Popular education in the SUS: current challenges from the perspective of the Observatory of Popular Health Education and the Brazilian Reality

This paper aims to bring reflections and notes for strengthening Brazilian structuring public policies, focusing on Popular Health Education in the Unified Health System (SUS) from the perspectives built in the Observatory of Popular Health Education and the Brazilian Reality. The Observatory is a valuable space for sharing health professionals’ and popular educa-tors’ interpretations and experiences about local and Brazilian realities from the perspective of Popular Health Education. During its two years of activity, the Observatory has gathered summary interpretations of Popular Health Education for the crises that traverse the country’s recent history in a dialogical and participatory way. In a panoramic view, the shared statements point to challenges for valuing the human approach to health promotion, including respecting local and community knowledge and social practices. Moreover, we underscore the importance of social participation in constructing participatory social processes in public health toward citizen autonomy and expanded democratic dynamics in the Brazilian State and its social equipment


Introduction
This manuscript presents and debates the current challenges for Popular Health Education (PHE) in the Unified Health System (SUS).This opinion article was drafted from constructs collectively produced within the experience of the "Observatory of Popular Health Education and the Brazilian Reality".Developed two years ago, it is institutionally anchored in the Health Promotion Department of the Medical Sciences Center of the Federal University of Paraíba (UFPB) through the Research and Extension Program "Comprehensive Health Promotion and Nutrition Practices in Primary Care" (PINAB).It is supported by the Popular Extension Research Group (EX-TELAR), linked to the Interdisciplinary Center for Research and Extension in Solidarity Economy and Popular Education (NUPLAR) at UFPB.
The reflections and notes presented here intend to contribute to the debate around the current agenda of strengthening and structuring public policies, primarily those aimed at building participatory social processes that value the institutionalization of actions and services characterized by a humanistic approach that promotes the population's emancipation, and which include and respect local and community knowledge and social practices in the actions of public services.
PHE is a broad and historical field of practices, experiences, and social movements that have accumulated knowledge and spread ideas, methodologies, approaches, and technology relationships between health professionals and the population over the last six decades.The latter -health professionals and the population -effectively point to new possibilities for formatting health services, building them with a dialogical, humanized outlook deeply articulated with listening and inclusion.
The set of civilizational setbacks to which the Brazilian population has been exposed over the last seven years, mainly with several dismantled and unstructured public policies, has also affected PHE experiences, movements, and practices, the initiatives anchored in the health services and management of universities and research and education centers, and those led by social movements and other popular and community groups 1,2 .Despite the setbacks, the Brazilian PHE movement, with its diversity and breadth of practices and groups, has remained active, even in the face of the COVID-19 pandemic.
During the pandemic period, precisely in 2021, PINAB/UFPB started the experience of the Observatory of Popular Health Education and the Brazilian Reality in a remote environment through videoconferences via Google Meet to preserve, promote and facilitate the meeting between the different leaders of PHE practices in a crisis.It aimed to encourage these people to participate in virtual meetings to reflect on the Brazilian situation and the challenges of social and political reality, envisioning, through dialogue, possibilities, alternatives, and strategies for resisting and overcoming challenges, keeping experiences and their potential alive 3 .
This article aims to study this process in depth to improve the principles of comprehensiveness, equity, and community participation in the day-to-day running of local health practices.

Popular Health Education and its current role
The words formulated and shared in this manuscript are meant as inputs to the activities of national peers who persist in their journey through Popular Education (PE) and its interface with health.
PHE has been presented as a significant reference in guiding the construction of spaces, initiatives, and concrete experiences for the critical development of social and educational work connected to social reality and the life that pulses in the territories 4 , particularly within Primary Health Care (PHC).
In this context, PE mobilizes people to organize themselves in formulating and developing a critical, participatory, and reality-transforming action 5 , whether through research, teaching, and social action or through educational and therapeutic groups, projects, listening spaces, and community meetings, social support and solidarity actions, workshops, popular courses and the creation of local organization spaces.Its leading figures are social stakeholders from different places with varying experiences in social movements and popular practices, through students, technicians, university professors, health workers, and other social areas, such as education, the environment, and social assistance 6 .
