Intersectoriality in health and work in the current brazilian context: the utopia of reality? ^*

Abstracts

The social-economic-political scenario since 2015 presents new challenges and characterizations for the worker’s comprehensive health care. The aim was to give visibility to the perspective of public policies managers and formulators directed to the worker regarding intersectoriality in the transition period in the last three Brazilian governments. To this end, we interviewed some people from different sectors (Health, Labor, Social Welfare, and Justice) linked to the workers’ health. There was a consensus concerning the difficulties faced in implementing intersectoral practice. Overall, this led to the weakening of building a systemic view of the field and of how a sector, rather than completing actions of another one, is part of a single system that aims to ensure the worker’s health. This is an issue of the field vulnerability that toughened the construction of collective strategies of resistance to labor and social welfare reforms.

Worker’s health; Intersectoriality; Public policies; Comprehensive health care

O cenário político-econômico-social vivido desde 2015 traz novos desafios e caracterizações para o cuidado integral ao trabalhador. Objetivou-se dar visibilidade à perspectiva de formuladores e gestores de políticas públicas direcionadas ao trabalhador, no que se refere à intersetorialidade, no período de transição entre os três últimos governos. Atores vinculados à saúde do trabalhador (ST) de diferentes instâncias (Saúde, Trabalho, Previdência Social e Justiça) foram entrevistados. Houve um consenso quanto às dificuldades para concretização da prática intersetorial. De modo geral, isso enfraqueceu a construção de uma visão sistêmica do campo e de como um setor, mais do que completar ações do outro, faz parte de um sistema único que objetiva garantir a ST. Trata-se de uma vulnerabilidade do campo que dificultou a construção de estratégias coletivas de resistência frente às reformas trabalhista e previdenciária.

Saúde do trabalhador; Intersetorialidade; Políticas públicas; Integralidade do cuidado

El escenario político-económico-social vivido desde 2015 presenta nuevos desafíos y caracterizaciones para el cuidado integral al trabajador. El objetivo fue proporcionar visibilidad a la perspectiva de formuladores y gestores de políticas públicas dirigidas al trabajador, en lo que se refiere a la intersectorialidad, en el período de transición entre los tres últimos gobiernos. Fueron entrevistados actores vinculados a la salud del trabajador de diferentes instancias (Salud, Trabajo, Previsión Social y Justicia). Hubo un consenso en relación a las dificultades para llevar a cabo la práctica intersectorial Por lo general, eso debilitó la construcción de una visión sistémica del campo y de como un sector, más que completar las acciones del otro, forma parte de un sistema único cuyo objetivo es asegurar la salud del trabajador. Se trata de una vulnerabilidad del campo que dificultó la construcción de estrategias colectivas de resistencia ante las reformas laboral y de previsión social.

Salud del trabajador; Intersectorialidad; Políticas públicas; Integralidad del cuidado

Introduction

Occupational Health (OH), a specific field of collective health knowledge and practices based on the development of surveillance, assistance, rehabilitation and health education actions, aims at protecting the workers’ health from risks and other potential injuries of work processes, and also at incorporating in care practices the work category as a component of the health-disease process ¹ .

This is a challenging field, as it has inseparable economic, social, political, and technical dimensions, and because it is undoubtedly intersectoral and multidisciplinary. Due to its characteristics, the OH necessarily dialogues with actions conducted in the justice, social welfare, work, and health sectors ^1,2 .

The actions performed in the work sphere aim to regulate the employer-employee relationship, standardize and characterize what would be safe and healthy work environments, besides monitoring rules compliance practice. On the other hand, the actions performed in the Social Welfare sphere aim to ensure that workers are economically safe when they need to temporarily or permanently leave their jobs, because of illness, disability or retirement age. Moreover, they promote professional rehabilitation actions whenever there is a partial or total loss of work ability to perform a certain function. Based on the current labor regulations, the Justice should enforce the workers’ rights, whether in the scope of the employer-employee relationship or by ensuring workers’ health protection ³ .

Although being addressed in public policies since the 1980s ⁴ , the OH intersectoral character was clearly evident in 2011 with the approval of the National Occupational Safety and Health Policy (PNSST) ³ , signed by the former President Dilma Rousseff and agreed by the then Ministries of Health, Labor and Social Welfare.

