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Brazil’s policy on healthcare for government workers: players, paths and challenges

Abstract

This article aims to analyze the extent to which Brazil’s public sector has made progress in institutionalizing an integral and participative model for the healthcare of government workers, based on the principles of universality, integrality and workers’ participation. Based on documents produced by the Rio de Janeiro Permanent Forum on Workers’ Health, the paper analyses the process of implantation of the Integrated Public Workers’ Healthcare Sub-System (SIASS) in the municipality of Rio de Janeiro over the period 2009–2016, based on the historical institutionalism. Although it was conceived as an integrated system referenced to the principles of workers’ health, as from 2013 an inflexion was observed in this Subsystem, in the direction of a conservative model of occupational health, such as had been traditional and hegemonic in labor relations in Brazil. One factor that emerges is the loss of the universal character of the system due to the flexibility of employment relations in the public sector. There are various challenges: the need to expand the dialogue, and integration of the Policies on health, employment relations and management of the public administration, in such a way as to guarantee the principles of workers’ health and the universality of the system, evolving from the concept of the ‘public servant’ to that of the ‘public employee’.

Health policy; Workers’ health; Healthcare; Public administration

Resumo

Este artigo propõe-se a analisar em que medida o setor público tem avançado no sentido da institucionalização de um modelo integral e participativo de atenção à saúde do servidor, pautado pelos princípios da universalidade, integralidade e participação dos trabalhadores. A partir dos documentos produzidos pelo Fórum Permanente de Saúde do Trabalhador do Rio de Janeiro foi feita uma análise do processo de implantação do Subsistema Integrado de Atenção à Saúde do Servidor Público (SIASS) no Município do Rio de Janeiro, no período de 2009 a 2016 com base no institucionalismo histórico. Embora concebido como um sistema integrado referenciado pelos princípios da saúde do trabalhador, observa-se uma inflexão, a partir de 2013, na direção de um modelo conservador da saúde ocupacional, tradicional e hegemônico nas relações trabalhistas no Brasil. Destaca-se também a perda do caráter universal do sistema em função da flexibilização das relações de trabalho no setor público. Como desafios têm-se a necessidade de ampliar o diálogo e a Integração das Políticas de Saúde, Trabalho e Gestão na Administração Pública, de forma a garantir os princípios da saúde do trabalhador e a universalidade do sistema, evoluindo-se do conceito de servidor público para o de trabalhador público.

Política de saúde; Saúde do trabalhador; Atenção à saúde; Administração pública

Introduction

Regulation of employment in Brazil has its beginnings in the 1940s, with the Consolidated Labor Laws (‘Consolidação das Leis do Trabalho’, or ‘CLT’), which centered on individual and collective employment relationships. Until 1988, policies on social protection and regulation of work were, like the other social policies, selective and directed to segments of the population. The 1988 Constitution resulted in important social achievements, one of which was the creation of Brazil’s Single Health System (Sistema Único de Saúde – SUS), which made healthcare and the Single Legal Regime (Regime Jurídico Único – RJU), universal in concept, obligations and practice (Law 8112/90), creating a new institutional and legal framework for work in the public service. A start was made on the process of overcoming the historical dichotomy of rights under the employment laws and under the social security system, which had operated as hegemonic conductors of the conditions of life and health in the workplace11. Andrade E, Martins M, Machado J. O processo de construção da política de saúde do trabalhador no Brasil para o setor público. Config Rev Sociol 2012; (10):137-150..

Until the Constitution of 1988, the mechanisms for protections of employees’ health were limited to the regulatory rules of the CLT, guided and oriented by the concept of occupational health, with a focus on preservation of the workforce as a field of intervention restricted to the activities of care, and inspection: medical expert opinions, periodic exams and prevention of risks and work accidents. For government workers there was no type of regulation and instruments for protection of health. The first measures in this direction start with the RJU, and were translated into specific regulatory rules, restricted to medical leave, and retirements due to disablement.

In the context of health policies, the principles of integrality, universality, equity and social participation, which are the basis of the SUS, strengthened a new model of employees’ health referenced on the concepts of promotion, oversight and participation in health, defined as “the group of activities which is dedicated, through actions of epidemiological and health oversight and inspection, to promotion and protection of health of workers, and also recovery and rehabilitation of the health of workers submitted to risk and other adverse factors relating to working conditions”22. Brasil. Lei nº 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União 1990; 20 set..

According to Vasconcellos and Machado33. Vasconcellos L, Machado J. Política nacional de saúde do trabalhador: ampliação do objeto em direção a uma política de Estado. In: Minayo Gomes C, Machado JMH, Pena PGL, organizadores. Saúde do Trabalhador na Sociedade Brasileira Contemporânea. Rio de Janeiro: Editora Fiocruz; 2011. p. 37-65., the field of workers’ health “(...) is the permanent linking between health action and political action, with employees, as subjects and protagonists of a political-institutional action, which includes construction of knowledge and the Instruments of Intervention”.

