Construction of emancipatory practices with health councilors through educational workshops and concept maps

Violeta Campolina Fernandes Regina Stella Spagnuolo About the authors

Resumo

Objetivou-se conhecer como se dá a participação comunitária no âmbito da capacitação profissional de conselheiros municipais de saúde por meio da realização de oficinas educativas e mapas conceituais. Trata-se de estudo qualitativo, do tipo pesquisa-ação, desenvolvido em três municípios pertencentes a Região de Saúde do Pólo Cuesta, São Paulo, Brasil, com 28 conselheiros. Foram realizadas oficinas educativas e mapas conceituais, sendo os dados avaliados conforme análise temática dialógica e análise semiótica de imagens. A discussão foi alicerçada pela Teoria da Aprendizagem Significativa. Os resultados evidenciaram a importância da Atenção Primária à Saúde no que se refere à escuta qualificada e às ações de promoção e prevenção da saúde. Para os participantes, exercer a função de conselheiro significa estar presente nas reuniões e representar seu segmento populacional. Sentem-se importantes como colaboradores na elaboração de políticas públicas e no auxílio a outros órgãos no controle orçamentário e fiscalizatório. Conclui-se que as oficinas educativas e os mapas conceituais se revelaram como estratégias pedagógicas a serem trabalhadas com conselheiros de saúde, uma vez que possibilitaram momentos de aprendizagem, trocas de experiências, interação e criação de vínculo.

Palavras-chave:
Aprendizagem; Conselhos de saúde; Educação em saúde; Participação social; Saúde pública

Abstract

The aim of the study was to find out how community participation occurs within the scope of professional training of municipal health councilors through educational workshops and concept maps. This is a research-action, qualitative study, developed in three municipalities belonging to the Health Region of Cuesta Pole, São Paulo, Brazil, with 28 councilors. Educational workshops and concept maps were carried out and data were analyzed according to the dialogic thematic analysis and semiotic image analysis. The discussion was supported by the Significant Learning Theory. The results showed the importance of the Primary Health Care regarding qualified listening and health promotion and prevention actions. For the participants, exercising the role of councilor means being present at meetings and representing their segment to the population. They feel important as collaborators in the creation of public policies and assistance to other governing bodies related to budgetary and fiscal control. Educational workshops and concept maps were shown to be pedagogical strategies to be worked with health councilors, as they allowed moments of learning, exchanges of experiences, interaction and creation of bonds.

Key words:
Learning; Health councils; Health education; Social participation; Public health

Introduction

As a guideline of the Brazilian Unified Health System (SUS, Sistema Único de Saúde), community participation is guaranteed by Law N. 8,142/1990, having the health councils and conferences as collegiate bodies. Health councils are responsible for strategies and for controlling the health policy implementation, including those related to the economic and financial aspects, being constituted by government representatives, service providers, health professionals and users11 Brasil. Lei n° 8.142, de 28 de dezembro de 1990. Dispõe sobre a participação da comunidade na gestão do Sistema Único de Saúde (SUS) e sobre as transferências intergovernamentais de recursos financeiros na área da saúde, e dá outras providências. Diário Oficial da União 1990; 31 dez..

Participating in the creation and control of public policies requires empowerment, autonomy, engagement, knowledge of the legal bases of the health system, definition of strategies, capacity for socio-political analysis for decision making, understanding the concepts, respect for others and good communication, and there are many difficulties to be faced in order to establish the role attributed to the actors who participate in the health councils.

The main obstacles to community participation are related to the lack of health information and knowledge about the councilor’s role; irregularities regarding the composition, ownership and frequency of meetings; lack of knowledge to analyze the financial management and accountability; the population’s lack of interest in collective issues and low motivation for participation22 Bispo-Júnior JP, Sampaio, JJC. Participação social em áreas rurais do Nordeste do Brasil. Rev Panam Salud Publica 2008; 23(6):403-409.

3 Flores W, Gómez-Sánchez I. La gobernanza en los Consejos Municipales de Desarrollo de Guatemala: Análisis de actores y relaciones de poder. Rev Salud Pública 2010; 12(1):138-150.

4 Rocha CV. Gestão pública municipal e participação democrática no Brasil. Rev. Sociol. Polit. 2011; 19(38):171-185.

5 Shimizu HE, Pereira MF, Cardoso AJC, Bermudez XPCD. Representações sociais dos conselheiros municipais acerca do controle social em saúde no SUS. Cien Saude Colet 2013; 18(8):2275-2284.
-66 Busana JA, Heidemann ITSB, Wendhausen ALP. Participação popular em um conselho local de saúde: limites e potencialidades. Texto Contexto Enferm 2015; 24(2):442-449..