Despite prospective overlapping of attributions, as for example the Occupational Health surveillance, and important gaps, like going back to the work market process, there was an attempt, albeit modest, towards consolidating the intra/intersectoral networks, aiming at the implementation of an integrated and global system of workers’ care ^2,5,6 .

The Occupational Health, being dependent on strong public policies, is directly influenced by the national, state and municipal conjuncture. The social-economic-political situation since 2015 brings new challenges to the field, in the same manner it gained relevance in the 1980s with the Brazilian redemocratization, the promulgation of the Federal Constitution ⁷ , the creation of the Brazilian National Health System (SUS) and, more recently, with the establishment of the National Network of Comprehensive Attention to Occupational Health (RENAST) ⁸ (2002) and the promulgation of the National Policy for Occupational Health (2012) ^9,10 .

Among the national conjuncture changes, we highlight President Dilma Rousseff’s impeachment and removal from her presidential office, followed by the entry of the Vice President Michel Temer, who ruled the country from 31 August 2016 to 31 December 2018, when a new team took over the Brazilian government, headed by Jair Messias Bolsonaro.

This is still a period in which national policies protecting the workers in the country have been suffering setbacks. This situation is triggered by institutional imbalances, ministerial reconfigurations, ongoing policies disarticulations and disruptions, added to the establishment of new policies that have clearly diminished the workers’ rights.

The actions triggered by the former Brazilian president Temer led to a process of uncertainty and instability that continues to the present day in the deconstruction and discontinuity of Brazilian public policies. There seems to have been no concern regarding the systemic impact of changes in each sector. With ministerial rearrangements and the abolition of the Ministries of Labor and Social Welfare, it is becoming more and more clear that these areas are not a priority of the Brazilian Government ¹¹ .

With all these changes and movements, relevant actions -- such as inspections in safety and health at work and enforcement of sanctions provided for in legal or collective norms -- were under the responsibility of the Special Secretariat of Welfare and Labor of the Ministry of Economy. The latter is not intended primarily for the labor laws and workers’ rights maintenance. To date, no details have yet been disclosed on the future of the tax auditors and of other services provided by the extinct Brazilian Ministry of Labor. In addition, there are several unanswered questions, such as those concerning the use hereafter of occupational health and safety regulatory standards^f .

Still as part of this context, among the processes with significant implications for the Occupational Health (OH), there can be found the already implemented Labor Reform ¹² , and the Social Welfare Reform, which is still underway ¹³ . With the speed and contemporaneity of the ongoing changes, the effective analysis of the impacts on workers’ health cannot yet be found in the scientific literature. Nevertheless, from the point of view of intersectoriality, what becomes clear, when observing this picture, is the complete disregard and lack of a systemic view of the potential implications on OH.

Immersed in this conjuncture, research funded by the São Paulo Research Support Foundation (FAPESP), entitled “The construction of intersectoriality in the health and work fields: the perspective of professionals inserted in the network service of São Paulo city”, has been conducted since 2016. Its purpose is to know, to give visibility and to analyze the actors’ work processes involved in the different instances related to health and work public policies, taking into account the proposed intersectoriality brought by the National Policy of Safety and Health at Work (PNSST), besides detecting overlaps and lacks, and developing advances for the consolidation of intra and intersectoral networks, aiming at establishing an integrated and global system of attention to the Occupational Health.

This paper specifically aims at giving visibility to the formulators and managers’ perspective of public policies directed at workers, assigned at the municipal, state, and national levels, concerning intersectoriality, notably in the period shortly preceding Michel Temer’s and Jair Bolsonaro’s governments, but also in the transition periods (i.e. from 2016 to 2018) in the three governments.

Methods (g)

Using qualitative action research ^15-18 , this ongoing case study, which has been conducted in São Paulo city since 2016 and is expected to be completed by early 2021, employs mixed procedures for getting closer to and understanding the Brazilian reality.