The principle of integral workers’ health invokes the right to health in its unrestricted sense of full citizenship. It includes actions of promotion, prevention and care, to be carried out in an integrated manner with the objective of achieving integral health of the employee, through an interdisciplinary and inter-sectorial approach. It presupposes an action of coordination with wide and effective participation of employees, technical people and researchers, learning institutions, union representatives, services, civil society and other institutional and social players44. Andrade E. O processo de implementação da política de atenção à saúde do trabalhador em instituições públicas federais: o desafio da integralidade. [Internet]. 2009 [citado 2016 jul 24]. Disponível em: http://www.arca.fiocruz.br/handle/icict/2522
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Pressured by an international agenda, in Brazil, this discussion made a strong appearance in the National Health Conferences, and in the agendas of social and workers’ movements, which began to call for a public policy governing workers’ health. In 1993, the Inter-ministerial Executive Group on Workers’ Health (Grupo Executivo Interministerial em Saúde do Trabalhador – GEISAT) was created, with the aim of building a proposal to provide rules for, regulate and monitor Work and Health relationships of employees, including public employees.

The 1990s and the 2000s were a period of debate on regulation and laws on Workers’ Health in the ambit of the SUS, and this debate culminated in 2011 in the National Work Health and Safety Policy (Política Nacional de Saúde e Segurança do Trabalho – PNSST), put in place by Decree-Law 7602 of December 7, 2011, and in 2012 with the National Workers’ Health Policy – for both genders (Política Nacional de Saúde do Trabalhador and da Trabalhadora – PNSTT)55. Brasil. Portaria no 1.823, de 23 de agosto de 2012. Institui a Política Nacional de Saúde do Trabalhador e da Trabalhadora. Diário Oficial da União 2012; 24 ago..

The aim of the PNSTT was to define the principles, directives and strategies to be obeyed in the three spheres of management of the SUS – federal, state and municipal, in achieving Integral Healthcare for workers, aiming to promote and protect their health and reduce morbimortality arising from the development models and production processes55. Brasil. Portaria no 1.823, de 23 de agosto de 2012. Institui a Política Nacional de Saúde do Trabalhador e da Trabalhadora. Diário Oficial da União 2012; 24 ago..

In parallel, but influenced by this debate, there were discussions in the Planning, Budget and Management Ministry (Ministério do Planejamento Orçamento and Gestão – MPOG), with participation of various federal public institutions, representatives of unions and managers, aiming to prepare a specific policy for federal public employees, taking into account that they are subject to a specific and differentiated legislation of their own.

In an attempt to structure and regulate a system of social protection for government workers, Brazil’s Planning Ministry, in 2006, instituted the Occupational Health System for Government Workers (Sistema de Saúde Ocupacional do Servidor Público – SISOSP)66. Brasil. Decreto no 5961, de 13 de novembro de 2006. Institui o Sistema Integrado de Saúde Ocupacional do Servidor Público Federal - SISOSP. Diário Oficial da União 2009; 14 nov..

This was initially targeted to civilian government employees. The proposal was that it should cover, universally, all non-retired workers, in the federal public service. In this initial phase, the proposal was still based, as a foundation, on the traditional conception of occupational health.

The experience with the States, and the debates which took place in the various forums of participation instituted by the new model, led to reformulation of the SIOSP and its replacement by the Integrated Sub-System for Workers’ Healthcare (Subsistema Integrado de Atenção à Saúde do Trabalhador – SIASS)77. Brasil. Decreto no 6.833, de 29 de abril de 2009. Institui o Subsistema Integrado de Atenção à Saúde do Servidor Público Federal - SIASS e o Comitê Gestor de Atenção à Saúde do Servidor. Diário Oficial da União 2009; 30 abr..

The SIASS took the concept forward from the initial restricted remit of occupational health to the concept of Workers’ Health, defined as “[...] the expression of the workers’ power to both enjoy full health and also take the control of their own lives, health and work into their own hands”88. Minayo-Gómez C. Campo da Saúde Trabalhador: Trajetória, Configuração e Transformações. In: Saúde do Trabalhador na Sociedade Brasileira Contemporânea. Rio de Janeiro: Editora Fiocruz; 2011. p. 23-34.. The relationships between work and health presuppose an interdisciplinary basis, and participation by workers as active and central subjects in planning and implementation of actions for transformation of the processes of work.

The State of Rio de Janeiro has stood out in the process of construction and implementation of the SIASS. The experiences of the worker’s healthcare programs that have been put in place since the decade of the 2000s by the federal institution that have head offices in the state of Rio, which comprise 20% of the total of federal public workers, were important in the construction of this new policy for healthcare of government workers. The creation, in 2009, of a Rio de Janeiro Permanent Forum on Workers’ Health set a benchmark for the process of construction and implementation of the SIASS. For the managers of the Department for Government Workers’ Rules and Benefits (Departamento de Normas and Benefícios do Servidor – DENOB/MPOG), Rio de Janeiro can be considered to be an example where the proposal has been implemented in a collective and participative manner99. Fórum Permanente. Fórum Permanente do SIASS RJ: Entrevista com gestores do DENOB [Internet]. 2016 [citado 2016 jul 10]. Disponível em: http://forumsiassrj.blogspot.com.br/2016/07/entrevista-com-gestores-do-denob.html
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Methodology

To understand the process of construction of the policy on public workers’ healthcare, a choice was made to use historical institutionalism, which focuses on analysis of institutions – as a theoretical reference frame for methodology. Steinmo1010. Steinmo S. The new institutionalism. In: Clarke PB, Foweraker J, editors. Encyclopedia of Democratic Thought. London: Routledge; 2001. p. 560-565., when presenting this model, argues that institutions are important both because they are focal points of political activity and also because they supply incentives and restrictions to the political players. In his view it is possible to explain the variations of a policy only by examining the way in which the political institutions structure and conduct the process of implementation.

