The Idealized Brazilian Health System versus the real one: contributions from the nursing field1

OBJECTIVE: to identify the perceptions of professionals working in a facility connected with the Brazilian Unified Health System - SUS in regard to what they know, think and talk about public health policy. METHOD: this exploratory-descriptive study with a qualitative nature was conducted with 28 professionals working in a facility connected with the SUS. Data were collected through interviews with guiding questions and analyzed through the thematic content analysis technique. RESULTS: coded and interpreted data resulted in three thematic axes: The SUS - perfect web that does not work in practice; The recurrent habit of complaining about the SUS; The need to rethink the way of thinking about, acting in and managing the SUS. CONCLUSION: the professionals working for the SUS are aware of the principles and guidelines that govern the Brazilian health system, however, they reproduce a dichotomous and linear model of conception and practice strongly linked to the thinking of society in general.


Introduction
The Alma-Ata Declaration of the International Conference of Primary Health Care conducted in 1978 reaffirmed that nations around the world would effectively participate in the health promotion of their citizens through health practices intended to attain physical, mental and social wellbeing, a fundamental right of their inhabitants. From this perspective, health became one of the most important goals of world society and to achieve such a goal, there needs to be cooperation among the diverse social, economic and political sectors (1)(2) . Therefore, the Brazilian Constitution of 1988 established that every Brazilian citizen has the right to access primary, secondary and tertiary healthcare that is provided free of cost by a national health system (1)(2)(3) .
Based on this premise, the Unified Health System (SUS) was created with unique characteristics in Latin America. Its implementation resulted in decentralization, and consequently, in increased access for people to healthcare services, especially primary health care, through the Family Health Strategy (2)(3)(4)(5)(6) .
In this process, Brazil has invested in a universal system centered on primary health care at the same time in which many other countries opted for selective care and other, less equitable, funding strategies. This change has led to an expressive increase of coverage with positive effects in various fields (3) . One study conducted in 2008 revealed that 93% of Brazilians seeking healthcare services successfully accessed healthcare and that many interventions in the maternalinfant field are close to achieving universal coverage as ensured by SUS principles (3)(4)(5) .
Formed by a network of services and health actions provided by federal, state, and city institutions and facilities, the SUS can be considered one of the greatest social achievements consecrated in the Federal Constitution of 1988 (3)(4) . Achieved amid participatory and democratic struggles, the SUS is grounded on principles such as universality, equity, and integrality and is structured based on organizational guidelines such as decentralization, regionalization, hierarchization, and popular participation (6)(7)(8)(9) .
The SUS is the materialization of an broadened and contextualized expectation of health, due to the possibility of SUS practice transcending the biologicist logic and reaching a conception of health as a social good (8)(9) . Its creation, was therefore, the greatest movement of social inclusion ever seen in Brazilian history. Since that time, there has been in Brazil intense and expanding advancements in the health sector, but at the same time, great and important challenges are faced both in the management field and in the field of processes and care delivery (9) . At the same time, there is a culture that discredits and devalues issues concerning the SUS, both on the part of managers and professionals regarding the system and on the part of the population, who in general enjoy its services. This perception, is in many cases, related to misinformation concerning the principles and guidelines that govern the SUS and also due to the dominance of the biomedical model, still centered in secondary and tertiary care (2,(10)(11) .
It has been asserted that the development of a systemic, proactive form of management that values issues regarding the SUS should begin among its own workers, providing healthcare though theoreticalpractical interventions proposing new ways of thinking and acting. For that, continuous education in the health field is an important mechanism to linking learning needs and working needs, considering that continuous education is part of the SUS's purposive roles (12) . Continuous education in the health field can be characterized as a methodological proposal of significant learning at work, in which learning and teaching are incorporated into the routines of organizations and into their work itself, to enable the qualification of professional practices (13) .
In this process of attaining achievements, nurses have played an increasingly decisive and proactive role, especially in terms of identifying healthcare needs, as well as promoting policies directed to the promotion and protection of the health of individuals, families and communities. Even if interconnected and complemented by other types of professional knowledge, nursing can be largely defined as the science that integrates healthcare, both in the sense of assisting and coordinating care practices and in the sense of promoting strategies directed to continuous education in health (14)(15) .
This study is linked to a larger project of continuous

