Nursing as a supportive partner of the Brazilian National Health System

Abstracts

Neste texto, fruto da reflexão de quem acompanha os sucessivos acúmulos do Sistema Único de Saúde (SUS), apresentamos nossa avaliação do SUS, ressaltando aquilo que consideramos seus maiores progressos, sem negar que precisamos reafirmar uma agenda contemporânea de compromissos políticos e sociais para o Sistema. Defendemos que a Enfermagem brasileira, com os processos de profissionalização de seus trabalhadores, representa uma grande parceira do SUS.

Enfermagem; Enfermagem em saúde pública; Sistema Único de Saúde; Pessoal de saúde

REFLECTION

Nursing as a supportive partner of the Brazilian National Health System

Roseni Rosângela de Sena^I; Kênia Lara da Silva^II

^IPh.D. in Nursing and Emeritus Professor at the School of Nursing, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil. [e-mail]

IIPh.D. in Nursing and Professor in the Department of Applied Nursing at the Federal University of Minas Gerais, Belo Horizonte, MG, Brazil. [e-mail]

ABSTRACT

This article is based on the authors' reflections from following the successive accumulations of the Brazilian National Health System (Sistema Único de Saúde - SUS). We present our evaluation of the SUS, emphasizing what we consider to be the utmost progresses, recognizing the need to reaffirm a present agenda of political and social commitments for the System. We defend that Brazilian nursing, with the processes of professionalizing its workers, is a strong partner of the SUS.

Descriptors: Nursing; Public health nursing; Unified Health System; Health personnel

RESUMEN

En este texto, fruto de la reflexión de quien hace seguimiento de las sucesivas sobrecargas del Sistema Único de Salud (SUS), presentamos nuestra evaluación del SUS, exaltando aquello que consideramos como sus mayores progresos, sin negar que precisamos reafirmar una agenda contemporánea de compromisos políticos y sociales para el Sistema. Defendemos la causa de que la Enfermería brasileña, con los procesos de profesionalización de sus trabajadores, representa una gran aliada del SUS.

Descriptores: Enfermería; Enfermería en salud pública; Sistema Único de Salud; Personal de salud

INTRODUCTION

The creation of the Unified Health System (SUS) occurred in the context of democratization of the Brazilian state, which was promoted by a broad political movement in the country with a focus on establishing the rule of law.

The SUS was supported by the Health Reform Movement (MRS), which was configured in the 1980s to include health professionals, trade unionists, and social leaders, having as one of its main goals the creation of a free and effective public health system. In the context of MRS, it is important to note that the movement offered a contrast to the excesses of the pharmaceutical and hospital equipment industries. In this scenario, the liberal practices of health professionals such as physicians and dentists presented a strong barrier to establishing the constitutional principle of universal access to health care. For its part, Nursing has always been a supportive partner of the SUS, contributing to its creation and consolidation.

The Brazilian Federal Constitution was promulgated in 1988, and Section II of the chapter About the social order incorporated some aspects discussed by the Health Reform Movement, especially the defense of health as a universal right and duty of the State, which symbolizes the redemption of the values of the social welfare state.

In the 20 years since these regulations were put in place, the SUS has faced resistance and barriers, but its impact on Brazilian society is unquestionable. Its legal-juridical framework is one of its greatest achievements, incorporating a proposal for social control, administrative transparency, and democratic and participative management. The system has become part of the collective social consciousness, with a presence everywhere throughout the country. It is based on the principle of social justice, and does not distinguish gender, race, color, religion, or the political connection of its users.

However, the SUS remains a political challenge, requiring the continued engagement of Brazilian society as a whole, to ensure the right to health for all Brazilians ⁽¹⁾. The advances of the SUS coexist dialectically with the challenges of enforcing a health and social system underpinned by the principles of respect for all human beings and social solidarity, given the prevailing economic model that favors the logic of the market⁽²⁾.