The concept of path-dependence, which is central in the approach of historical institutionalism, starts from the principle that the prior choices in relation to a policy define paths, and influence the future possibilities for decision: The present is a result of past decisions and their respective consequences, and not only of contemporaneous conditions. This is not translated simply by the fact that ‘the history, and the past, both count’, but rather because, in the context of public policies, when one adopts a path, the political and economic costs of changing it are, usually, very high1111. Lima L, Machado C, Gerassi C. O neo-institucionalismo e a análise de políticas de saúde: contribuições para uma reflexão crítica. 2011. [citado 2016 jul 27]. Disponível em: http://www.ims.uerj.br/ccaps/?p=42
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In this study the concept was used as “an analytical tool for understanding the importance of temporal and development sequences, in time, of social events and processes”1212. Bernardi B. O conceito de dependência da trajetória (path dependence): definições e controvérsias teóricas. Perspect Rev Ciênc Sociais [Internet]. 21 de dezembro de 2012 [citado 2016 jul 24];41(0). Disponível em: http://seer.fclar.unesp.br/perspectivas/article/view/4978
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. Starting from the principle that the choices made during the process of preparation and implementation of a policy condition its future, an attempt was made to identify the social players and institutional agents that conducted the process of institutionalization of the SIASS, recovering its path and having as a temporal framework the period from 2009-2016.

Considering that the State of Rio de Janeiro is a benchmark in the implementation of the SIASS99. Fórum Permanente. Fórum Permanente do SIASS RJ: Entrevista com gestores do DENOB [Internet]. 2016 [citado 2016 jul 10]. Disponível em: http://forumsiassrj.blogspot.com.br/2016/07/entrevista-com-gestores-do-denob.html
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, a choice was made in favor of a case study, analyzing the experience of implementation of the SIASS in Rio de Janeiro, identifying the members of the Permanent Forum on Workers’ Health in Rio de Janeiro as the principal players. They are: the unions; federal health institutions of Rio de Janeiro; and managers. From the point of view of the public institution two ministries were chosen as the institutional agents: the Health Ministry, and the Planning, Budget and Management Ministry, which as from 2016 was named the Development and Management Ministry.

Results

To make it possible to understand the path of the workers’ health policies from an historical point of view, it becomes important to recuperate the information on the path of the MPOG in the process of constitution of the bureaucracy in Brazil which has as milestones the Constitutions of 1934 and 1988.

The Figure 1 shows this trajectory, highlighting the Constitutions of 1934 and 1988 as inflexion points.

Figure 1
Government employees and Health – Relationship timeline.

The Constitution of 1934, and the Constitution of 1988, both created by National Constituent Assemblies, had in common the concern to guarantee and promote liberty, justice and social and economic wellbeing in the country. The former, which was progressive in relation to the employment-law legislation had, according to Gissel1313. Gissel M. Características da Constituição de 1934 [Internet]. Scribd. [citado 2016 jul 22]. Disponível em: https://pt.scribd.com/doc/99533991/CARACTERISTICAS-DA-CONSTITUICAO-DE-1934
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, clear influences from the socialist ideas prior to the Revolution of 1930, but lasted only three years, as it was replaced by the Constitution of 1937, under the Estado Novo (‘New State’)1414. Gambarotto J. Sociologia e Democracia: Constituição de 1988 [Internet]. Sociologia e Democracia. [citado 2016 jul 22]. Disponível em: http://sociologiaedemocracia.blogspot.com.br/2013/06/constituicao-6.html
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The Constitution of 1934 instituted the minimum wage, made provisions regulating a working day of eight hours, a weekly rest day and annual paid vacations, and indemnity for dismissal without just cause. Unions and professional associations were now recognized, with the right to function autonomously. In 1943 the Consolidation of Employment Laws (Consolidação das Leis do Trabalho – CLT), which regulates these workers’ conquests, was signed.

The Constitution of 1988 marks the return of the democratic state after 20 years of military dictatorship. It was nicknamed and regarded as the “Citizen Constitution”, since it made progress in the direction of guaranteeing the exercise of social and individual rights, liberty, security, wellbeing, development, equality and justice.

Social Players and Institutional Agents in the process of formulation of the SIASS

The Coordinating Unit of Government Workers’ Social Security and Benefits (Coordenação de Seguridade and Benefícios do Servidor – COGSS/SRH/MPOG) was created in 2003, to coordinate the process of construction of a policy specifically on relations between work and health for government workers. COGSS is the name of the Unit responsible for Healthcare of Federal Public Workers in the structure of the Human Resources Department of the Planning, Budget and Management Ministry. In 2010 it became DESAP, and in 2016 DENOB. It was responsible for the formulation and implementation of the SISOSP nationally, in which its strategy was to put four pilot projects in place in four municipalities: Rio de Janeiro, Brasília, Recife and Florianópolis. In Rio de Janeiro, the entity that originally took over coordination of the project was the Oswaldo Cruz Foundation (Fiocruz) and Rio de Janeiro Federal University (UFRJ) through the related Workers’ Health Coordination Units.