Therefore, in order to support the exercise of social control in health policy, it is necessary, for the political subjects involved in it, to effectively know SUS and its legislation, its epidemiological, assistance, financial, political, cultural and social paradigms, aiming at monitoring and evaluating the health information system at the municipal, state and federal levels. Therefore, the learning can be built through experiences in which subjects interact in search of the same ideal.

In this sense, initiatives by the Ministry of Health, such as the issuing of Ordinances N. 198 of 2004 and N. 1,996 of 2007, assumed the management responsibility with the training of human resources through Permanent Education in Health, in which qualification actions were incorporated with the integration of teaching, service and community, transforming professional practices and work organization in a problematization perspective77 Brasil. Portaria n° 198, de 13 de fevereiro de 2004. Institui a Política Nacional de Educação Permanente em Saúde como estratégia do Sistema Único de Saúde para a formação e o desenvolvimento de trabalhadores para o setor e dá outras providências. Diário Oficial da União 2004; 13 fev.,88 Brasil. Portaria n° 1.996, de 20 de agosto de 2007. Dispõe sobre as diretrizes para a implementação da Política Nacional de Educação Permanente em Saúde. Diário Oficial da União 2007; 20 ago..

Aiming to promote a more effective practice of health councilors and strengthen participatory democracy, in 2006 the National Policy of Permanent Education for Social Control in SUS was approved by the National Health Council (CNS, Conselho Nacional de Saúde), highlighting education initiatives for social control that contribute to the development of the action of the social subject, with participatory methodologies that value people’s experiences and are not restricted to councils and, thus, involve the entire population regarding the improvement of SUS99 Conselho Nacional de Saúde (CNS). Política Nacional de Educação Permanente para o Controle Social no Sistema Único de Saúde - SUS. Brasília: Editora do Ministério da Saúde; 2006..

The working group of the aforementioned policy became the Inter-Sectoral Commission of Permanent Education for Social Control in SUS (CIEPCSS, Comissão Intersetorial de Educação Permanente para o Controle Social no SUS), through Resolution N. 374, of June 14, 2007, with the objective of assisting CNS in monitoring the Permanent Education Policy for Social Control in SUS at the national level, training multipliers and trainers to strengthen social control and articulate a national permanent education network for social control1010 Brasil. Resolução n° 374, de 14 de junho de 2007. Diário Oficial da União 2007; 14 jun..

It is necessary to progressively stimulate the citizens’ autonomy through emancipatory practices, understood as those that make it possible to contribute and improve life conditions, respond critically and assume the freedom. These practices teach the subjects to access their rights and fight for them, encouraging solidarity values ​​and rescuing the human condition as a social condition1111 Campos CMS, Silva BRB, Forlin DC, Trapé CA, Lopes IO. Práticas emancipatórias de enfermeiros na Atenção Básica à Saúde: a visita domiciliar como instrumento de reconhecimento de necessidades de saúde. Rev Esc Enferm USP 2012; 48(n. esp.):119-125..

Based on this scenario, the following question arises: did educational workshops result in significant learning based on the reality experienced by health councilors?

This study aimed to find out how community participation occurs within the professional training setting of municipal health councilors through educational workshops and concept maps.

Method

This article is part of the Ph.D. thesis “Mobilization strategies for the community participation of municipal health councilors”, based on action research, developed in three municipalities that belong to the Health Region of Cuesta Pole (RSPC) - Regional Health Department (DRS) VI Bauru / Regional Health Care Network (RRAS) 9 - of the state of São Paulo, Brazil.

The RSPC consists of 13 municipalities, comprising a territorial area of ​​6,394.44 km² and a population of 279,329 inhabitants1212 São Paulo. Diretoria Regional de Saúde 6 (DRSIV). Mapa da Saúde do Pólo Cuesta. Bauru: DRSIV; 2012.. This region was chosen by a non-probabilistic convenience sample, as we sought a population sample that was more accessible to the researcher.

The selection criteria of the municipalities were established according to the population profile, as follows: a small municipality 1 (MPP1), with up to 20,000 inhabitants, a small municipality 2 (MPP2), from 20,001 to 50,000 inhabitants and a large municipality (MGP), with 100,001 to 900,000 inhabitants.