In the actions of these people and their groups, PE is revealed as a set of ethical-political and pedagogical principles that support the shared construction of the social action needed to tackle local social inequalities and unveil alternatives and possibilities for new horizons for life with quality and dignity.
While it is true that PE cannot just call upon itself to mobilize processes of change in the face of injustice, it is also true to say that it is proper from this perspective to mobilize strategies for confronting and overcoming injustice, which necessarily involves a critical reading of the world and life 7 .
Thus, we understand that PE is a work-mediated teaching-learning process 8 , understood as a transformative action on social reality for its permanent humanization.PE is an educational approach based on the dialogue of knowledge and practices and people's active, critical, and purposeful participation in the shared construction of possibilities for overcoming the social problems they experience in everyday life.PE is thus a human action 9 whose content lies in the reality of the concrete lived and in people's ways of feeling, thinking, and acting in the concrete world of social reality 10 , in their quest for autonomy and emancipation.
As Jara Holliday 11 points out, PE is a theory of knowledge with specific assumptions and philosophical bases to guide purposeful, consistent, and socially referenced human action.

Methodological aspects
This qualitative opinion article 12 was elaborated in the light of the methodological perspective of the systematization of experiences, under the terms founded by Oscar Jara Holliday 13 , who indicates, in his method, that it is fundamental to make explicit the experience to be systematized and the guiding thread (focus) of the systematization.As mentioned above, the experience analyzed occurred at the Observatory of Popular Health Education and the Brazilian Reality, and the systematization focused on the PHE proposals in the Lula government, formulated by the Observatory's participants during debates at two of its meetings.The systematized meetings were held at the Observatory's Eighth Meeting on 14/11/2022 14 and Ninth Meeting on 19/12/2022 15 .These gatherings were attended by 74 people with different health-related backgrounds: health counselors, members of social movements and popular health practices, health workers and managers working in SUS services, and students, professors, and researchers in health and related areas from higher education institutions.
The first meeting included a presentation by Osvaldo Bonetti (popular educator and researcher at Fiocruz) and Eliana Cruz (popular educator and researcher in Collective Health), followed by dialogue and debate, raising questions for reflection, and formulating proposals.There were no initial presentations at the second meeting, so the space was opened primarily for proposals and suggestions for strengthening PHE in the SUS.
The meetings were recorded and posted on YouTube on the PINAB/UFPB channel.The Observatory's researchers and organizers transcribed the debates to systematize them, then read and analyzed the material to identify relevant proposals.After listing the proposals, the researchers attempted to build summaries that gathered the related themes.After this stage, the proposals were divided into categories didactically and comprehensibly.
As recommended by Jara Holliday 13 , our analysis is based on a dialectical methodological approach.The author affirms it is "a way of conceiving reality, approaching it to know it, and acting on it to transform it.It is, thus, a comprehensive way of thinking and living: a philosophy" 13 .He also mentions that this method of analysis involves considering the object from the perspective of a moving reality, historicity, contradictions, and totality in the light of the Marxist approach.

Observatory members' proposals
The proposals presented in this article derive from discussions by members of the Observatory of Popular Health Education and the Brazilian Reality in collective action with more than a hundred people working in public health in the country.From this perspective, we aimed to emphasize the making of i) the State, which could break with the pre-participatory perspective; ii) public policies, which would deepen humanized healthcare processes; and iii) the perspectives of participatory, democratic, and comprehensive construction of health.
Strengthening and consolidating Popular Health Education: • Valuing PHE experiences and practices and their potential to point out and propose methodologies, approaches, and ethical-political and pedagogical principles to improve care, management, social participation, and health training in the SUS; • Establishing spaces for discussion and joint national construction with several groups, entities, and movements that advocate for and practice PHE in Brazil to revive issues and debates discontinued since PHE left the institutional scene in recent years; • Mobilizing dialogue and enchantment strategies to gather and integrate younger leading fig-ures in PHE actions and social participation in health and revitalize leadership.