Nationally, the COGSS/SRH/MPOG gave continuity to the process and implementation of the SISOSP, producing the first Manual on Health Services of Civilian Federal Government Workers, instituted by Ministerial Order MPOG/SRH 1675 of October 6, 2006, with orientation on workers’ healthcare activities, but, however, still restrictive to actions relating to expert-opinion processes.

In the period 2006-7, the process of implementation of the SISOSP was slowed down by management changes in the COGSS/MPOG. The process was resumed in 2008, aiming to construct and implement, by 2010, a health policy for federal public service workers with the participation of all the federal public institutions, throughout the country1515. Andrade ET. Políticas Públicas Saúde Servidor Federal, Bases técnicas para uma a ação transformadora [Internet]. Fórum Permanente SIASS. 2014 [citado 2016 jul 20]. Disponível em: https://drive.google.com/open?id=0B4no5ZMnUMDWY18wQVBCTVB1TU0
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In Rio de Janeiro activities continued, with organization, at the end of 2007, of work groups (grupos de trabalho – GTs) made up of representatives of the federal public institution, which have, since then, produced proposals for implementation of the system in the State.

With a view to rethinking the policy on workers’ health in a more integral and wide-ranging perspective, in May 2007 the Health Ministry and Fiocruz, through the Human Resources Coordination Department of the Health Ministry, and the Workers’ Health Coordination Unit of Fiocruz organized a Forum on the Health of Workers in the Health Institutions of Rio de Janeiro. The objective of the event was to enable institutional mobilization for the development and adoption of lines of activity that would ensure the practice of actions in workers’ health. An element of this that was considered to be essential was establishment of partnerships to provide employees with a means of discussing the daily routine of their work, establishing their protagonist role as subjects of this process.

The Forum produced, as its outcome, signature of a commitment undertaking between the Coordinating Unit for Integral Healthcare for Government Workers, of the Health Ministry CAS/MS and the Workers’ Health Coordinating Unit of Fiocruz. The focus of this partnership was development of the Permanent Education Program, directed to the sector of workers’ health, from the point of view of strengthening of the SUS. This undertaking was the embryo for formation of a Permanent Workgroup to Debate Workers’ Health in Rio de Janeiro, which had representation by the State Nucleus of the Health Ministry in Rio de Janeiro (NERJ) and hospitals and institutions of the Health Ministry, functioning as a space exchange of experience and knowledge between the professionals working in the area of workers’ healthcare, and the possibility of integration and coordination of actions.

The debates that followed pointed to the need to achieve more conceptual uniformity in relation to the field of Workers’ Health. The work dynamic of this forum included periodic meetings dealing with subjects relating to: health oversight in workers’ health, health promotion and participation – discussed as conceptual frameworks that gave support to the actions in this field – and the preparation of proposals to be implemented in the practice of the services.

According to Andrade et al.11. Andrade E, Martins M, Machado J. O processo de construção da política de saúde do trabalhador no Brasil para o setor público. Config Rev Sociol 2012; (10):137-150., there was concern to propose alterations in the scope of the SISOSP in the direction of a plan based on the concept of workers’ health in its wider sense of transformation of the technical and organizational basis of jobs, conditions and the work environment, in the context of democratization of decisions and social control relating to the process of work and the work environment as it relates to health.

On this line, the MPOG, in 2008, organized the First National Workers’ Healthcare Congress (ENASS), in Brasília, for the purpose of discussing the basis of the new policy of workplace healthcare and safety for federal public workers. This was attended by 583 federal public workers, representing bodies of the states and the Federal District, and also unions and associations1616. Brasil. Ministério do Planejamento, Orçamento e Gestão (MP). Política de atenção à saúde do servidor público federal “Um Projeto em Construção Coletiva”. Brasília: MP; 2008 [citado 2016 jul 21]. Disponível em: https://drive.google.com/drive/folders/0B85ZqXHwhyEJWHZRVnV1ZnRoeDg
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The SIASS was created to substitute the SISOSP, aiming to ensure implementation of the workplace healthcare and safety policy for federal public workers, with the objective of carrying out actions to promote and monitor workers’ health, prevent adverse events, and provide expert opinions and assistance.

To make the new system operational, technical subgroups were constituted for discussion of Expert Medical Opinions, Health Oversight and Health Promotion, and a specific subgroup for Implementation, with the task of providing input for structuring of the system.

In Rio de Janeiro, these groups functioned for two years, later coalescing into two, the Expert Medical Opinions Group and the Workers’ Health Oversight Group, and as from 2009 became a single group, the Permanent Forum on Workers’ Health in Rio de Janeiro. This meets monthly and, since 2011, has held an Annual Congress that is open to all government workers of the State and of Brazil.

