Experiences and Stages in the Reality of the Unified Health System Project: line of flight in health education for collective health action

ABSTRACT

In a scenario in which health education has been intensively discussed, due to fragmentation between theory and practice, among other deficiencies that may compromise an articulation towards collective health, this theoretical essay was written to reflect on the Experiences and internships in the Reality of the Unified Health System Project as a line of flight for an interprofessional training for the management and organization of the Unified Health System (SUS). In this context, it became essential to systematize the discussion in two moments, namely: From fragmented training to problematizing social reality; and Possible scenes based on the understanding of the Unified Health System through the experiences and internships. This essay was based on the line of flight perspective pointed out by Gilles Deleuze and Félix Guattari, as well as on Foucault’s perspective of the subjects. Through the reflections prompted, it was possible to realize that the Project emerged as a line of flight that allows a distinct training of subjects who would have leading roles in the teaching-learning process, in order to organize and manage the system according to their reality, besides allowing for a (de)transformation of a crystallized and deficient education.

KEYWORDS
Education; Unified Health System; Public health

RESUMO

Em um cenário no qual se tem discutido de forma intensa a formação em saúde, devido a uma fragmentação entre a teoria e a prática, entre outras deficiências que podem comprometer uma articulação direcionada à saúde coletiva, construiu-se o presente ensaio teórico, com o objetivo de refletir sobre o Projeto Vivências e Estágios na Realidade do Sistema Único de Saúde como uma linha de fuga para uma formação interprofissional para a gestão e organização do Sistema Único de Saúde. Nesse âmbito, tornou-se essencial sistematizar a discussão em dois momentos, sendo eles: Da formação fragmentada à problematizadora da realidade social; e Cenas possíveis a partir da compreensão do Sistema Único de Saúde por meio do estágio de vivência. Fundamentou-se o presente ensaio a partir da perspectiva de linha de fuga apontada por Gilles Deleuze e Félix Guattari, bem como da perspectiva de sujeitos, de Foucault. Por meio das reflexões realizadas, pôde-se perceber que o Projeto surgiu como uma linha de fuga que oportunizava uma formação diferenciada dos sujeitos que viriam a ser protagonistas no processo de ensino-aprendizagem, com vistas a uma atuação direcionada à organização e gestão do sistema de acordo com a realidade na qual estariam inseridos, além de possibilitar a (des)transformação de uma formação cristalizada e deficiente.

PALAVRAS-CHAVE
Educação; Sistema Único de Saúde; Saúde pública

Introduction

In Brazil, healthcare provider training has become the focus of analysis and reflection with greater emphasis in the last decades, considering the process of construction of the Unified Health System (SUS) and its need to respond to the social health demands of the population consistently with its principles and guidelines aimed at reorganizing the healthcare model.

In this context, the National Curriculum Guidelines (Diretrizes Curriculares Nacionais, DCN) of health courses are responsible for guiding curriculum planning and point to a different type of education, in which there must be the integration between theory and practice, teamwork and interprofessional work, the integrality of health care with co-responsibility, bonding and inseparable partnership between work and professional training¹.

Therefore, there is the need to materialize the reorientation of health education, which should be based on the recommendations established by the DCN, as its implementation is considered to have the potential to contribute to the reorganization of both the care and training models, aiming at coping with health needs, for which the biomedical model is insufficient.

However, difficulties in implementing curriculum guidelines in health courses can be pointed out, from which clues can be brought about curriculum change, in which the training of care providers should be guided by the insertion of new content and the incorporation of innovative pedagogical practices, such as the use of active teaching methodologies² that are able of making them reflect based on the reality in which they will face up to, allowing them to be critical and subjects capable of changing the reality, of not separating theory from practice.

In parallel with this discussion, it is necessary to mention that several actions have been proposed and are likely to be implemented in order to advance and strengthen health education in Brazil, such as the Tutorial Education Program (Programa de Educação Tutorial, PET) and the National Program for Reorienting Vocational Training in Health (Programa Nacional de Reorientação da Formação Profissional em Saúde, Pró-Saúde). Thus, there was the support of organizations or government incentives and/or guidelines aimed at stimulating, collaborating and articulating among educational institutions, health services and/or the community, aimed at meeting the society’s health needs, focusing on teaching, research and extension activities¹.