We have used an extensive research design and organized it in various steps. Firstly, using a macrostructural investigation, we conducted a documentary survey to analyze the set of public policies in the health and work fields ¹⁰ . Next, after the project approval by the Research Ethics Committee of the School of Medicine of the University of São Paulo - FMUSP (CAAE: 58418816.1.0000.0065), we conducted interviews, among other still in progress methodological procedures, with key informants who take part in the preparation of national policies and legislations for the area, as well as with managers and other professionals responsible for their implementation, specifically with reference to the city of São Paulo. The results of this step will be the focus of this paper.

Methodological trajectory for conducting the interviews and characterization of the interviewed population

We conducted 16 individual and group interviews with actors linked to the Occupational Health from the following sectors: Health, Labor, Social Welfare, and Justice, in the period ranging from the second semester of 2016 to the end of 2018. We have not named the positions held by the respondents at the time of data collection for respecting their anonymity -- an important ethical aspect to ensure the subjects’ participation in this study and which is protected by the signature of the Free and Informed Consent Form (ICF).

With reference to the health sphere, the following items were contemplated: Primary Care, Technical Area of Occupational Health and Surveillance in Occupational Health. In relation to the social welfare sector, we interviewed the subjects linked to the Occupational Health theme. With regard to the Justice, some Public Ministry of Labor representatives agreed to participate in this study. Finally, we interviewed some representatives linked to the training/professional development processes in the workplace (former Ministry of Labor - ML).

The interviews were conducted in private places and at pre-arranged times, according to each interviewee’s availability. The interviews were fully recorded and transcribed, and they had an average duration time of 90 minutes each. They were performed according to the following guiding script: professional career description in the public network; details of the responsibilities of the agency under its responsibility; possibilities, difficulties and strategies faced to carry out the specificities related to the scope of the service it represents regarding other institutions; impacts of model changes and network reorganization on the development of their professional practice; expectations, suggestions and difficulties experienced; strategies found in everyday work; perspectives on intersectoriality in the health and work fields.

Data analysis

The purpose of the data analysis is to know and find out new elements that answer the research questions, and then confront them with the other outcomes, therefore expanding the possibilities of understanding the studied phenomena ^19,20 .

For data analysis of the collected interview material, we used the Thematic Content Analysis Technique ²⁰ . Throughout the planned steps (i.e. pre-analysis, categorization and reconstruction of the research content), the research team found reports that indicated perspectives for the set of public policies in this field, in addition to referring to the interviewees’ experience. We consider such portrayal of this historical moment of the Brazilian reality relevant to be shared with the scientific community.

As previously mentioned, it should be noted that the interviews were sometimes performed individually and sometimes in pairs/groups. Therefore, the reference at the end of each one of them points to the “unit” interview, rather than to a particular interviewee.

Results

The information gathered was organized into two broad categories: macrostructural aspects that render it difficult the realization of intersectoriality, and everyday challenges for the attainment of intersectoriality. In the end, there was a consensus among the respondents regarding the global difficulties to implement this practice.

It [the intersectoriality] is not elementary, it isn’t born of the will of some. You must have the will of power, of command to be given, because otherwise you run into corporatism, into categories, into disqualified managers to in fact be able to build an intersectoral team, into the difficulty of operating the budget at the end. Intersectoriality is not a spontaneous attribute of the public policy. It must be forged, promoted. (Interview 1 – the Social Welfare)

In their opinion, it is theoretically insufficient to have guiding documents for the interviewees, since intersectoriality needs to be built every day from the emphasis on the common aspects that surpass the corporatism of each category or sector. They also underlined the fact that there is some isolation and emptying of practices, and also duplicity of actions and conflicts of attributions.

Macro-structural aspects that hinder intersectoriality accomplishment

[Integration] is the interest of no one. We’ve never really tried to join the Public Ministry of Labor/ the Labor Court. Then, there are those arguments between the sectors of Health and Work. It’s absurd, incomprehensible, a historical and stupid thing [...] When did the National Social Security Institute (INSS)^h want something intersectoral? Never, in any government. The Brazilian Social Welfare never wanted that. It was the desire of people, of the top brass, but the structure didn’t favor this approach. People make no distinction in this steamroller. (Interview 1 - former Ministry of Labor - MS)

Some respondents highlighted that the different sectors sometimes do not know each other’s roles, leading to the lack of visibility of developed actions and shared experiences. Resources and information are missing, thus compromising the construction of joint strategies to address the difficulties.