The study participants consisted of the municipal health councilors, members and / or their respective alternate members, from three municipalities in the Health Region of Cuesta Pole, state of São Paulo, who agreed to participate in the research, after signing the Free and Informed Consent (FIC) form, totaling 28 councilors, 15 from the MGP, 8 from the MPP2 and 5 from the MPP1.

Analyses of documents from the municipalities and councils belonging to the Health Region of Cuesta Pole were carried out and, subsequently, educational workshops.

This analysis allowed the characterization of the municipality, according to the main activity developed, predominant area of activity, economically active population, year of creation and the internal regulations of the municipal health councils. These data were requested from the Municipal Health Secretariats and also from secondary sources, such as the minutes of council meetings, which were also used to complement the information on the profile of the municipality and the council. This profile was necessary to support the choice of topics and promote the discussions during the workshops.

For the creation of the first workshops, topics proposed by the participants were collected according to the local reality experienced by them. The topics chosen from the MGP workshops were: “Organization and function of the health system”; “Health planning: budget and financing”; “The control of SUS policies and actions: monitoring, evaluation and inspection mechanisms” and “Main responsibilities of the councilor”. In the MPP2 the choice of topics comprised: “Organization and function of the health system”; “Health planning: budget and financing”; “The control of SUS policies and actions: monitoring, evaluation and inspection mechanisms”. In the MPP1, the choice of topics comprised: “Health planning: budget and financing”; “The control of SUS policies and actions: monitoring, evaluation and inspection mechanisms” and “Main responsibilities of the councilor”. The days, time and frequency of the workshops were agreed upon according to the participants’ availability.

Ten educational workshops were held, 4 in the MGP, three in the MPP1 and three in the MPP2, from December 2016 to October 2017, through participatory observation, field diary and concept maps during the educational workshops.

The Educational Workshop is characterized by a space provided for interaction, reflection and exchange of knowledge that allows students to expose and assimilate new knowledge about the topic being presented1313 Freire P. Pedagogia do Oprimido. 17ª ed. Rio de Janeiro: Paz e Terra; 1987.. At the end of each educational workshop, the concept map (CM) was used as a measure to monitor and evaluate the councilors’ learning.

A CM is defined as a hierarchical diagram of the relations between concepts that allow the organization and representation of knowledge, aiming at providing greater understanding and assimilation of the study topic1414 Novak JD, Cañas AJA. Teoria subjacente aos mapas conceituais e como elaborá-los e usá-los. Práxis Educativas 2010; 5(6):9-29.. CMs contain concepts, usually depicted inside circles or charts, and the relations between the concepts, which are represented by lines that interconnect them. The words on these lines, which are connecting words or phrases, describe the relations between the two concepts1414 Novak JD, Cañas AJA. Teoria subjacente aos mapas conceituais e como elaborá-los e usá-los. Práxis Educativas 2010; 5(6):9-29.,1515 Moreira MA, Masini EFS. Aprendizagem significativa: a teoria de David Ausubel. 2ª ed. São Paulo: Centauro; 2006..

Additionally, there are propositions in the CM, which are statements about an object or event. A proposition is formed when two concepts are interconnected through words, phrases or symbols to constitute a meaningful statement1414 Novak JD, Cañas AJA. Teoria subjacente aos mapas conceituais e como elaborá-los e usá-los. Práxis Educativas 2010; 5(6):9-29..

Data analysis was carried out according to the suppositions of Bakhtin’s dialogic thematic analysis1616 Bakhtin M. Estética da criação verbal. São Paulo: Martins Fontes; 1992., which proposes the definition of topics and the description of dialogic processes as a way to understand interactions at the time of the construction of information, being extremely dynamic, flexible and non-linear, along with the semiotic analysis of still images1717 Penn G. Análise semiótica de imagens paradas. Pesquisa qualitativa com texto, imagem e som. Um manual prático. Petrópolis: Vozes; 2003..

For Penn1717 Penn G. Análise semiótica de imagens paradas. Pesquisa qualitativa com texto, imagem e som. Um manual prático. Petrópolis: Vozes; 2003., the image itself is its description as it is seen, that is, its denotative quality. The cultural dimension of the elements, which are the formed propositions that integrate the image, represent the connotative level, that is, the existing relations of the elements with the connection of words.

The field diary and workshop observation were used to analyze the production that accompanies the images. Based on this material, the correlation between scientific knowledge and constructed learning was interpreted. Thus, when analyzing the image, the stories developed by the participants were used to understand them.