Analyzing the minutes of meetings of the GTs and of the Rio de Janeiro Forum1717. Fórum Permanente. Fórum Permanente do SIASS RJ: Atas e Relatórios [Internet]. Fórum Permanente do SIASS RJ. 2016 [citado 2016 jul 13]. Disponível em: http://forumsiassrj.blogspot.com.br/2016/07/atas-e-relatorios.html
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, in the period 2008-2016, one sees the concern with the process of collective construction, involving a variety of players and institutional agents. What one sees in the documents is the difficulty of articulating and conjugating different healthcare models and organization of services, considering the diversity of the conceptions on the relationship between health and work and its determining factors.

According to Cozendey da Silva and Andrade1818. Cozendey da Silva EN, Andrade ET. A Construção Coletiva da Política de Atenção à Saúde e Segurança do Trabalho do Servidor Público Federal: Bases legais e político-sociais. In: Políticas Públicas de Saúde: Servidor Público Federal [Internet]. 2014 [citado 2016 jul 20]. Disponível em: https://drive.google.com/open?id=0B4no5ZMnUMDWY18wQVBCTVB1TU0
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, this moment of collective construction has been important in the forging of a tacit alliance to get from the State a policy that is coherent with the real demands for work relationships in the federal public service.

According to these authors, the implementation of the network of the SIASS represents progress for the State in terms of its social responsibility. However, implementation of actions in healthcare for the federal public worker, in an interdisciplinary and intersectorial context, demands continuity of investments for effective articulation of the actions and services1818. Cozendey da Silva EN, Andrade ET. A Construção Coletiva da Política de Atenção à Saúde e Segurança do Trabalho do Servidor Público Federal: Bases legais e político-sociais. In: Políticas Públicas de Saúde: Servidor Público Federal [Internet]. 2014 [citado 2016 jul 20]. Disponível em: https://drive.google.com/open?id=0B4no5ZMnUMDWY18wQVBCTVB1TU0
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The information recorded in the communications media made available by the Forum of Rio de Janeiro point to a reduction, starting in 2013, in the investment for implementation of the Units of the SIASS and its projects, the budget being restricted to the periodic medical examinations, required by law1717. Fórum Permanente. Fórum Permanente do SIASS RJ: Atas e Relatórios [Internet]. Fórum Permanente do SIASS RJ. 2016 [citado 2016 jul 13]. Disponível em: http://forumsiassrj.blogspot.com.br/2016/07/atas-e-relatorios.html
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In an interview given to the Permanent Forum of the SIASS (9) in Rio de Janeiro in July 2016, the Director of the DENOB/MPOG states that “initially it was possible to decentralize funds to various actions such as construction of units, refurbishment, and acquisition of environmental oversight equipment. But the budget provisions were reduced over the years and today we do not have a specific budget allocation for this purpose, except for carrying out of the periodic medical examinations, because that is specified by law”99. Fórum Permanente. Fórum Permanente do SIASS RJ: Entrevista com gestores do DENOB [Internet]. 2016 [citado 2016 jul 10]. Disponível em: http://forumsiassrj.blogspot.com.br/2016/07/entrevista-com-gestores-do-denob.html
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As for the participative strategy of construction and monitoring of the implementation of the SIASS, the axis around which the sub-system was structured, this does not appear as a priority in the agenda of the federal government, as can be seen in the speech of the Director of DENOB/MPOG in an interview: “the establishment of a group like the one that existed before, which had a scheduled monthly meeting with a workgroup in the states bringing together the agencies to have a dialogue about this, we don’t have any arrangements for this to continue. What we have is one-off, and praiseworthy, work by some states that come together for this, such as Rio de Janeiro”99. Fórum Permanente. Fórum Permanente do SIASS RJ: Entrevista com gestores do DENOB [Internet]. 2016 [citado 2016 jul 10]. Disponível em: http://forumsiassrj.blogspot.com.br/2016/07/entrevista-com-gestores-do-denob.html
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Analyzing the participation of the various institutional agents, along with the outstanding ones are Fiocruz, IBGE, NERJ, UFRJ and social players such as the unions of the workers connected to these institutions, it is possible to state that there was an initial moment of involvement of the institutions and of an institutional commitment of the MPOG to implementation of the Sub-System. But, as from 2013, there has been a retraction of the part of the MPOG, which reduces and directs its investments only to activities specified in the law governing occupational health.

The role of the Permanent Forum of Rio de Janeiro in the construction of the SIASS