This scenario leads to a dynamic that emphasizes the specificities of each sector and neglects the confluence of common and transversal aspects that would otherwise favor unity and collaboration. The information produced by each sector is not shared, hardening even more the exposure of problems, and thereby the development of projects, actions and coordinated solutions. In this respect, the interviewees feel powerless when facing crystallized, hierarchical and disjointed structures.

Intersectoriality is still a desire. In practical terms, consensus, resources, and shared databases are lacking. The citizen goes there, he’s a user of the Unified Health System (SUS)ⁱ . For us, he’s a user of the Social Welfare services, he’s insured; for the Social Work service, he’s a beneficiary; and for the Ministry of Labor, he’s unemployed. He’s labeled depending on where he goes to, and we understand him from the logic of each organ he uses. “So, here, he’s a policyholder. I only provide care for the policyholders, and I’m only concerned about policyholders”. (Interview 1 – the Social Welfare)

Intersectoriality was underlined as a never achieved utopia. In order to have it built, changes in the way of thinking the Occupational Health would be required. In a number of instances, intersectoriality happened more due to passion, militancy and personal and small-group initiatives than as a result of institutional and programmatic actions with State support.

[...] the former tax auditors [several names are mentioned], they were people of our generation, they were related to CEREST^j , they belonged to CEREST [...]. Intersectoriality was something more personal than an institutional policy. They were people of the same generation and had a similar form in their way of thinking and such things. Therefore, they were people we were closer to. However, when they stopped composing that group [...], we were left without a point of contact. (Interview 1 – the Health)

According to the opinion of the interviewees who work specifically in the health care sector -- a sector referred to as one of the main responsible for the articulation and effectiveness of intersectoriality in the Occupational Health (OH) policies --, not even in this sector such policies are prioritized as programmatic actions. The respondents reported that the work and its consequences are still scantily incorporated and poorly understood. Health policies have always been fragmented into specific, specialized actions. This organization ignores that the OH is transversal, permeating multiple specialties.

I think people have some difficulty because the Brazilian policies have always been extremely fragmented. Therefore, you have the women’s health, the elderly’s health, the children’s health, the workers’ health. The person may be old, hardworking… In general, you are a lot of things. You never stop being male or female, having a specific gender, and at the same time you have a job [...] The worker’s health comprises several fields of acting, thinking, knowledge. The work relationship is related to the sciences that reflect upon work: the sociology of work, the economy, the work rights - everything that you think about… This work relationship involves numerous problems, including people’s health. (Interview 1 - former Ministry of Labor - ML)

The respondents question both the guiding political trends and the priorities of the diverse governments that Brazil has been going through in the last years, including in the alleged democratic period, which gave neither priority to the Occupational Health intersectoriality nor to the construction of policies and practices that actually promote health and social welfare.

We no longer have a bridge linking the Ministry of Labor to the Social Welfare. The Social Welfare has this way of being as an agency. We have tried [to build it], and we were welcomed many times under Lula and Dilma’s terms, but we could never actually turn it into politics. Therefore, institutional policy differs greatly from what we do. (Interview 1 – the Health)

What is the priority? Health Surveillance isn’t a management priority, it isn’t a policy priority. It’s a special service, very important from the public health perspective, but unfortunately it doesn’t win votes, it isn’t a gimmick. Quite the opposite, it causes problems, because it leads you to supervise, to punish a large company, which polemicizes with the public power [...] To think about sanitary surveillance is to think of an area of conflict between the regulatory State and the market. In this field, therefore, there is no way to romanticize; it’s objective. (Interview 2 – the Health)

The respondents highlighted in their statements that the logic of productivity and the organization of actions in public services do not really appreciate intersectoral practices, and consequently they end up undermining the effectiveness of the whole system.