The theoretical framework used in the study started from the conceptual supposition for the use of the CM of the Meaningful Learning Theory (MLT) by constructivist David Ausubel1818 Ausubel DP. Aquisição e retenção de conhecimentos: uma perspectiva cognitiva. Lisboa: Plátano; 2003.. The TML proposes that, for a more efficient learning, it is necessary that knowledge be understood, significantly relevant and well-integrated1414 Novak JD, Cañas AJA. Teoria subjacente aos mapas conceituais e como elaborá-los e usá-los. Práxis Educativas 2010; 5(6):9-29.,1818 Ausubel DP. Aquisição e retenção de conhecimentos: uma perspectiva cognitiva. Lisboa: Plátano; 2003..

Meaningful learning consists in the integration of new concepts into the learner’s cognitive structure, considering their previous knowledge, aiming at demonstrating interrelated learnings, which facilitates the establishment of solid conceptual associations1818 Ausubel DP. Aquisição e retenção de conhecimentos: uma perspectiva cognitiva. Lisboa: Plátano; 2003.,1919 Souza NA, Boruchovitch E. Mapas conceituais: estratégia de ensino/aprendizagem e ferramenta avaliativa. Educ. Rev 2010; 26(3):195-218..

At the end of each workshop, individual CMs were applied and after that, the synthesis CM was applied by the researcher, created based on the observed similarities and word repetitions. The ten educational workshops resulted in 63 individual CMs, 32 from the MGP, 19 from the MPP2 and 12 from the MPP1, which were synthesized one per municipality, with the purpose of joining individual production and construct synthesis maps about the meanings that the participants attributed to the workshop topics. Thus, three synthesis CMs were disclosed, one for each municipality, containing the meanings attributed to the workshop learning.

Finally, a new synthesis of the three resulting maps was applied, creating a new map, called the final semiotic map containing the most significant data and their main relations with the meanings expressed by the councilors.

The project was approved by the Ethics Committee of Research with Human Beings of the School of Medicine of Universidade Estadual Paulista “Júlio de Mesquita Filho” (UNESP), at the Botucatu campus and received financial support from Fundação de Amparo à Pesquisa of the State of São Paulo - FAPESP. The study was carried out with the authorization of the Municipal Health Secretariats and the participants’ consent by signing the free and informed consent form.

Results

The age of the 28 participants ranged from 22 to 70 years, with a mean age of 45 years. As for gender, 71.42% were females and 28.58%, males. As for the level of schooling, 39.28% had finished College/University, 28.58% has finished High School, 25% had finished Post-Graduation and 7.14% had finished Elementary School. The most often reported profession or employment status was ‘retired’ (14.29%).

Regarding the representativeness in the municipal health councils (CMS, Conselhos Municipais de Saúde), 42.85% represent the health service users, 21.45% represent health service providers, 17.85% represent health workers and 17.85% represent health service managers.

Regarding the learning demonstrated in the educational workshops of the MGP, Figure 1 shows the key concepts that most frequently appeared together with the connecting words used by the councilors (Figure 1).

Figure 1
Synthesis Concept Map of the MGP, Botucatu, SP, Brazil, 2019.

A total of 61 concepts were included in the synthesis CM, which were related to the concepts subordinate to the general ones: “Organization and function of the health system”, “Budget”, “Management Report” and “Councilor’s role”.

Regarding the map structure, 100% were sequentially diagrammed, with hierarchy and development of some cross-links.

Most propositions presented logical meanings, and the words selected to interconnect the concepts showed to be adequate to disclose the nuances of meanings attributed at the systematization of knowledge.

It is noteworthy the fact that the concept “Enlightening the population” was the most frequently mentioned (nine times) in individual CMs, followed by “CMS approval” and “Control of health expenses” (both seven times), highlighting the relevance that councilors attribute to the dissemination of information to the population regarding health issues and their responsibility of approving and controlling health expenditures2020 Fernandes VC, Spagnuolo RS. Pesquisa-ação como caminho de mobilização à participação comunitária nos conselhos municipais de saúde. In: Atas do 7° Congresso Ibero-Americano de Investigação Qualitativa em Saúde; 2018; Fortaleza. p. 18-27..

The councilors’ mastery regarding the discussed topics was observed, since the created CMs allowed them to visualize the integration of contents covered in the workshops, that is, as a new key concept was learned, it was integrated into the CM, both coherently and homogenously. Moreover, we observed the councilors’ interaction, collaboration and commitment with the creation of the CMs, since the doubts and difficulties were resolved with the other members of the group, thus demonstrating the teamwork development2020 Fernandes VC, Spagnuolo RS. Pesquisa-ação como caminho de mobilização à participação comunitária nos conselhos municipais de saúde. In: Atas do 7° Congresso Ibero-Americano de Investigação Qualitativa em Saúde; 2018; Fortaleza. p. 18-27..