Popular Health Education, Guarantee of Rights, and Defense of the SUS: • Ensuring that the leading figures of PHE experiences and practices are heard in spaces for debate, construction, and deliberation of health policies in the SUS; • Valuing PHE experiences and practices and their potential to point out and propose methodologies, approaches, and ethical-political and pedagogical principles to improve care, management, social participation, and health training in the SUS; • Recalling, from the perspective of studying and critically analyzing neo-fascism, its movements, and policies, in order to not erase civilizational setbacks from the memory of social subjects, and taking care in health practices, to cultivate relationships and actions that explicitly oppose this political strand, not only by not being fascist but by being anti-fascist.
Popular Health Education, Institutionalization, and Management of the SUS: • Reconstituting the National Popular Health Education Committee (CNEPS) as a national coordination and articulation body around the resumption and strengthening of the National Popular Health Education Policy (PNEPS-SUS) in a participatory manner, with the several groups, entities, and movements that defend and practice it; • Escalating health planning initiatives effectively and participatively, thus prioritizing a more dialogical relationship between society, government, and the Unified Health System in health construction projects and the several forums and bodies of discussion and deliberation; • Reestablishing the National Policy for Participatory Health Management at the federal level; • Valuing initiatives that organically bring the dimension of popular culture and ancestral knowledge into health actions in the territories; • Encouraging health communication strategies that value popular culture and include/involve its masters.
Popular Education in Primary Health Care and its support for teams and the dynamization of actions in the territories: • Valuing PHE's role in the organization of PHC actions and services, encouraging educational practices with this approach, supporting and valuing health professionals to perform care, social participation, management, and health surveillance practices with a dialogical approach in the territories; • Establishing institutional arrangements that guarantee PHC workers the availability of time to dedicate to community educational practices, to perform care, social participation, management, and health surveillance practices with a dialogical approach in the territories, transcending the care aspect of emergency care; • Encouraging, valuing, and supporting the active involvement of community health workers in care, health promotion, and health surveillance actions in the territories, especially those that emphasize and develop community health leadership; • Strengthening network initiatives and social support experiences in the territories to consolidate collective care and community participation in healthcare actions; • Prioritizing the capillarization of popular participation in the territories, primarily through local councils, popular health surveillance, popular health workers, and other local and community initiatives for the participatory construction of health.
Popular Health Education, Health Work, and Continuing Education: • Developing strategies for continuing health education processes that include elements such as dialogue and criticality in their methodologies and pedagogical bases; • Valuing continuing health education processes that emphasize the perspective of health as a shared construction, and dynamics, methodologies, and possibilities for workers to recognize, value, and include the role of the community and its leading figures in the day-to-day running of health services, especially in PHC; • Conducting PHE training processes for health professionals at the national level and in the states and municipalities; • Strengthening grassroots health work initiatives and experiences, building on projects such as the popular health workers; • Valuing extension experiences, emphasizing the community, in the training of health professionals; • Disseminating and expanding, in training institutions, the discussion around the University Extension foundations and extension approaches, dynamics, and methodologies that effectively move toward strengthening the SUS, comprehensiveness, and tackling inequalities; • Supporting the realization of university extension projects, built in a shared way in the territories and family health teams, as a way of supporting PHE experiences in PHC; • From the health communication perspective, supporting training initiatives for health professionals to enhance the dialogical encounter with the community and the territory.