What is encouraged in each of these sectors? Productivity! Thus, if you want to be productive, is it easier to produce alone or as a team? Or is it easier to produce intersectorally? It’s easier to produce alone, of course, because you do things in a procedural way, often without any effectiveness, but on the paper, you write down that you made ten contacts, talked to 15 people, visited several residences. By all means, this is a necessary control. However, the way it was implemented leads you to favor management only by quantity, not discussing the quality of these things. And who is this system for? And that happens in all sectors. It involves the Public Prosecution Service, everywhere. People get into a machine system that leads you to the obligation to attend to the paperwork, to fill up many papers, to meet that numerical need. People have no time to think, and they don’t even think about it. Serving in the public service means being fully aware that you have to serve the public in the best way, and not that you do anything, and that takes time. We, for instance: what’s the use of giving five hundred lectures, of publicizing them? This represents much less than publishing a paper no one will read, you know? Therefore, the priorities aren’t those that attend the workers’ needs. It is an enemy logic of the public policies. (Interview 1 - former Ministry of Labor - ML)

Finally, the interviewees indicated economic aspects as unfavorable to workers’ welfare.

The only thing that matters to the country is the economy: for the government, if the economy is doing well, then everything else is doing well, but that isn’t true. The economy works just fine at the expense of the workers’ health, and that is quite evident to us. Then, there’s intensification, cutting jobs because of automation [...] If the economy is doing well, the worker will make more money and buy more. This is the law of consumption. Therefore, the more s/he buys, the better her/his living conditions will be, but this has nothing to do with it... This is the logic of capital. It has won the hearts and minds of people, including of those who were previously critical, of the government. Intersectoriality is lost in this bog of difficulties. Thus, when we try to do something, it’s something specific as “Let’s try to use intersectoriality in asbestos, in the Repetitive Strain Injury. In the mental health sector, there’s more difficulty in thinking about intersectoriality. There’s quarrel at work in the work organization. The concrete example of motorcyclists who died indicates that: intersectoriality. We gather the Unions and the companies, and they say: “You have to reduce productivity.” / “However, if you reduce productivity, the motorcyclist has no use.” / “We want him to be at two places at the same time. That’s what he’s for!” This logic doesn’t follow the logic of people living better, and I think society is thinking the same way, too. (Interview 1 - former Ministry of Labor - ML)

Daily challenges for implementing intersectoriality

Educational background, technical-political perspectives of public workers, and their beliefs concerning good practices in Occupational Health were identified as challenges for implementing intersectoriality in the daily practice.

[...] occupational doctors have a technical education, including ideological background, focused on business interests. Therefore, they aren’t focused on the worker’s health. This is a discrepancy, because a professional enters the area of the worker’s health, but in practice what he does, and unsatisfactorily, is occupational health. [...] And we perceive such deficiency in the education of occupational doctors. This doesn’t occur in all cases, but the majority has an employer-biased education, occupational medicine bias, a work medicine bias, which differs from the workers’ health; they are different objects. [...] I perceive that there’s a tendency to create professionals and students more focused on a more technical-operative market, and not on a humanized, critical education that is ready to challenge the economic model, the health management, the practices. From my point of view, this may lead us to a very serious problem in the future. (Interview 3 – the Health)

The National Social Security Institute (INSS) changes, implemented in the ministerial reform of the interim Temer government, was unfortunate for everything that was being done within that government, because the National Association of Medical Experts (ANMP) started strongly influencing the National Social Security Institute (INSS), and the ANMP perspective is not to think on intersectoriality, it is not to have this comprehensive view. (Interview 1 – the Social Welfare)

The respondents also noted that there was a great loss of working conditions in all sectors, with workers’ reduction due to retirement, without their respective replacements and also without them having the opportunity to transmit their accumulated expertise and developed skills. This situation led to work meaning demotivation and loss.

Furthermore, there is often a controversial use of public resources, and this is not only due to the scarcity of those still available, but also because of the very possibility of recognizing the contribution of each body to the functioning of the policy as a whole.