However, seven CMs did not have interconnecting words and some concepts showed unrelatedness and repetitiveness, especially in the first maps, which can be justified by the fact that it was their first contact with the learning tool.

A total of 53 concepts were included in the MPP2 synthesis CM (Figure 2), which were related to the concepts subordinate to the general ones: “Problems in health organization and function”, “Budget”, “Financing” and “CMS management inspection”.

Figure 2
Synthesis Concept Map of the MPP2, Botucatu, SP, Brazil, 2019.

The synthesis CM has a branch stemming from the root concept up to six hierarchical levels, which constitute the concepts from the most general to the most specific ones, passing through different levels of intermediate concepts and four cross-links, with the concepts and propositions being formed 100% in sequential form.

Some of the listed propositions were relevant ones, since the members were not familiar with the topics, for instance, the proposition constituted by: “the budget requires planning through the Annual Budget Law (LOA, Lei Orçamentária Anual), the Budget Guidelines Law (LDO, Lei de Diretrizes Orçamentárias) and the Multiannual Plan (PPA, Plano Plurianual)”, “financing is carried out through a fund-to-fund transfer at the municipal, state and national levels”, “the management inspection at the CMS occurs through a report, which is the annual management report, promoting transparency of the management through accountability”.

It is observed that the councilors refer to the Brazilian budgetary model, the budgetary laws, to health financing and inspection, which generated significant learning, since based on the participants’ observations and the researcher’s field diary, the councilors did not know about these concepts before the workshops were held.

The concept “Lack of information and guidance to the population” was the most often mentioned (eight times) in the individual CMs, followed by “To encourage health promotion and prevention”, “Planning” and “Management Transparency” (both four times), demonstrating the councilors are aware that the population needs to receive more information about health actions, which necessitates encouragement by councilors, managers and professionals working in health promotion and prevention. Moreover, one can observe the emphasis given by the participants to the fact that the budget occurs with its due planning and that the councilor has as their primary function the inspection through management transparency, aiming to carry out the social control.

The MPP1 synthesis CM (Figure 3) includes 35 concepts, which are subordinate to the general one: “Management report”, “Councilor’s role” and “Budget and financing”.#

Figure 3
Synthesis Concept Map of the MPP1, Botucatu, SP, Brazil, 2019.

The concepts are placed inside the box, linked by interconnecting words, a branch stemming from the root concept, up to five hierarchical levels, and two cross-links, with the concepts and propositions being formed 100% in sequential form.

The concept “To check the progress of health” was the most frequently mentioned (five times) in the individual CMs, followed by “To carry out the control and supervise” (four) and “Transparency” (three). It can be observed that the most frequently mentioned concepts refer mainly to the role of the CMS regarding the SUS management, related to the participation of society in the process of monitoring resources and the progress of the work carried out by health management with transparency.

These concepts are more remarkable mainly due to the fact that the councilors are, in their majority, health workers, who know the nomenclature of the performed actions. However, despite understanding the vocabulary, acronyms and other activities that are part of the participatory reality, they are largely unaware of the laws, deadlines and goals.

It can be observed that most maps depict a concern with the interconnecting words, selection of concepts and the formation of propositions. As the workshop progressed, the concepts became more complex and the councilors gradually improved the creation of the CM, exercising their creativity and reflection of the acquired knowledge.

Based on the synthesis of the concept maps, the strategy used to guide the discussion was to interrelate the three synthesis CMs, aiming to create a single map that can represent the learning experienced in the educational workshops, which were analyzed according to David Ausubel’s significant learning model1818 Ausubel DP. Aquisição e retenção de conhecimentos: uma perspectiva cognitiva. Lisboa: Plátano; 2003.. Therefore, a final semiotic map (Figure 4) was disclosed, containing the data considered to be the most relevant and the main relations of meanings expressed by the councilors.

Figure 4
Final semiotic map. Botucatu, SP, Brazil, 2019.

Based on the synthesis of the maps, the interaction between the learning of all the members that emerged from the experiences of the educational workshops can be understood and, as a final result, a new semiotic map was created. This strategy allowed revealing the meanings attributed by the participants to the topics chosen by themselves.

The final semiotic map demonstrates how the councilors understand the contents portrayed in the educational workshops. It has 49 concepts arranged inside the boxes, interconnected by link words, three branches from the root concept, up to seven hierarchical levels and two cross-links, with the concepts and propositions being presented sequentially.