Method
This exploratory-descriptive study used a qualitative approach because of its importance in the field of social and health investigation, particularly in the context of studies focusing on symbolic dimensions and demanding deeper understanding, analysis and impact assessment (16) .
Data were collected through interviews between The interviews were transcribed and the empirical material was submited to content thematic analysis (17) in order to identify core meanings that compose communication, the presence or frequency of which added significant perspectives to the object of study.
The notion of this thematic treatment was associated with recurrent statements expressed by words, phrases or ideas. Hence, the operationalization of this process followed the three stages recommended to conduct a thematic content analysis.
Exhaustive reading of data was performed in the first stage, pre-analysis, followed by the organization of material and the formulation of hypotheses. Afterwards, the material was explored, that is, raw data were coded.
In the third and final stage, data were interpreted and thematic axes were concomitantly delimited based on the understanding of the meanings established (17) .
To comply with ethical criteria, we folowed the recommendations of Resolution No. 466/2012 from the Brazilian Council of Health, which regulates studies involving human subjects (18) . The project was submited to and aproved by the Institutional Review Board (No. 308.493/2013). To maintain the confidentiality of the participants, the reports are idnetifiied in the text by the letter "P" followed by the number corresponding to the order in which the interviewes were conducted.

Results
Coding and interpretation of data resulted in three thematic axes, namely: The SUS -perfect web that does not work in practice; The recurrent habit of complaining of the SUS; The need to rethink how you think about, act in and manage the SUS.

The SUS -perfect web that does not work in practice
All the workers' reports make clear that the SUS is a perfect web/network, the best national health system and an example for other countries. They recognize that it reaches different economic classes and comprises from the basic to the most complex services, provided free of cost. Therefore, it is a system that had been improved through new programs and policies but which, in practice, presents operational obstacles.
In this antagonism and dialectical perception, the informants mentioned that difficult access and delay experienced in the services are the main obstacles hindering the proper functioning of the SUS in practice: In general, the participants are aware of the principles and guidelines governing the SUS and acknowledge its importance for the health of Brazilians.
They also show a reflective process upon the questions presented and try to understand why the delays exist, why patients need to remain in lines throughout night to ensure they will get a consultation, that is, why there are these barriers that would apparently be possible to solve. Changing the way of thinking about and managing the SUS, according to the professionals' reports, implies rethinking the system's management process, the conception that the SUS is a universal system and not only for the poor and the needy. The understanding of the system as effectively a web/network that involves dialogue, interaction, and the commitment of all those involved in the process is essential. These reports also show that both workers and users need to be engaged in and committed to the system. For that, we need to transcend specific issues of four consultations a day or providing 20 forms daily and conceive of the system as an integrated whole, so this web/network will actually work in practice.

Discussion
The SUS is by itself a complex phenomenon. Thus, the more complex will the discussion be concerning a search to outline new theoretical abstractions for the system to truly work in practice. Therefore, only a framework that is also complex will enable a new understanding and new strategies and avoid theoretical- It is worth noting that, a priori, the SUS is composed of a health system with a strong connotation of disease.
When the system is conceived as disease-centered and/ or focused on the needs presented by a specific disease,  (11,13,(19)(20) . and form a complex unit (21)(22) .
By complex, we mean everything that is decided together (21) . In this direction, the complexity originates with the other types of knowledge in order to make the SUS as a complex and dynamic unit (11,15) .
In the process of gaining achievements and facing challenges related to the SUS, nursing has the opportunity to operate proactively and systemically at the different levels of healthcare, whether through education, promotion or rehabilitation of health. This operation particularly occurs in an effort to raise critical situations and the systematized intervention of a healthcare plan, capable of overcoming fragmentation and ensuring the continuity of healthcare and its problem-solving capacity (20) .

Conclusion
The conclusion is that SUS workers have a superficial knowledge of the principles and guidelines that govern the Brazilian healthcare system. The participants reproduce a model of healthcare conception and dichotomous, occasional and linear performances in their practices. For the principles and guidelines to be translated into practice, it is inevitable that new theoretical-practical frameworks be proposed.
The study shows that a health system that can serve as a model for international countries or is a perfect web, as expressed by the workers in it, is not enough. It is necessary that this system be translated into practice, From this perspective, continuous education in health is presented as a dynamic device that energizes more affirmative professional attitudes in regard to the development of the SUS. The involvement of users through appropriating the proposal that guides this system, as well as their rights and duties, is also shown as an element with potential to enable new forms for analysis and to make the system more dynamic.
Nursing assumes, in this process, an increasingly decisive and proactive function of identifying the population's care needs as well as promoting and protecting the health of individuals in their multiple dimensions. In short, nursing care is a key component in the local health system, which are reflected at the regional and national levels, and therefore, also presents a motive for encouraging debates and new meanings.