Popular Health Education, Equity Policies, Social Control, and Participation: • Resuming action on health equity policies, building them in an integrated way with participatory management and PHE policies, considering themes such as Black Population Health Policy, Health of People with Disabilities, Health of the LGBTQIAPN+ Population, rural, forest, and water policy, homeless population, and Romani population; • Strengthening PE as one of the fundamental foundations for social control in health and the actions of its bodies, especially the Health Councils and Conferences; • Developing PE strategies aimed at comprehensive health promotion for the homeless population, in the training of professionals who unveil care for these people and activists in their movements and organizations; • Emphasizing the anti-racist, anti-sexist, anti-capacitist, and anti-lgbtransphobic nature of health practices through the application of communication strategies and care and health education practices; • Mobilizing the participation of women, Black, Indigenous, and LGBTQIAP+ leading figures in health practices, PHE experiences, and bodies of social participation in health; • Expanding and facilitating access to health care practices for the LGBTQIAP+ community in the territories, focusing on the transvestite population, guaranteeing the participation of this population in the construction of these policies; • Employing and updating the Councils as structures that exceed institutional rigidity, making discussion processes more attractive; • Articulating the actions of institutional councils and popular forums and spaces for social participation in health in a more organic and daily way, unifying the common agendas between these experiences.
Popular Health Education, Care Practices, and Comprehensiveness: • Expanding mental and emotional health care strategies in PHC, valuing the community and workers; • Valuing continuously Integrative and Complementary Health Practices (PICS) in dialogue with PHE; • Valuing the participation and contribution of popular health practices in SUS actions and services; • Structuring PICS training strategies based on community knowledge and practices; • Strengthening and disseminating the knowledge and practices of traditional peoples in health, ensuring their participation in the construction of action plans; • Providing opportunities for PHE in policies and actions to promote food and nutritional security, recognizing, valuing, and supporting PHE initiatives, mediated by dialogue and popular participation, in the fight against hunger and economic poverty.
These proposals were built collectively in remote dialogues through the Observatory.They enable us to recognize the many possibilities for popular health educators and the use of virtual technologies made available for the educational, organizational, and communicative processes proper and necessary for PHE.

Lessons learned, challenges, and prospects for the current agenda
The moments of building the proposals mentioned above recalled the power in forums and spaces when it comes to their shared construction and the ideas and strategies for strengthening PHE in the SUS, which was very much present in the process of building the PNEPS-SUS, from the establishment of the CNEPS, with its dozens of representatives from movements, groups, and technical areas of the Ministry of Health and other Ministries, encompassing regional and national meetings 16 .
This moment restores hope and reestablishes a sense of professional commitment to formulating proposals aligned with the wishes of most of the Brazilian population.Thus, the significant participation of many people from several PHE groups, practices, and movements in the Observatory's meetings resulted in the proposals listed here, which reveal society's strength toward rebuilding the structuring public policies and the resilience of so many groups and social movements.
In this sense, in the set of proposals, we should underscore the urgent need to revive the CNEPS insofar as, in the 2009-2016 period, this was precisely one of the significant marks of the PNEPS-SUS as a democratic, public, and open space for participatory construction, follow-up, monitoring, and evaluation of the development of the main actions considered in its operational plan.
Another important dimension that the proposals listed reveal is that PHE and its expressions in the current management of the Ministry of Health need to insist on supporting and encouraging local PHE practices, experiences, and movements, primarily within PHC.The previous experience of implementing the PNEPS-SUS had a great deal of support for projects of national relevance and with a broad scope.However, the dimension of support for local and community practices (while present, primarily through the Victor Valla Popular Health Education Award) needed to be more significant.Aligning this thought with the proposals formulated collectively by the Observatory, we see how much we must effectively guide financial support to incentivize local practices in the capillarity of territories and communities.
To this end, the proposals presented assertively state the centrality of valuing the role of PHE in PHC.We refer here to the misguided way in which many PHC units are managed, acting as emergency care centers, much like the Emergency Care Units (UPA), failing to play an essential role in terms of community approach, health promotion actions, territorialization, health surveillance, health prevention actions, and local social participation.By focusing too much on emergency care, with a centralized medical approach, many Brazilian PHC units have become somehow spaces permeated by disease instead of health, by sadness instead of joy, by hopelessness instead of power, by the fear of death instead of the desire to live longer and better.The PHE has methodologies, dynamics, and strategies to support the actions of professionals and community leaders in collaborating with the construction of PHC units as reference centers for building life and happiness projects 6 .We can, therefore, energize and support PHE experiences in PHC, with groups, actions, and local projects built in a shared way in the territories with the Family Health teams, as is already the case in many places in Brazil 17,18 .