It shows us that the context of knowledge construction involves three important meanings, called by Ausubel et al.2121 Ausubel DP, Novak JK, Hanesian H. Psicologia Educacional. 2ª ed. Rio de Janeiro: Interamerica Ltda; 1980. as more inclusive concepts, namely: health care, inspection and the role of the councilor (Figure 5).

Figure 5
Meanings of the councilors on the learning from the educational workshops, Botucatu, SP, Brazil, 2019.

The concept of “Health care” aggregates the meanings constructed about the Brazilian public health, in which one can identify the councilors’ perception of the health system organization and function. Thus, this concept has different meanings, ranging from the most comprehensive to the least inclusive concepts, with the most comprehensive being: a) Primary Health Care as a strategy for health care organization and b) Health care barriers2020 Fernandes VC, Spagnuolo RS. Pesquisa-ação como caminho de mobilização à participação comunitária nos conselhos municipais de saúde. In: Atas do 7° Congresso Ibero-Americano de Investigação Qualitativa em Saúde; 2018; Fortaleza. p. 18-27..

Primary Health Care (PHC) or Basic Health Care (BHC) has as its fundamental strategy the reorganization and articulation of the resources available in SUS with the purpose of meeting the demands and needs of the population and being included in the context of the health care network2222 Mendes E. A construção social da atenção primária à saúde. Brasília: CONASS; 2015..

It is structured as the first place of care and the main door into the system, being the organizer of flows and counterflows and the coordinator of the actions and services provided by the network2323 Brasil. Portaria n° 2.436 de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2007; 21 set..

Thus, councilors understand PHC as a health care organization strategy that includes actions of promotion, prevention, reception and treatment, in which prevention of injuries and qualified listening must effectively occur in health care models, ensuring to the user the necessary assistance to their problem, preventing overcrowding in the emergency room and allowing networking2020 Fernandes VC, Spagnuolo RS. Pesquisa-ação como caminho de mobilização à participação comunitária nos conselhos municipais de saúde. In: Atas do 7° Congresso Ibero-Americano de Investigação Qualitativa em Saúde; 2018; Fortaleza. p. 18-27.. The abovementioned proposition shows that the information stored by the councilors was organized and hierarchized, as more specific elements of knowledge were interconnected to and assimilated into more general concepts, as proposed by Ausubel1818 Ausubel DP. Aquisição e retenção de conhecimentos: uma perspectiva cognitiva. Lisboa: Plátano; 2003.,2424 Moreira MA. Teorias de Aprendizagem. 2ª ed. São Paulo: EPU; 2011..

Discussion

The CMs demonstrate the importance that councilors attribute to PHC, especially the performance of qualified listening, so that the user’s need is identified, and care is provided, with health promotion and prevention actions, not being restricted to the medical consultation2020 Fernandes VC, Spagnuolo RS. Pesquisa-ação como caminho de mobilização à participação comunitária nos conselhos municipais de saúde. In: Atas do 7° Congresso Ibero-Americano de Investigação Qualitativa em Saúde; 2018; Fortaleza. p. 18-27..

This understanding is in line with the National Primary Care Policy (PNAB, Política Nacional de Atenção Básica), which depicts that services must ensure accessibility and welcoming in an organized manner, ensuring that all people who seek the services be heard in a universal manner and without distinction2323 Brasil. Portaria n° 2.436 de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2007; 21 set..

Therefore, health services must assume the central role of welcoming, listening to, and solving most of the population’s problems, mitigating the injuries and suffering, aiming to integrating the health care network2323 Brasil. Portaria n° 2.436 de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2007; 21 set..

Moreover, the councilors point out the main obstacles to health care: the lack of information and guidance to the population, the lack of humanization by the professionals and the scarce funds for health care2020 Fernandes VC, Spagnuolo RS. Pesquisa-ação como caminho de mobilização à participação comunitária nos conselhos municipais de saúde. In: Atas do 7° Congresso Ibero-Americano de Investigação Qualitativa em Saúde; 2018; Fortaleza. p. 18-27..

The proposition stating that “the final semiotic map considers that Health Care has problems, such as the lack of information and guidance to the population, and it is necessary to disclose existing services and enlighten the population” is in accordance with a study that points out a difficulty in understanding the variables that interfere with health and disease, as well as with the health system function by a portion of the community, requiring the creation of strategies to communicate with this population, aiming to improve the provided health care2525 Viegas APB, Carmo RF, Luz ZMP. Fatores que influenciam o acesso aos serviços de saúde na visão de profissionais e usuários de uma unidade básica de referência. Saude Soc 2015; 24(1):100-112..

