizations.The objectives of the projects can only be achieved if articulated.The health sector is inserted in this premise, which articulates different units, programs and services to ensure care for society (12) .When the public policies which underpin the SUS are considered and implemented, it is fundamental to analyze the health profile of each population.The national ICP policy was carried out in order to expand the forms of care and healing, which has been studied, understood and inserted as a tool to strengthen the SUS (6) .
The inclusion of these practices in PHC should follow the guiding principles of the SUS through identifying risk factors and intensifying actions with an emphasis on health promotion (13) .There is a gap regarding the ways/strategies to organize, adapt and include ICPs in SUS, both in the FHS and NASF, as well as in secondary and tertiary care (14) .
The need for support from managers to promote a reorganization of services, giving greater visibility to health promotion practices which can be realized through ICPs is emphasized.To do so, permanent education and time available in the schedules of the FHS and NASF teams is essential, as well as the insertion of other professionals such as the naturologist can be an important alternative, as evidenced by this research.Naturology is a recent profession in Brazil which seeks to understand human beings in their multidimensionality and respect their singularity in the quest for well-being, quality of life and health through ICPs, constituting a harmonious relationship between people and nature (15) .
One study conducted to evaluate introducing ICPs into the SUS, specifically in the PHC of five Brazilian cities: Campinas (São Paulo state), Florianópolis (Santa Catarina state), Recife (Pernambuco state), Rio de Janeiro and São Paulo, evidenced different forms of introduction: through family health teams, exclusive exercise professionals, NASF matrix teams, and specialized institutions.Of these, it is believed that the path of greatest potential is via the FHS and NASF teams because they are in direct contact with the communities and implanted within the PHC (16) .
Thus, it is believed that the aforementioned path is the most promising, prioritizing and strengthening the FHS and NASF teams to work with ICP in SUS.However, it faces some resistance because it is a relatively new area, even from the health professionals themselves who are often overloaded by their activities.In spite of this, ICPs are tools to stimulate the comprehensiveness, promotion, prevention and treatment of individuals and families, as prioritized by the SUS (5) ; therefore, it is fundamental to overcome adversities in order to consolidate it within PHC.
Thus, not only the training and performance of health professionals is necessary, but also to meet the needs and realities of the population, taking into account the cultural factors, beliefs, values, ways of being and feeling in the world, seeking to unite scientific knowledge with the popular knowledge of the individual, focusing on valuing the subjectivity of care.
The current training process limits the skills of the future health professional; however, undergraduate courses need to adapt new teaching/learning philosophies, as well as new concepts on ICPs and their relation to health promotion with a holistic conception, which enables stimulating the health of the individual in the physical, mental, social and spiritual dimensions, involving an expanded concept of health through disciplines, seminars, discussions, and teaching, research and extension projects (17) .
Integrative and complementary practices in the Unified Health System: unveiling potentials and limitations Rev Esc Enferm USP • 2019;53:e03506 When reflecting on the real implantation of ICPs in SUS, change strategies through dialogue between managers and health professionals were planned considering popular participation, modifying the health services and therefore trying to replace the hegemonic and biomedical model which prioritizes (until that point) individual and curative actions, to the detriment of those promoting health, since the SUS has popular participation as one of its principles (6) .
One of these spaces of discussions could be contemplated with the popular participation in the meetings of the Municipal Health Council, instituted by the sanction of Laws 8.080 and 8.122 of 1990 (18) .Through these laws, it is understood that a pillar of health policy is universal and equal access under construction following the model of the SUS guidelines, modifying services and promoting health.It is essential to create strategies which encourage an empowerment of individuals and communities.The spaces of popular participation are a way for people to expose their ideas, since the council has its strengths and weaknesses, and one of the weaknesses is due to the lack of popular participation (19) .However, the current economic crisis has an impact on people's health as risk factors increase and protectors decrease, leading to a regression process in the Public Health area.The rights of users and workers are constantly attacked, and SUS care practices are weakened as there is little appreciation of actions regarding promotion and prevention.