There is a waste of public resources when the process is opened both by the Public Ministry of Labor and the City Hall, generating double work which sometimes involves different performances, besides the work that has to be carried out twice by distinct teams… The Fiscal Auditors have a strong resistance in acknowledging the work conducted by the City Hall Health Authorities. (Interview 1 – the Justice)

Few expert engineers work in partnership with the technicians (health authorities) of the Occupational Health Reference Centers (CRSTs). There is limited knowledge and little proximity. Some of them really enjoy working with the CRSTs and they think it would be ideal if prosecutors recognized more the work of those professionals and worked more with them. That would ease the Public Ministry of Labor experts’ work. (Interview 2 – the Justice)

There are some prosecutors who ask the Occupational Health Reference Centers to begin the process in the companies and afterwards, when they get the reports, they ask the Public Ministry of Labor experts to verify compliance with the agreements, disregarding the work that had already been started by the Health sector. (Interview 1 – the Justice)

We emphasize the political engagement and militancy of the workers of this study. They joined those services during the Brazilian redemocratization process, in the 1980s/1990s. Thereby, they live with regret the breaking up of the Occupational Health as a specific area of knowledge and intervention, and the utopia of a never reached intersectoriality.

Discussion and final remarks

This study allowed us to understand, from the perspective of the Occupational Health professionals, various aspects that interfere in the construction of intersectoriality, in the actions of services in this field ^5,6,10 . Even though the interviews were focused on intersectoriality, the period in which they were conducted markedly influenced its content, since a considerable amount of changes has taken place in the country and, consequently, directly affecting this field.

In this scenario, the respondents perceived the services they worked for being further depleted and disjointed, functions and coordination extinguished, and Occupational Health protection laws modified. The intersectoriality process, as well as the laws and documents that led to the recognition of their importance, seemed to have been forgotten ^1-3,8 .

Despite the fact the interviewees pointed towards intersectoriality as an evidently utopian construct, taking into account the numerous challenges to its operationalization that precede the current political context since 2015, with the President Dilma Rousseff’s impeachment and her subsequent mandate annulment the following year, the country undergoes an acute process of public policies disarticulation -- a formal aspect that somehow guaranteed the legitimacy of this practice. The fragmentation and extinction of some ministries, the emptying of the Occupational Health and Social Welfare services, the recent labor reform ^12,21,22 , and the ongoing social welfare reform ^9,13 are examples of this process.

The Social Welfare Reform has already started “from the edges” on the basis of the Social Welfare Benefit Review Program (PRBP)^k , which has induced many former retirees, who were retired due to disability or to long-time work absence, to go back to the labor market. This policy, coupled with the lack of a framework tailored to the professional rehabilitation of these former insureds, as well as the absence of return and job retention programs, will engender in the short term a population that has neither work nor social welfare ^12,13,23 .

Within the extent of labor reforms, it begins a process of legitimation of work precariousness through outsourcing, hiring people as self-employed workers (i.e., people working without an employment relationship), introduction of intermittent work, changes in working time rules, rest periods (breaks), vacations, career plans, end of compulsory union dues, etc ^12,24 . Some of those changes directly undermine the Brazilian unions, the workers’ health protection guarantees. Moreover, it is still questionable their impact on the institutions, on the workers’ health, on the labor court and on the other institutions operating in the sector ¹¹ . It is worth noting that this process has not yet been completed. On the contrary, changes continue to occur, and the outlook is rather pessimistic.

Numerous actions have been taking policies apart “from the edges” by emptying the sectors, and without taking into account the interrelationship between them. For instance, the labor reform and deregulation increase the social security deficit and the assumed increase in workers’ illnesses will overload the other sectors involved. In a nutshell, it can be implied that the difficulties in implementing intersectoriality ultimately weakened a systemic view of the field and of how one sector, beyond complementing the actions of the other, is part of a single system that aims at ensuring Occupational Health ¹⁰ .

This process, known as ultra-liberalism, has been undermining all discussions about work conditions and organization, all the theoretical, empirical, and clinical advances about the work relevance in building the individuals’ health, the richness of their physio-psychosocial development, their know-how, their subjectivity, and the own crucial role of work in people’s lives.

With regard to the Brazilian context, it is known that

[…] in the RENAST (the National Network of Comprehensive Attention to Occupational Health) proposal, the CRSTs (the Occupational Health Reference Centers) cease to be a gateway and assume the technical support role, radiator pole of the work centrality culture and social production of diseases, and the locus of agreement of intra/intersectoral health actions in its coverage territory ²⁴ .