Regarding the user’s relationship with the health professional, the lack of humanization of the professionals was demonstrated, indicating the need for continuous training. Thus, it is necessary to reflect on the working conditions of health professionals, whether they are able to guarantee humanized care, since they are usually subjected to mechanized work processes and are weakened by the conditions of work overload, terms of employment, work turnover and living with suffering and death2626 Goulart BNG, Chiari BM. Humanização das práticas do profissional de saúde - contribuições para reflexão. Cien Saude Colet 2010; 15(1):255-268..

Therefore, some actions are crucial to improve access and humanization, as follows: establishing partnerships with training institutions, building lines of care, encouraging the active participation of professionals in health policies, promoting meetings between peers aiming at practical reflection (case studies, problem situations), permanent education activities, among others.

Also noteworthy is the concept of “scarce funds for health care”, demonstrating the councilors’ understanding regarding the SUS development process, the way the transfer is carried out - through a fund-to-fund transfer to the states, the Federal District and Municipalities, according to Ordinance N. 3,992, which provides for financing, under the responsibility of the three management spheres and the transfer of federal resources to SUS public health actions and services2727 Brasil. Portaria n° 3.992, de 28 de dezembro de 2017. Altera a Portaria n° 6/GM/MS, de 28 de setembro de 2017, para dispor sobre o financiamento e a transferência dos recursos federais para as ações e os serviços públicos de saúde dos Sistema Único de Saúde. Diário Oficinal da União 2017; 28 dez..

To make the SUS viable, it is necessary to guarantee sufficient and permanent financing; however, Constitutional Amendment 95/16 freezes public spending for twenty years, without appreciating the demographic and epidemiological changes and the need to include technologies into SUS. Considering this scenario, it is essential to mobilize the population in favor of the fight for democracy and social justice, so that health is included in the agenda of the national political debate2828 Reis AAC. O que será do Brasil e do SUS? Rev Eletron Comum Inf Inov Saúde 2018; 12(2):119-124..

It can be said that the councilors organized the knowledge from the workshops based on concise representations of the conceptual structures that were taught to them, which probably facilitated the learning of these structures as proposed by Ausubel’s Meaningful Learning Theory.

According to Ausubel1818 Ausubel DP. Aquisição e retenção de conhecimentos: uma perspectiva cognitiva. Lisboa: Plátano; 2003., the structuring of knowledge is verified in a non-arbitrary way, by receiving new information, which allows the learner to internalize them, thus making them more understandable. Thus, the concepts interact with the new contents, helping to assign new meanings that also undergo changes. This continuous modification becomes a subsumer, that is, a more complex, more differentiated previous knowledge, capable of acting as an anchor for the acquisition of new knowledge, a sequence called progressive differentiation.

In significant learning, a change occurs with the new information and also in the previous knowledge, with which the new knowledge establishes a relationship, and the product of this interaction is the incorporation of meanings and the externalization of knowledge2121 Ausubel DP, Novak JK, Hanesian H. Psicologia Educacional. 2ª ed. Rio de Janeiro: Interamerica Ltda; 1980., as evidenced in the final semiotic map.

Moreover, the final semiotic map once more disclosed the understanding of the participants when exercising the role of municipal health councilor, which means being present at the CMS meetings to help the manager to create public policies and represent the population, informing the discussed topics and demanding the rights of SUS users.

Health councils have legal and specific attributions of social control. Their responsibility is to contribute to the formation of councilors committed to the creation of policies, based on the rights of citizenship of the entire population, in defense of life and health, with universal, integral and equal access99 Conselho Nacional de Saúde (CNS). Política Nacional de Educação Permanente para o Controle Social no Sistema Único de Saúde - SUS. Brasília: Editora do Ministério da Saúde; 2006., because they the representatives of society, who will lead the participatory process, the representative voice of the population to formulate and supervise health.

The final semiotic map showed the proposition comprised by: the inspection of the public budget and management work that occurs through reports, including the Annual Management Report and the Detailed Report, which promote the transparency of management actions through accountability that needs to be presented to and approved by the CMS, for better exercise of social control.