To overcome this contradiction, the Brazilian population needs to understand and recognize that the SUS is of all and for all.

Notwithstanding, Brazilian Nursing has made its own advances and encountered its own challenges, including those of its inclusion in the SUS. The expansion of jobs, the incorporation of technology and attendant change in the work, the challenges arising from demographic and epidemiological changes, and the expansion of scientific activity have nurtured and challenged Nursing.

In this text we aim to discuss the advances of and challenges facing the principles and processes of the SUS, highlighting the contribution made by Brazilian Nursing towards reaffirming the system's contemporary agenda of political and social commitments.

THE ADVANCES OF AND CHALLENGES FACING THE PRINCIPLES AND PROCESSES OF THE SUS

When the SUS was established, its doctrinal principles were defined as universality, equity, and integrity, and organizational policies were defined as decentralization, hierarchy, participation, and social control. When analyzed under these aspects, it can be said that the SUS represents a breakthrough in the conception of health and law, guiding the organization of supply of services in the country.

Following from the Brazilian Health Reform Movement, universality was advocated as a means of providing freedom of access to health services guaranteed by the state, regardless of any distinction of age, race, economic status, or epidemiological risk. Although its full provision remains an important challenge to the SUS, we see the evolution of this principle when we measure the total Brazilian population that has access to health services.

Data from the National Survey by Household Sample carried out by Brazil's statistics agency (IBGE) shows that access to health services in Brazil has improved considerably since the establishment of the SUS, an increase of 174% in the use of services⁽³⁾. In part, this increase is evidenced in the doubling of the number of beds available for hospitalization in the SUS and the coverage provided of the Family Health Strategy, which rose from 30% in the 1990s to 60% in 2008⁽³⁾.

However, the fact that universality remains a challenge for the SUS is demonstrated by the difference in access to health services. The middle and upper class groups capture public health resources for their own benefit, creating distortions in the way health services are organized and in the structuring of priorities, and furthermore reducing the possibility of offering appropriate services to different population groups⁽⁴⁾.

In analyzing the SUS, we realize that there is much investment, for example, in primary care programs offering greater coverage for lower income segments. However, for those in higher income groups, the coverage of primary health care programs is complemented by coverage from private health plans, so that overall this population group has greater access to health services, because it has more services available in its consumption basket.

Therefore, equity remains a challenge to the SUS, avoiding duplication of coverage for some groups while leaving other groups without⁽⁴⁾.

Similarly, when we analyze the principle of integrality—understood in its functional sense of providing all possible uses of resources and preventing abuses through explicit rules about what is included in the concept of integral health—it is undeniable that the SUS has advanced. In this sense, different demands for health were incorporated into the service: expansion of programs for health promotion and prevention of risks and diseases; extensive coverage for curative care and treatment; development of investment in rehabilitation services; pharmaceutical services; and production of inputs for health.

However, we must consider that the greatest expression of the demand for health care remains the search for health services when acute symptoms manifest. In particular, in population segments which lack knowledge or health information, the demand for health is lower than the need, but the way these groups use health services causes spending to multiply, since the demand for acute and emergency services requires the most funding⁽⁴⁾.

We must also consider that there are problems in the coordination of the various medical, welfare, and social services, with limited networking and thus little rationalization of the system.

Thus, for integrality to be realized to its fullest, advances are needed in the management of the health conditions of the population in terms of ranking health needs, and the economic evaluation of health technologies and incorporation of the most cost-effective.

In considering the definition of care models, the SUS has made great advances that can be demonstrated in the expression of its primary care program, the largest and broadest on the American continent; in the introduction of soft technologies in care processes supported by subjective relationships; in advanced models in the field of sanitary and epidemiological surveillance, with positive results in controlling infant mortality and morbidity, and infectious and noninfectious diseases; and in the development of a system of science and technology that drives innovation and knowledge production in the area.