In this scenario, primary care would occupy an advantaged position as the health care networks organizer, including the workers’ health ^25,26 . Notwithstanding, the articulated work between these two instances, albeit the existence of some successful experiences ^27,28 , seems to be neither perennially nor systematically configured in the daily work of the referred professionals, as stated in the literature ²⁹ . In this sense, health itself, as a potential protagonist of the integration process among the various sectors, as well as the specific practices of its competence, becomes vulnerable, as reinforced by some of the workers interviewed for this study.

To conclude this study, we raise the following question: If the intersectoral practices had been applied, as outlined by the National Occupational Safety and Health Policy (PNSTT), would this be a resistance pillar of the field to face the ongoing social-economic-political changes? This is a hypothesis that should be further investigated.

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• ¹³
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• ¹⁴
  Tong A , Sainsbury P , Craig J . Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups . Int J Qual Health Care . 2007 ; 19 ( 6 ): 349 - 57 . doi: https://dx.doi.org/10.1093/intqhc/mzm042 .
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  Bosi MLM , Mercado FJ . Pesquisa qualitativa de serviços de saúde . Petrópolis : Editora Vozes ; 2004 .
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  Minayo MCS . Conceito de avaliação por triangulação de métodos . In: Minayo MCS , Assis SG , Souza ER . Avaliação por triangulação de métodos - Abordagem de programas sociais . Rio de Janeiro : Fiocruz ; 2005 .
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  Gibbs G . Analise de dados qualitativos . Porto Alegre : Artmed ; 2009 .
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  Minayo MCS . O desafio do conhecimento. Pesquisa qualitativa em saúde . São Paulo, Rio de Janeiro : Hucitec, ABRASCO ; 2010 .
• ²¹
  Brasil . Ministério da Economia . Secretaria de Previdência [ Internet ]. Brasília : Ministério da Economia ; 2019 [ citado 19 Abr 2019 ]. Disponível em: http://www.previdencia.gov.br/2019
  » http://www.previdencia.gov.br/2019
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• f
  Wikipedia [Internet]. List of Brazilian Presidents. 5 February 2019 [cited 19 Apr 2019]. Available from: https://pt.wikipedia.org/wiki/Lista_de_presidentes_do_Brasil
• g
  Based on recommendations / checklist proposed by the Consolidated Criteria for Reporting Qualitative Research (COREQ) ¹⁴ .
• h
  The National Social Security Institute (INSS) is an autarchy of the Brazilian Government that was founded in 1990 by the merger of the Financial Administration Institute of the Social Security System (IAPAS) with the National Institute of Social Welfare (INPS). For a long time, it was linked to the Ministry of Social Welfare. In the term of President Temer’s interim government, it was transferred to the Ministry of Social and Agrarian Development, and more recently (from January 2019), under the Bolsonaro’s government, it was transferred to the Ministry of Economy ⁵ .
• i
  The Unified Health System (SUS) was established by the Federal Constitution of 1988. Recognized as one of the largest public health systems in the world, the SUS guarantees a comprehensive, universal and equal access to the Brazilian population, providing services ranging from simple outpatient care to organ transplants ⁷ .
• j
  The Reference Centers in Worker’s Health (CEREST) provide technical support to SUS in the promotion, prevention, surveillance, diagnosis, treatment, and health rehabilitation actions directed at urban and rural workers ⁸ .
• k
  The PM makes it harder to grant social security benefits and strives to restrain fraud. Retrieved from https://www2.camara.leg.br/camaranoticias/noticias/trabalho-e-previdencia/570684-mp-dificulta-concessao-de-beneficios-previdenciarios-e-busca-coibir-fraudes.html .
• l
  (l) Reviewing INSS benefits: know which benefits will be reevaluated. Retrieved from https://bxblue.com.br/aprenda/revisao-dos-beneficios-inss/ .
• Translator: Ryadh Weyersbach

• *
  Research funded by the São Paulo Research Support Foundation (FAPESP) for supporting their research (grant #14/25985-2).

Publication Dates

• Publication in this collection
  09 Dec 2019
• Date of issue
  2020

History

• Received
  20 May 2019
• Accepted
  11 Oct 2019