In this sense, authors (20) affirm that health cannot be understood as the opposite of disease.Therefore, in order to ensure the health conditions of the population, it is necessary to take into account the social determinants of individuals in addition to the availability of services and professionals, and the creation and insertion of public policies which ratify this right is fundamental.In relation to this background, it is pointed out that the use of ICPs as a policy has slowly been consolidated as a practice of multidisciplinary and interdisciplinary care.For its continuity, it is crucial to broadly discuss and overcome disciplinary boundaries in the context of science and healthcare, especially in PHC, which is a space where users generally exercise their autonomy, including the therapeutic option which best corresponds to their interests at a given moment (21) .
Still, there has been an increase in the search for ICPs; a fact which meets the user's empowerment, and which understands this form of care as a right, seeking it freely.In this way, this movement can mean a step forward in overcoming the biomedical model, indicating that there has been a change in health actions with the acceptance of new intervention strategies and deviation from the focus on medicine and surgeries, typical of contemporary Western medical rationality (14) .
It is necessary to rescue the spirit of collective struggle, but there is no collectivity without a collective project which surpasses the particular benefits.There are points of irrationality in the 21 st century which have hampered collective projects in all spheres of society.It is elementary to leave aside the hegemonic model of overvaluing the world of the self, since it is impotent, and empathy is shaped in practice in relation to people.The movement of the State and the Capital is intensely trying to prevent this construction, reaffirming the impotence of the citizens.Therefore, to remain active in the struggle and militancy of the SUS must be a priority for the Brazilian population (22) .One of the strategies of change/struggle focuses on the task of attracting the main leaderships of the trade union organizations to defend and strengthen the SUS.There is a great competition between the public and private sectors of health, and the latter has wide acceptance in the population for moving a considerable volume of resources (23) .
In making a connection between the previous discussions and the scenario of health systems in other countries, some similarities and differences stand out.For example, in Canada people with inflammatory bowel disease often use ICPs in a complementary way to conventional therapy (24) .In Poland, when a scale of physical, mental and social well-being was created, researchers evaluated: the physical domain: headache, fatigue, abdominal pain, palpitations, joint pain, sleep disorders; the mental domain: anxiety, guilt, helplessness, despair, sadness, dissatisfaction, hostility; and the social domain: security, communicability, protection, solitude, rejection, sociability and appreciation, concluding that there is a strong interrelation between the domains to achieve a holistic dimension of well-being in health and life (25) .
Therefore, it is evident that in Brazil there is an orientation through the national ICP policy for using these therapies in the promotion of health, treatment and recovery.Although there is no well-structured policy in other health systems globally, ICPs are also part of the lives of people and professionals, stimulating comprehensiveness in care/ cure approaches.
The limitations of this study are the limited contact time with professionals, because implementing participant research requires a close relationship between those involved with a bond, precisely so that there is a deepening in the discussions; in addition to the difficulty of bringing together professionals to the Culture Circles, which is related to the current organization of PHC services.

CONCLUSION
The research identified different aspects of ICPs in SUS, promoting action-reflection-action to unveil the reality of these in the FHS, highlighting potentials, limitations and coping strategies in face of the current scenario, and making it possible to (re)affirm militancy movements for its strengthening.
The implemented method proved to be adequate for the proposed objective, as Culture Circles were developed in addition to traditional data collection, with different actors discussing the work process in SUS, ways of doing/providing healthcare and transforming the spaces of care and healing, all connected by the transversality of ICPs.Thus, it is recommended to carry out research of a participatory nature integrating the investigated subjects to the investigation, assigning them an active and conscious role regarding the researched object.Foram identificadas as potências das práticas integrativas e complementares para o fortalecimento do sistema de saúde como um modelo de atenção diferenciado, de abordagem integral, holística e empoderadora, todavia, a sobrecarga de trabalho e os diferentes tipos de resistências constituem limites para a sua consolidação.Conclusão: As práticas integrativas e complementares constituem uma forma de cuidado com potencial para a transformação dos indivíduos, famílias, comunidades, profissionais e serviços de saúde, logo, são recursos importantes para o fortalecimento do Sistema Único de Saúde.
It should be noted that ICPs represent a rescue of the contemporaneity of healthcare, with the potential to transform individuals, families, communities, professionals and health services so they are important resources for strengthening the SUS in both care and in teaching, research, extension and management.