On the other hand, we still have to overcome the continuing challenges facing the SUS, such as insufficient funding to preserve universal access and to ensure comprehensive care; inadequate management systems and mechanisms; costly and misused technological incorporation; hospital-centered culture; inadequate training of health professionals; inadequate and insufficient functioning of the care network, with fragmented systems; and poor regulation of the system in its aspects of access and assistance.

Considering the contradictions present in the system that must be overcome, we must recognize the advances are many, without forgetting the challenges still facing the realization of health as a right of all and a duty of the State and Brazilian society.

NURSING AND SUS: FORMING ACTORS FOR THE CONSOLIDATION OF THE SYSTEM

It is important to recognize that upon its creation in the 1980s the SUS encountered a hospital-centered system of Nursing training and practice. At that time, a study by the Federal Council of Nursing and the Brazilian Association of Nursing showed that Nursing practice was carried out by attendants, the generic name for workers without special training for the sector.

As part of the implementation and consolidation of SUS, Brazilian Nursing joined the inter-ministerial agreement called the Large-Scale Project, involving the Ministry of Health, Ministry of Education and Culture, Ministry of Social Security, and the Pan American Health Organization, in order to qualify elementary and mid-level staff, establishing a public policy for training Nursing assistants and technicians.

The Large-Scale Project, begun in 1982, was a bold nationwide proposal, a pioneer in its concepts and methodologies, which allowed the training of nurses and made politicians and leaders aware of the importance of professionalizing the Nursing workforce⁽⁵⁾.

The professionalization of attendants in Nursing roles responded to a demand for extending the network coverage of services in the context of the Brazilian Health Reform. This contributed to the legitimacy and recognition of professional training, of assistants and Nursing technicians as well as sanitation visitors, part of the object of the Program.

Against the backdrop of the Unified Health System coming into effect at that time, the Large-Scale Project was seen as an instrument to fight inequalities and social injustices, and was a strategic priority for the preparation of human resources for the SUS. With the development of the project, it was possible to implement health reform concepts, introducing in the training the content and methodologies that have contributed to the establishment of the principles and policy guidelines of the SUS⁽⁶⁾.

The experience of successful implementation of the Large-Scale Project led to the progressive creation of public technical schools in the 1980s and 1990s, using resources from the health system itself, with the mission of training professionals to work in health and re-qualifying professional at a technical level^(7-8). The technical schools of the SUS represent important public spaces for training actors for the consolidation of the Unified Health System, since the industry's professionals are trained within their scope and using health care practices as a reference.

The Professionalization of Nursing Workers Project (PROFAE) was started in 2000, and has trained over 60,000 Nursing assistants across Brazil.

The Large-Scale Project and PROFAE have changed the composition of the Nursing workforce, increasing the number of assistants and technicians in the area. We can consider that these processes of professionalization have contributed to the advancement of the SUS, since the formation of Nursing staff has incorporated the principles of the SUS in its guidelines.

The accumulated experience of projects like the Large-Scale Project and PROFAE, which were focused on Nursing, thus allowed a leap forward in proposing a new model of health care in the country⁽⁵⁾, thereby reaffirming the position of Nursing as an important and caring partner of the SUS.

THE CONTEMPORARY AGENDA OF THE SUS AND NURSING

Brazilian Nursing, as a supportive partner of the SUS, faces the need to expand its purposeful actions within the contemporary agenda of the system's commitments.

The last three decades have witnessed rapid and intense demographic and epidemiological changes in Brazil. The demographic profile of the Brazilian population shows a rapidly aging population, which has major repercussions for the SUS. At the same time, we must consider the epidemiological profile of Brazilian society, characterized by a triple burden of disease: non-contagious chronic diseases, external causes; living with infectious-parasitic diseases; and perinatal conditions.

Brazilian Nursing supported the SUS, and the sector offered no resistance to the implementation of the system, unlike other professionals. The most important contribution that Nursing has contributed to the program lies in the advancement of three aspects: training, practice, and knowledge production.