The problems in the implementation of new curriculum guidelines are due to the distance between education and the real job world, and the lack of strategies that reorganize this education. Such reorganization in the training model is aimed at addressing health needs, for which the biomedical model is insufficient, as previously mentioned. Partnerships among training institutions and health services articulate this escape from the ‘prison’ of the academy, so that one can experience health services, approaching the community in order to meet the health needs of society with the university support¹.

Among these actions, it is possible to mention the Experience and Internship Project in the Reality of the Unified Health System (Projeto Vivências e Estágios na Realidade do Sistema Único de Saúde, VER-SUS), which seeks to stimulate the training of workers for SUS, who are ethically committed to its principles and guidelines, and who understand themselves as social actors and political agents capable of promoting transformation within society³.

The VER-SUS Project enables an intense theoretical, practical and experiential immersion in the health system, for a period of several days, on a transdisciplinary perspective, in which the participant is available for his activities throughout the period⁴. Therefore, VER-SUS is aimed at providing a significant learning process of the reality of health systems, in order to make participants realize the social role of those involved in the system - students, professionals, managers, social movements and users - in the process of strengthening SUS⁵.

The Project was inspired by other initiatives, which sought to provide university students with learning and experiences through their insertion in territories/communities which usually do not have opportunities in the academic environment⁶. Students are divided into working groups, with one facilitator in each group, usually a student who had already participated in the previous edition⁷.

In order to evaluate and enhance the ethical-political commitment of the participants in the SUS implementation process, as well as to provoke reflections about the student’s role as a transforming agent of social reality, the Project is aimed at sensitizing managers, workers and health educators, encourage discussions and practices regarding continuing health education (EPS) and the interactions between education, work and social practices. It is important to highlight the contribution of the development of interprofessional and interdisciplinary practices to interinstitutional and intersectoral articulation⁸.

In this context, the question is ‘Does the VER-SUS Project characterize a line of flight in health education and a tool aimed at transforming and training subjects for a differentiated performance in collective health?’.

This theoretical essay is aimed at promoting a reflection on the VER-SUS Project, based on the assumption that it is a line of flight for health education, as well as a tool for the transformation and training of subjects who are involved within SUS.

From the fragmented training to the problematization of social reality

The VER-SUS Project has a differentiated organizational structure for a training that can develop and/or enhance potentials of its participants, from movements of deterritorialization and reterritorialization with the lived experience in the context of a significant learning about the management and organization of the SUS project.

Deterritorialization presupposes a rupture with the old, which is characterized as a process of change, which is often conflicting, in which the subject is always placed before himself and the new territory that appears. Reterritorialization starts with experiencing the new, seeking identities built from sharing new references and knowledge productions⁹.

The uneasiness in the VER-SUS Project has potentials that involve encouraging student leadership regarding the training process, not only individually, but also collectively. These troubles have the power to collaborate with the analysis of work and training processes, linking technical skills with humanism³.

However, before continuing the discussion about the Project as a line of flight in health education and as a tool that enables the transformation and training of subjects for a differentiated performance in public health, it is important to unveil what is a line of flight in the perspective of Deleuze and Guattari, based on the work ‘Thousand Plateaus: Capitalism and Schizophrenia’, and subject, in the perspective of Foucault¹⁰.

Beginning with the concept of rhizome, it has its principle in biology and represents those types of underground extensions of the stem to store nutrients that extend horizontally, but which are not roots or tubers. Such extensions of the stem on a plateau form the image of a tangle of connected lines where the beginning, end, and founding or central nucleus cannot be distinguished. The image is of lines that propagate, each bearing its own becoming¹⁰.

For each component of the rhizome, there is a concept or other complementary or explanatory image. Part of these image-concepts that explain the rhizome are the lines, elements that, within a rhizome, comprise, in its becoming, the rupture of the one/multiple dichotomy. The lines of a rhizome are a multiplicity, for each individuality carries heterogeneity within it.

Each individual and each object is full of potentialities, which will only become a reality according to the encounters with other external objects, promoting leaps, breaks and connections with other becomings, with other lines, therefore producing agencies. The agencies, in turn, are the connections between the different strata of ‘reality’, driven by desire.

The VER-SUS provokes agencies in students, once its participants, after leaving this experience, are mobilized to defend the quality of SUS for the entire population¹¹. In this essay, the Project will be considered as a line of flight in health education in order to enhance the knowledge about SUS. The line of flight is not linked to the sense of fleeing from an academic background, but to the sense of creating possibilities for meaningful learning and of creating alternatives that make sense for participants to modify their practices based on an interprofessional experience, in which they are the stars of the whole process.