According to the report of the First National Workers’ Healthcare Congress (I ENASS), in 2008, the Federal Executive Power had 529,003 active civilian employees, distributed in the 26 States of Brazil and the Federal District. In this diagnosis, Rio de Janeiro has 110,101, and is the state with the largest number of federal public workers1616. Brasil. Ministério do Planejamento, Orçamento e Gestão (MP). Política de atenção à saúde do servidor público federal “Um Projeto em Construção Coletiva”. Brasília: MP; 2008 [citado 2016 jul 21]. Disponível em: https://drive.google.com/drive/folders/0B85ZqXHwhyEJWHZRVnV1ZnRoeDg
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In 2005, for comparison, a preliminary mapping carried out by Fiocruz in the 35 federal public institutions in Rio de Janeiro, showed a wide diversity between them as to structure and models of organization of workers’ healthcare services. Given this diversity, an Inter-Institutional Work Group was formalized in Rio de Janeiro to begin the process of implementation of the SISOSP in the State44. Andrade E. O processo de implementação da política de atenção à saúde do trabalhador em instituições públicas federais: o desafio da integralidade. [Internet]. 2009 [citado 2016 jul 24]. Disponível em: http://www.arca.fiocruz.br/handle/icict/2522
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According to the Director of the DENOB/MPOG, “the workgroups were the embryo for the formation of the Units of the SIASS, but after the creation of the units the Groups were not continued, because their purpose was, indeed, discussion of the formation of the Units”99. Fórum Permanente. Fórum Permanente do SIASS RJ: Entrevista com gestores do DENOB [Internet]. 2016 [citado 2016 jul 10]. Disponível em: http://forumsiassrj.blogspot.com.br/2016/07/entrevista-com-gestores-do-denob.html
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The workgroup of Rio de Janeiro, on the other hand, did not stop its activities, continuing independently of the MPOG, and transforming itself into a group making proposals and bringing together the federal public institutions of Rio de Janeiro.

When analyzing the activities of the workgroups, Pacheco comments that the Forums of the SIASS emerged as a more appropriate strategic space for identification and overcoming of blockages, and strengthening of the field of workers’ health. The space formed a veritable network for discussion and activity between all those operating at the moment. The forum [...] has a fertile potential, not losing sight neither of healthcare in the SIASS nor of the challenge of the conceptual line that Workers’ Health represents1919. Pacheco MV. Uma Análise da Implementação da Política de Atenção à Saúde do Servidor Público Federal (PASS) com Foco na Equipe Multiprofissional [dissertação]. Rio de Janeiro: Universidade Federal Fluminense; 2015..

The Permanent Forum of Rio de Janeiro was created in 2009, and has been meeting monthly, using the participating institutions as headquarters, with an agenda of discussions of a technical and political nature related to workers’ health and the SIASS.

Perceiving the need for greater institutional integration and with the intention of reactivating the process of collective participation of the workers of the Federal Public Service, the Permanent Forum of Rio de Janeiro has been carrying out annual regional meetings, since 2011. The First SIASS/RJ Forum was hosted by the Federal Rural University of Rio de Janeiro (UFRRJ), with the theme “Ways forward for PASS: progress and challenges”, and was attended by 92 workers in the Public Service2020. Fórum Permanente. Relatório do I Fórum SIASS-RJ Fórum Permanente do SIASS RJ: [Internet]. Fórum Permanente do SIASS RJ. 2011 [citado 2016 jul 13]. Disponível em: https://drive.google.com/open?id=0B4no5ZMnUMDWbWZrRUVqQjNJenc
https://drive.google.com/open?id=0B4no5Z...
.

According to the report of the First SIASS/RJ Forum2020. Fórum Permanente. Relatório do I Fórum SIASS-RJ Fórum Permanente do SIASS RJ: [Internet]. Fórum Permanente do SIASS RJ. 2011 [citado 2016 jul 13]. Disponível em: https://drive.google.com/open?id=0B4no5ZMnUMDWbWZrRUVqQjNJenc
https://drive.google.com/open?id=0B4no5Z...
, the principal objective was to strengthen the actions for implementation of the SIASS Units in the State of Rio de Janeiro and, more specifically, to analyze the path of construction and implementation of the SIASS in the State, taking into account the work carried out by the workgroups, the implementation of the first units, and the difficulties they found for implementing the actions of the Government Workers’ Healthcare Policy, and also to set out guidelines for creation of new units.

Pacheco1919. Pacheco MV. Uma Análise da Implementação da Política de Atenção à Saúde do Servidor Público Federal (PASS) com Foco na Equipe Multiprofissional [dissertação]. Rio de Janeiro: Universidade Federal Fluminense; 2015., also said that the Forums of the SIASS constitute potential spaces for overcoming the instituted concept of occupational health in the services that concentrate on workers’ health in the public institutions of Rio de Janeiro, because they are an instance of participation of these workers in relation to the subject of workers’ health in general.

From the minutes1717. Fórum Permanente. Fórum Permanente do SIASS RJ: Atas e Relatórios [Internet]. Fórum Permanente do SIASS RJ. 2016 [citado 2016 jul 13]. Disponível em: http://forumsiassrj.blogspot.com.br/2016/07/atas-e-relatorios.html
http://forumsiassrj.blogspot.com.br/2016...
, one sees that the Permanent Forum of Rio de Janeiro resists political and institutional barriers, carrying out not only the role initially proposed by the MPOG of contributing to implementation of the Sub-System, but also perpetuating itself as an instance of collective construction of Workers’ health.

Chart 1 gives a summary of the annual Forums up to its date of preparation.

Chart 1
Summary of the Annual Forums of the SIASS/RJ (2011, 2012, 2013, 2014, 2015).

The plenary session of the Fourth Forum approved the creation of an Interinstitutional Committee to submit demands, specifically for direct and effective participation of the MPOG in the implementation of the SIASS and the PASS2222. Fórum Permanente. Relatório do IV Fórum SIASS-RJ Fórum Permanente do SIASS RJ: [Internet]. Fórum Permanente do SIASS RJ. 2014 [citado 2016 jul 13]. Disponível em: https://drive.google.com/open?id=0B4no5ZMnUMDWX3NkMlVaVzk3MGM
https://drive.google.com/open?id=0B4no5Z...
.