The councilors acknowledged the important role they have in helping other bodies, in overseeing and controlling the public budget. However, through participatory observation, it was observed that this process is still a deficient one, as it occurs in a fast and unplanned manner2020 Fernandes VC, Spagnuolo RS. Pesquisa-ação como caminho de mobilização à participação comunitária nos conselhos municipais de saúde. In: Atas do 7° Congresso Ibero-Americano de Investigação Qualitativa em Saúde; 2018; Fortaleza. p. 18-27..

It is extremely important that health councilors have access to this information in advance, in order to properly analyze and criticize it, as well as disseminate it in society, making the user co-responsible for it, through participatory management2020 Fernandes VC, Spagnuolo RS. Pesquisa-ação como caminho de mobilização à participação comunitária nos conselhos municipais de saúde. In: Atas do 7° Congresso Ibero-Americano de Investigação Qualitativa em Saúde; 2018; Fortaleza. p. 18-27..

Also, regarding the public budget, the listed propositions were extremely relevant, as the councilors were not yet familiar with the topic. As an example, the following proposition: “The final semiotic map comprises the inspection of the public budget, which requires planning with responsibility, preventing unnecessary expenses by means of specific instruments, namely Multiannual Plan (PPA), Budget Guidelines Law (LDO) and Annual Budget Law (LOA)” makes it clear that the councilors refer to the Brazilian budget model and the budget laws used for the planning of public resources2020 Fernandes VC, Spagnuolo RS. Pesquisa-ação como caminho de mobilização à participação comunitária nos conselhos municipais de saúde. In: Atas do 7° Congresso Ibero-Americano de Investigação Qualitativa em Saúde; 2018; Fortaleza. p. 18-27..

The essential purpose of the PPA is to establish, on a regionalized basis, the guidelines, objectives and goals of the federal public administration adequate to the expenditures and those resulting from them and for those related to the continuous duration programs2929 Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União 1988; 5 out..

The LDO is responsible for defining the goals and priorities of public administration and guiding the creation of the LOA, of which main assignment is to establish fiscal targets3030 Culau AA, Fortis MFA. Transparência e controle social na administração pública brasileira: avaliação das principais inovações introduzidas pela lei de responsabilidade fiscal. In: XI Congresso Internacioal del CLAD sobre la Reforma del Estado y de la Administración Pública; 2006; Cidade de Guatemala. p. 1-16..

The new ideas and information that were learned in the individual’s cognitive structure were demonstrated, as the formed concepts were relevant, inclusive and clear.

The sharing of experiences, aiming to signify the discussed topics, were extremely important to allow the meaningful learning, since the created dialogue, and the exposition of experiences complemented each other and were related to the individuals’ prior knowledge.

Finally, one can infer, considering these results, that the work contributed to the advancement of science, as it was able to provide new knowledge to the participants about important topics in the field of health, making them the protagonists in the learning process. This fact provided an opportunity for the exchange of knowledge, skills, feelings and experiences, encouraging them to participate in the community in an emancipatory, critical and reflexive way2020 Fernandes VC, Spagnuolo RS. Pesquisa-ação como caminho de mobilização à participação comunitária nos conselhos municipais de saúde. In: Atas do 7° Congresso Ibero-Americano de Investigação Qualitativa em Saúde; 2018; Fortaleza. p. 18-27..

We expect that the results can be replicated in the different realities of municipal health councils aiming to stimulate and give visibility to community participation as a SUS guideline. It is also important that municipal managers and universities incorporate community participation in their debate spaces, stimulating the participation of the organized civil society through health councilors, improving better social control.

As a limitation factor, we mention the resistance of some councilors regarding the participation in educational workshops, resulting in different learning for the group members, since those who participated in the meetings were able to experience reflections and changes about the performed practice.

Final considerations

The educational workshops and concept maps were shown to be excellent pedagogical strategies to be used with municipal health councilors, as they allowed moments of learning, exchange of experiences, interaction and establishing bonds between the participants.

The group space and the making of concept maps allowed the disclosing of ideas, previous knowledge, moments of connection, relationships, exchanges, different worldviews for each of the councilors and the opportunity to build individual and collective knowledge, therefore improving the councilors’ performance and, as a result, increasing the visibility of the community participation as a SUS guideline.

The analysis of the data through the Dialogic Thematic Analysis and Semiotic Analysis of the Still Image allowed dynamicity to the analysis and the construction of a final semiotic map that materialized the meanings constructed by the councilors in relation to the health field topics.

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Publication Dates

  • Publication in this collection
    12 Feb 2021
  • Date of issue
    Feb 2021

History

  • Received
    12 Mar 2020
  • Accepted
    25 Apr 2020
  • Published
    27 Apr 2020
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