As discussed in the beginning of this essay, there are still many challenges to be overcome in health education, including better integration between theory and practice, the need for a more strategic articulation for collective health, and other advances that allow us to materialize what is established in the DCN (The Brazilian National Guidelines) and that allow for the training of subjects involved with SUS. In addition, these advances should take an interprofessional perspective on the health needs of the population, which is often not possible in the academic world.

From this point on, it is argued that the VER-SUS Project emerges as a line of flight that allows those involved to dynamically and interactively experience collective health in direct contact with reality, interprofessionally going through the health training quadrilateral: teaching, management, care service and social control¹².

In this sense, the lines of flight are rupture lines; true disruptions that promote sudden, often unnoticeable changes, and are not overcoded by hard lines or tractable lines. They are ruptures that undo the self with its established relations, surrendering it to the pure experimentation of becoming, at least momentarily¹⁰.

Moving forward in the discussion, to address the transformation and training of subjects from the VER-SUS Project, Foucault’s thoughts about the subject can be used. This author postulates that the subject is historical but produced based on his/her own history and the history that surrounds him/her, through what he called ‘history of truth’¹³. Thus, the VER-SUS is inserted as part of the history of the subjects who experience it and play the leading role.

Thus, Foucault’s goal was to create a history of the different ways in which humans became subjects. These modes of subjectivation are the practices of the subject’s self-constitution. Such practices refer to the forms of activity upon oneself. The author uses the concepts of ‘self-practices’, ‘self-techniques’ and ‘self-care’ from Ancient Greece to analyze the subject’s self-constitution¹³.

Foucault does not define the subject, but makes a ‘history of truth’, through which he seeks to know which ‘games of truth’ were present in the individuals, in their relationship with themselves and regarding culture, and what has made them subjects¹³.

Through ‘self-practices’ and ‘self-care’ human beings become subjects in an active way. These practices are related to ‘games of truth’, that is, to how the individuals position themselves in an exercise about themselves, transforming themselves, by elaborating a way of being in face of instituted values, such as madness, disease, work, crime and sexuality¹³.

VER-SUS, in the context of health education, is an innovative initiative that provides meaningful learning through experience, immersion in the community (territories), and health services and social devices. It approaches many discussions about SUS, addressing its historical process, its guidelines, its principles and its operationalization. Participating subjects are transformed and trained as they get in touch with this reality and share this experience with various actors, allowing the subject to think about the problems and about collective and viable solutions.

Students problematize reality along with various health professional categories and related areas, and have contact with users, professionals and managers of health services that affect them in their ways of life and existence.

The Project’s essence is the development of social transformation, as well as its impact on reasoning about changing the minimum curriculum and teaching-learning strategies. It is also verified that the proposal of internships and experiences is related as an alternative to evaluate and intervene in the academic formation¹⁴. This initiative can guide new pedagogical practices through the articulation of the university support and new health practices, contributing to the insertion of public policies in different regions, opening to intersectoral actions⁶.

This is confirmed by the methodologies used during the experiences, which are dialogical and participatory, with student-centered learning. The activities are theoretically based on the concept of popular education and meaningful learning, which can contribute to the social reality in which students will be inserted as future professionals.

Experiential learning is one of the facilitated learning approaches, which represents a greater involvement of the learners with their learning in global aspects, that is, a denser processing of knowledge and skills through experience, reflection, experimentation and application¹⁵.

From these aspects of the Project, it is possible to visualize a rupture with singularity. It is a line of flight, promoting ruptures and connections with other becomings, which corroborates to produce agencies. The process of transformation and training of subjects is directly related to the opportunity to learn from the aforementioned devices, so that, in the future, they will enhance SUS, based on actions and interventions stimulated through the experience and performed with the participation of all the social actors that constitute it. It is important to highlight that the Project is also aimed at training political agents that significantly contribute to strengthen SUS, that is, contributes to the training of political actors.

The VER-SUS Project may be a tool capable of sensitizing future professionals in the country to recognize the potential and limitations of SUS, bringing students to face the challenges that permeate public health and the consolidation of the system. Thus, it is aimed at reaffirming health as a universal social right, which is free and has quality, stimulating the involvement of the various social and political actors in the struggle in defense of SUS and the democracy, as well as training professionals ethically and politically committed to the health needs of the population¹⁶.