In September 2015 this Committee, comprising delegates from the institutions Fiocruz, UFRJ, UFF and NERJ/MS, was received by representatives of the former Government Workers’ Health, Social Security and Benefits Policies Department (DESAP, now the DENOB). At this meeting a presentation was made of the Permanent Forum, its actions, and exposition of the requests decided in the plenary session of the Fourth SIASS/RJ Forum.

According to the minutes of September 24, 2015, based on the positioning of the managers during the meeting, in which they explained the lack of budget provided for actions other than the periodic medical examination, and the absence of financial resources for training, the delegates perceived that the representatives of the MPOG were stating that they had abdicated any obligation in relation to any demands, help, or in any way getting closer to the workers2323. Fórum Permanente. Fórum Permanente do SIASS RJ - Ata - 24-09-2015 [Internet]. Fórum Permanente do SIASS RJ. 2015 [citado 2016 jul 13]. Disponível em: https://drive.google.com/open?id=0B4no5ZMnUMDWUk1ZcXpSZWoxLTQ
https://drive.google.com/open?id=0B4no5Z...
.

According to the Director of DENOB, the proposal for action continues to be the same: making of rules on issues related to government workers’ health, and making available of a computer system for recording occurrences related to government workers’ health. All this is maintained, what will possibly happen is a less ostensive presence of the MPOG in these negotiations99. Fórum Permanente. Fórum Permanente do SIASS RJ: Entrevista com gestores do DENOB [Internet]. 2016 [citado 2016 jul 10]. Disponível em: http://forumsiassrj.blogspot.com.br/2016/07/entrevista-com-gestores-do-denob.html
http://forumsiassrj.blogspot.com.br/2016...
.

With this positioning, DENOB abandoned its responsibility for the function instituted in Normative Ministerial Order 2, of March 22, 2010 by the SRH, of acting as the coordinating unit of the Technical Corporation Agreements, and this makes the inter-institutional relationships more fragile.

After this withdrawal by the MPOG, in support and financing of the units of the SIASS, especially in relation to the collective actions for oversight and promotion of workers’ health, activities began to be undertaken on an individualized basis, restricted to medical expert opinion reports and periodic medical examinations2424. Fórum Permanente. Fórum Permanente do SIASS RJ - Ata - 14-04-2016 [Internet]. Fórum Permanente do SIASS RJ. 2016 [citado 2016 jul 11]. Disponível em: https://drive.google.com/open?id=0B85ZqXHwhyEJYlF0c3hfc1pVVWJxNV9CRlp0a19uTDRaNGQ0
https://drive.google.com/open?id=0B85ZqX...
.

In this scenario, the Permanent Forum seeks to be made effective as an instrument of collective action for strengthening of the field of workers’ health in the federal public service, aiming to preserve the historical and social character of the health-illness process and ensure the protagonist position of workers in the conduction of the process.

The political-institutional context of which the SIASS is a part

The Administrative Department of the Public Service (DASP), created on July 30, 1938, in the government of President Getúlio Vargas, had the purpose of professionalizing the public sector, standardizing the employment relationships and creating a public career in public administration, which according to Marsiglia was based on the belief in “scientific administration”2525. Marsiglia R. Funcionários públicos, Estado e saúde no Brasil. Saúde e Soc. 1993; 2(1):93-118.. This meritocratic model was not applied universally in the public administration. In practice, other mechanisms of entry, through recommendations and contracting, were maintained, and public employees were divided into two main groups: those admitted by competitions included in the merit system, and the “supernumeraries”, who were outside the merit system. This situation was continued until 1988, when various different forms of entry and employment-law relationship for the federal public administration were admitted. The statutory workers, considered as public sector workers, were a minority in the workforce as a whole, while the major part comprise people working under the CLT and other types of employment relationship depending on their involvement and the nature of their work. From the point of view of employment-law relationships, i.e. up to 1988, the contracting of workers for the public sector took place in a variety of forms (statutory, under the CLT, temporarily contracted, etc.)2525. Marsiglia R. Funcionários públicos, Estado e saúde no Brasil. Saúde e Soc. 1993; 2(1):93-118..

The 1988 Constitution, by instituting the RJU, established a single form of employment-law relationship in the public service, creating its own regime, with entry into the career through public competition.

A new period began in the history of Brazilian public administration which, however, lasted only a short time due to economic and political pressures, national and international, which induced choices of government policies oriented by reduction of the State and by flexibility in employment relationships, giving priority to their regulatory role to the detriment of their execution role, which had until then been predominant2626. Martins M, Molinaro A. Reestruturação produtiva e seu impacto nas relações de trabalho nos serviços públicos de saúde no Brasil. Cien Saude Colet 2013; 18(6):1667-1676..