We understand that the experience of the Observatory of Popular Health Education and the Brazilian Reality has pointed to a new perspective of building meeting places, dialogues, and exchanges.The Observatory differs from other spaces in that it is managed collectively without the organizational demands that many large movements and collectives require.There is no room for tensions over representation or inter-nal management.The people who visit this space meet to get to know each other, share reflections, socialize inventions, discoveries, and their work potential, learn from the knowledge and work of others, and learn together.Without any demerit whatsoever to the experiences of movements, groups, and organizations with greater complexity and political and organizational tensions, the Observatory experience is a lighter space for articulation and communication insofar as, being an extension project, people participate in a more unpretentious way and detached from other expectations, including from the viewpoint of power struggles.At the Observatory, people meet to get to know each other, recognize each other, learn, relearn, formulate, and perform PHE actions collectively, as well as humanization and recivilization experiences.
From this perspective, we should underscore in this text the unique contributions made by Observatory participants, not just at the two meetings mentioned above but during all 12 that have occurred since May 2021.In the periodic meetings for critical evaluation and participatory planning of our work, we accepted guidance, possibilities, proposals, and new ways to improve what we do.We also aimed to understand and accept criticism about our actions' limitations.Thus, the Observatory has become a place for PHE leading figures to share their impressions of the challenges of their practices.In the dialogues, we shared ideas and reflections, news, and information in virtual conversation circles with a national reach.
The COVID-19 pandemic has mobilized us to do PE remotely.Without losing sight of the fact that PE requires face-to-face meetings, human interactions, bonds, and connections that only occur in face-to-face human encounters, we recognize how much virtual meetings have enabled dialogue between leading figures from different places and contexts.Moreover, the idea proposed by the Observatory from the outset that face-to-face meetings accompany each remote session has contributed to understanding this remoteness as an essential part of the educational and mobilizing process.
In short, the experience of the Observatory of Popular Health Education and the Brazilian Reality has provided a space for more significant opportunities for meetings between people building PE practices in health services, social movements, and life territories.It provides exchanges, experiences, discoveries, expression of dilemmas, and collective and shared perspec-tives.Participating in the Observatory also opens up spaces to discuss the current situation and how it affects our practices.Examples of these dynamics include: a) how the processes of eugenics, discussed in one of the Observatory's sessions, are influencing our practices regarding tackling racism and inequalities; and b) how the escalating food insecurity and the dismantling of public food security policies in Brazil are impacting PHE practices.

Moving considerations
The proposals put forward by the Observatory of Popular Health Education draw attention to the need to expand and strengthen spaces, experiences, movements, and practices that mobilize and qualify people's social participation in SUS actions and services.The current Brazilian context allows us to deepen a participatory and citizen culture closer to democracy, dialogue, mutual respect, and peace.
We, therefore, have some principles and possibilities for building PHE actions in the SUS based on the specific reality of the population and their ways of feeling, thinking, and acting in health, thinking of health action as work that occurs in social and meaningful communication, and relationships based on exchange, cooperation, and community development.We hope that the PHE and the Observatory's actions will contribute to supporting experiences and practices in PHC in health surveillance, from an emancipatory perspective, in the planning and management processes of the SUS and the care model's territorialization activities, and the discussion of financing and social control.

Collaborations
PJSC Cruz, PNA Brito, ELP Santana and JC Silva contributed to the conception, design, data analysis and interpretation, and drafting of the article and approving the version to be published.DS Barbosa contributed to the critical review and approval of the version to be published.OA Moraes contributed to data analysis and interpretation.