Despite the acknowledgment of all potentialities of the Project, it is necessary to consider its weaknesses, which are based, above all, on the issue of the lack of funding, which may make its implementation unfeasible¹⁷.

Possible scenes based on the understanding of SUS through experience and internship

In this part of the study, we intend to, considering the VER-SUS Project as a line of flight and transformation and training of subjects, to develop a thought, based on the evidence in the literature about possible (de)transformations experienced by the participants of the initiative. Here we talk about scenes due to the possibilities of understanding that they arise from the subjectivities of the various actors of the Project.

The VER-SUS Project can be fundamental to qualify training. The principles underlying SUS, such as integrality, universality and equity, are also substantial for professionals who want to have a humanized perspective, to understand the system’s performance and face daily challenges differently, considering the limitations and potentialities of the service, offering the population satisfactory assistance¹⁸.

Participation in the VER-SUS Project can break paradigms, promoting a broader view, instigating the questioning of social interactions and the way health is based on SUS. It trains militants and critical subjects about current health practices¹⁹. When students experience the activities provided by the Project, they are invited to problematize reality.

After experiencing, in practice, and being able to know the health devices, the concepts are reformulated, that is, the VER-SUS can provide the experience of deconstructing and reconstructing paradigms through this integration into the daily work in the services, generating leading professionals in the struggle for the right to have access to health, who, in an exercise of citizenship, can learn much more than the content offered in the curriculum, achieving the purpose of the Project, which is to “transform minds and hearts toward a quality health system”^(19(22)).

The uneasiness produced by VER-SUS has several potentials, which include encouraging student leadership in their individual and, above all, collective training process. The inconveniences have the power to operate in the analysis of work and training processes, combining technical skills with humanism²³.

They also point out that ‘experiences in SUS’ can provide ‘collectives’ - gathering of groups of people that are interconnected by an activity with a productive purpose. In this case, it means to live, experience SUS, as well as debate about it, in an ‘organized’ collective, that is, a group articulated for a purpose. In relation to organized collectives, they are grouped based on a production purpose, and not by a priori identity (to be a student, to be a teacher).

In this sense, the VER-SUS has the power to bring together not only students, but also teachers, users, managers who have affinity, in a health production aimed at strengthening SUS. In this process, it is possible to notice the leading role of students and health providers in health and care practices that establish relationships of alterity with users²³.

The VER-SUS represents a necessary experience for the education of the professional who will work in SUS, as it contributes to enrich the knowledge, besides providing the development of the decisions to be taken in favor of the community needs. In addition, it promotes a connection between higher education institutions and the public health system, thus contributing to vocational training in the quality of individual and collective healthcare²².

The incentive to a ‘critical perspective’ is something that can also be noticed, linked to several subjects, such as: difficulties at SUS, professional performance, academic education, political representations in health, etc. And when such an incentive is intertwined with suggestions for improvements, so that professionals and users identify problems and at the same time propose solutions in a constructive manner, it is a sign that the VER-SUS proposal is something that is showing, at least initially, satisfactory results, since a critical sense is one of the characteristics that demonstrate the success of the educational process of the professionals in question²⁴.

Finally, it would be interesting if all students had the opportunity to go through the experience of VER-SUS, which would reveal future professionals as social actors in the changes at which SUS and the society are aimed at¹⁹. It is also worth noting the importance of students who experience the Project, as they become multipliers and mobilizers of more students in defense of SUS, in the places where they work.

Final remarks

Through the reflections prompted, it was noticeable that the VER-SUS Project can become a line of flight, as it contributes to a differentiated way of training subjects who may have a leading role in the teaching-learning process, aiming at a performance focused on the organization and management of the system, besides enabling (de)transformation of blurs caused by a crystallized and deficient training. In this sense, the VER-SUS can be one of the potentials for the effectiveness of SUS.

In general, it is important to emphasize that the experiences provided by the Project have been presented as initiatives that are not aimed at being a training model for the health area. The VER-SUS is aimed at provoking uneasiness, discomfort and curiosity among those involved, regarding the training of health providers.

Thus, it is believed that the Project collaborates with the training of subjects who can be strategic to enhance the organization and management of SUS, as well as be allies in the militancy for its defense.

• Financial support: non-existent

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Publication Dates

• Publication in this collection
  25 Nov 2019
• Date of issue
  Jul-Sep 2019

History

• Received
  09 June 2018
• Accepted
  15 May 2019