The training of Nursing professionals has been analyzed and conducted in accordance with the policies of the SUS. In addition to the Large-Scale Project and PROFAE programs discussed in the previous section are other initiatives, such as the Project for Incentive to Curriculum Changes in Undergraduate Courses (PROENF), Experience and Training in the reality of the Unified Health System (VER-SUS), the National Program for Reorientation of Professional Training in Health (Pró-Saúde), and the Program of Education through Work for Health (PET-Saúde), all of which were supported and endorsed ​​by the Nursing sector.

The development of these programs has allowed a change in the method used for the training Nursing staff, making it more suitable for imparting an understanding of the health system's limits and challenges.

The field of Nursing has made its own advances and faces its own challenges, in addition to those arising from the growth of the SUS. The evolution of the profession of Nursing responds to advances in the SUS, as the public health system remains the largest employer of Nursing workers.

The technological recomposition of Nursing within the SUS can be seen through the incorporation of new technologies, which have led to innovations in the work. Contemporary skills include reception, case management, home care, intersectorial operations, and—in non-traditional spaces—the actions of multiprofessional teams building interdisciplinary objects.

In the field of knowledge production, Nursing has seen a great improvement in the quantity and quality of training of researchers, technical-scientific production, and delivery of events. However, it is still necessary to align the objects of production of Nursing with the SUS agenda of research priorities.

One of the most important contributions made by Nursing to SUS is its political commitment. The Nursing workforce numbers over a million workers, involved in health services across the country. Nursing is daily front-line work that has a direct connection with users and civil society groups, and therefore possesses a power that needs to be considered and reanimated.

We thus argue that the agenda of Nursing's commitment to the SUS must be based on the expansion of democratic spaces in health services; of training processes more closely aligned with the content and methodologies needed to consolidate the SUS; strategies and methodologies specific to Nursing work that contribute to health promotion for the population, and innovations in the recomposition of the work with new technologies to help overcome the limitations that still exist in the SUS model of health care.

Nursing must strengthen its role as a supportive partner of the SUS.

REFERENCES

• 1. The Lancet. Saúde no Brasil [Internet]. 2011 maio [citado 2011 jul. 12]. Disponível em: http://www.abc.org.br/IMG/pdf/doc-574.pdf
• 2. Mendes EV. Uma agenda para a saúde. São Paulo: Hucitec; 1996.
• 3. Instituto Brasileiro de Geografia e Estatística (IBGE). Microdados PNAD: 1981, 1998, 2003; 2008. Rio de Janeiro; 2009.
• 4. Medici AC. Do global ao local: os desafios da saúde no limiar do século XXI. Belo Horizonte: Coopmed; 2011.
• 5. Sena RR, Silva KL. Izabel dos Santos e a formação de profissionais de enfermagem: capacidade de transformar o impossível em política pública. Rev Min Enferm. 2011;15(1):9-10.
• 6. Almeida AH, Soares CB. A dimensão política do processo de formação de pessoal auxiliar: a enfermagem rumo ao SUS. Rev Latino Am Enferm. 2002; 10(5):629-36.
• 7. Gottems LBD, Alves ED, Sena RR. Enfermagem brasileira e a profissionalização de nível técnico: análise em retrospectiva. Rev Latino Am Enferm. 2007;15(5):1033-40.
• 8. Bagnato MHS, Bassinello GAH, Lacaz CPC, Missio L. Ensino médio e educação profissionalizante em enfermagem: algumas reflexões. Rev Esc Enferm USP. 2007;41(2):279-86.

^*

La enfermería como asociada solidaria del Sistema Único de Salud

Correspondence addressed to

Publication Dates

• Publication in this collection
  04 May 2012
• Date of issue
  Dec 2011

History

• Received
  31 Oct 2011
• Accepted
  29 Nov 2011