As part of the Administrative Reform begun by the government of Fernando Henrique Cardoso, Constitutional Amendment 19 of June 10, 1998, changed the regime of public administration which, among other changes, limited the expenses on personnel, expanded the conditions for temporary contracting, made changes to the social security regime of government workers, and opened the possibility of contracting of Social Organizations (OSs), to carry out public activities that were inherent to the State. In this new context of flexibilization of employment-law relationships, once again new forms of contracting began to be used by the public sector, including contracting of labor, in the form of outsourcing. Thus, the RJU (‘Single Legal Regime’) became not quite so ‘Single’ as it had been conceived to be2626. Martins M, Molinaro A. Reestruturação produtiva e seu impacto nas relações de trabalho nos serviços públicos de saúde no Brasil. Cien Saude Colet 2013; 18(6):1667-1676..

The contracting of companies to carry out support and maintenance services, and management contracts for carrying out end-use activities, are mechanisms that have intensified at the state level and, above all, at the municipal level, especially in the field of health. In the municipality of Rio de Janeiro, the whole of the Basic Healthcare (ABS) system is now being carried out through management contracts with Social Organizations2727. Martins M, Carneiro C. Política de Gestão do Trabalho e a Atenção em Saúde: um estudo de caso sobre a experiência de contratualização da Atenção Básica no Município do Rio de Janeiro. 2014 [citado 2016 jul 24]. Disponível em: http://www.arca.fiocruz.br/handle/icict/9590
http://www.arca.fiocruz.br/handle/icict/...
.

According to Martins and Molinaro2626. Martins M, Molinaro A. Reestruturação produtiva e seu impacto nas relações de trabalho nos serviços públicos de saúde no Brasil. Cien Saude Colet 2013; 18(6):1667-1676., from the point of view of the regulations, differentiation between employment-law relationships and the intermediation of contracts put the worker in a vulnerable position in that the negotiations are made by the companies or by the OSs directly with the contracting governments. These new management mechanisms result in the work in the public service being managed outside the direct control of the State and its capacity to influence the workforce and process of working conditions – which reduces the impact of the actions proposed by the SIASS.

Discussion

When we look at the path of the PNSST, it has been possible to identify moments of inflexion in relation to the initial proposal, due to the institutional players that assumed the process of its implementation.

Oriented by an integral and expanded approach, the first discussions and proposals initially took place in the federal hospitals of Rio de Janeiro, and this debate was taken to and absorbed by the Health Ministry in a context of institutionalization of the proposal of the SUS.

The concept of workers’ health that was at that time orienting the construction of the basis of a workers’ health policy considered that the work conditions and contexts are determined in the health-illness process and that measures for promotion, prevention and oversight should be oriented to change the work, with the workers being protagonists in this change.

With the approach, in 2005, between the Health Ministry and MPOG, the expectation was that a new legal-institutional framework would be created, creating integrality of the health of workers in the federal institutions.

While at the beginning there was a commitment by the government to this new model, over time, with the changes in the conduct of management, one sees an inflexion in the sense of a redirecting of the basis from a Workers’ Health model, to the more conservative model of occupational health, which has been dominant in employment-law relations in Brazil.

The Health Ministry assumed the leadership in the defense of a more integral and universal policy, investing in the consolidation of the PNSTTs, and the MPOG reduced its activity from the point of view of implementation of an integral and interdisciplinary policy for government workers – restricting its intervention to the traditional activities of provision of medical opinion.

Similarly, the participation of unions and workers’ movements, a structural element of the participative model, has not happened in a very systematic form – concentrating its claims and demands in relation to medical care and social benefits. The experience of Rio de Janeiro reveals an attempt to bring them to this wider discussion on the health of the worker, introducing new questions and proposals that lead to structural changes in the approach to workers’ health.

The new scenario which began as from 1998, with the approval of Constitutional Amendment 19 of that year, has a direct impact on the PASS and on the position of workers’ health in the SIASS itself. The system, conceived within the principle of universality, integrality and social control of labor, presupposes that all the workers who operated in the public sphere belonged to the RJU. The emptying of the effectiveness of the RJU resulted in the reduction of the possibilities that this policy might be implemented universally, in a way that was balanced, fair and with social participation. The challenge that imposes itself at this moment is that of reviewing the SIASS and the PASS itself in such a way that it may be able to cover all workers, evolving from a concept of ‘public servants’ to that of ‘public employees’

The experience of construction and implementation of the SIASS in the municipality of Rio de Janeiro, analyzed in this paper, brings forward elements that evidence the institutional agents and the various social actors mobilized in the process of institutionalization of policies of government workers’ health. The results indicate the need for expansion of the dialogue between the Policies on Health, Labor and Management, and for an alliance with the unions and representation of the workers in the sense of a common agenda that could give priority to actions for promotion and oversight of health, transforming them into agents of change and transformation of these spaces of work.

In spite of the significant progress on expansion of the legal resources for putting in place an effective policy for the healthcare of government employees, it is observed that there is a need for a greater articulation with the principles that orient workers’ health, such as integrality, interdisciplinary, and participation of the workers, with actions in both oversight and care, and with focus on prevention and promotion of health.

Summing up, as well as these challenges we should also bear in mind the problems related to work today, with management models that perpetuate precarious work situations, with results for the health-illness process.

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Publication Dates

  • Publication in this collection
    May 2017

History

  • Received
    30 June 2016
  • Reviewed
    12 Sept 2016
  • Accepted
    06 Dec 2016
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