HEALTH MANAGEMENT : THE UNDERGRADUATES ’ LEARNING AND ACADEMIC EDUCATION Gestão em saúde : o aprendizado e a formação acadêmica de estudantes de graduação

(1) SLP; PhD student, Department of Pediatric Dentistry, Orthodontics and Public Health, Bauru Dental School/ USP, Bauru, São Paulo, Brazil. (2) SLP; Master by Department of Pediatric Dentistry, Orthodontics and Public Health, Bauru Dental School/ USP, Bauru, São Paulo, Brazil. (3) SLP; Associated professor of Department Speech Language and Hearing Sciences, Bauru Dental School/ USP, Bauru, São Paulo, Brazil. (4) SLP; PHD Professor of Department Speech Language and Hearing Sciences, Bauru Dental School/ USP, Bauru, São Paulo, Brazil.

The general skills and abilities to work with health care, communication, leadership, administration and management, continuing education, present in the undergraduate health care's Curriculum Guidelines, are closely linked, and even dependent on the understanding of the conditions and general elements of health services management.Thus, the theme taught in the classroom, will give opportunity to graduates, to strengthen the reorientation processes of the health care model 4 as well as the daily practices in services on the "organization of the health work process based on the NHS guidelines" 5 .
In this context, the same authors emphasized the role of health-disease process, which was modified during the development of beliefs and values socially constructed.Admitted as part of reality, differentiated approaches are promoted since organic instance to the challenges of a "non-reductionist approach that restored the meaning of the individual in his singularity and subjectivity in relation to the others and with the world."The social ways of life production define the health challenges commonly related to the social groups formation and transformation, and thus must be fully understood in order to advance in the knowledge of more complex problems 6 .
This process suffers direct influences of health services offered to the population, and significant changes were made by many socialist and capitalist countries , as about its organization, exploring more intensely scientific and technological aspects offered for health systems services management 7 .Defying the student to operate in setting priorities as well as goals and strategies, acting in the service configuration and transformation of professional practices, evaluate, especially their efficiency, effectiveness and investment effectiveness, as well as substantial research articulated to the health services and population needs, are some functions of teaching management practices.
Conceptions about democracy, empowerment and community, are values considered fundamental in the public services quality since the individual growth is a prerequisite for the empowerment community and social changes 8 and thus allowing the individual autonomy in their choices and competence in disseminating information in the health field 9 .These concepts rely on constant experience to be assumed and improved during the academic training, trespassing, in contrast, the specificities of the several health disciplines.
The research Swedish showed that health quality is related to the satisfaction of the user's needs and the efficient use of health resources.In addition the ability of the citizens to realize the changes that are materialized in quotidian where are the opportunities for collective learning 10 .In this context that involves the health-disease process, human and ethics values, social groups transformation, setting priorities, citizen satisfaction and collective learning, the purposed of this research was to compare the previous and posterior education-learning knowledge of the 3 rd year students of Speech-Language and Hearing Sciences about the topic Health Management.

METHOD
The present study, which shows a longitudinal, descriptive and qualitative character, was developed after the acceptance of FOB/USP Ethics and Research Committee under the case number 146/2010.
Participants in the first sample totaled 36 and the second 31 students who signed the consent form.Its development occurred through the application of a semi-structured protocol, previously elaborated by the researchers with indirect questions.The students responded the instrument before and one year after being taught the module Health Management (30 hours) so that the different categories could be obtained: how the health-disease learning process occurred; the administration of this content in their daily lives and what would they consider as a guiding management principle in the Speech-Language and Hearing Sciences (SLH) profession.
The obtained data were analyzed qualitatively, with the application of the "tree of ideas association methodology" (Árvore de Associação de Ideias) 11 , which consists in reading and extracting relational categories, constructed to allow the visualization of the idea in the discourse flow (oral and written, individual or collective) and the results were substantiated in the light of the literature.

RESULTS
The collected data were organized into three categories and the results received detailed reading analysis and style expression condensation on the same content, and then related to literature.

Category 1. Health-Disease process (questions 1 and 2)
In the first data collection, the result is related to the health-disease process conceptualization, presented in an opposition between health and disease, focusing on traditional hegemonic models.In the second collection, they understand the health-disease process as an inherent factor of the individuals quality of life 12 , considering psycho emotional factors, bringing to critical discussion of the definition assigned by the World Health Organization (WHO) preconized in 1948, in which health is "a state of complete physical, mental and social well-being and not merely the absence of disease."None of the collections refer questions about the social order adopted in the NHS implementation.The compilation of data analyzed is shown in the Figure 1.When asked about seeking care, in case they get sick, 66.6% in the first collection and 51.6% in the second one, students opted for private clinics, in the first place, and the emergency care in the second place.On this issue it is possible to observe four relevant data: 1) when this research was conducted, the University of São Paulo granted private health insurance to students.
2) there is a Health Care Center on the campus of University tied the USP's Rectory.
3) there is little disclosure and little municipal investment in the Primary and Family Health Care Center, whereas the latter attends only 7% of the population.
4) it is embedded in the "culture" of the population to seek the Emergency Service Centers.What we are calling "culture" is the society strategy maintained and enhanced the demand for emergency health centers since there are few primary health centers (18) and family health (seven teams, divided into two strategic locations, plus a program of Community Health Agents) for a population nearly about 360,000 inhabitants, and reduced and/or poorly quantity distributed health professionals.
Regarding to the self-medication procedure in the first collection almost 50% of the responses were positive, considering homeopathic, homemade and pharmacological allopathic medication.In the second collection, the same percentage was found, using the same drugs, highlighting some therapeutic actions (antipyretic, analgesic, among others).
A summary of this information using the tree of ideas association (Árvore de Associação de Ideias ) is presented in Figure 2.

Category 3. Speech-Language and Hearing Sciences: therapy as a way of healing (question 5)
Observing the data obtained during the ideas association in the first collection the participant contradicted themselves: (1) SLH Sciences diagnose and cure organic illnesses (in the area), (2) does not heal but helps in the maintenance of a better quality of life, (3) does not heal (because there is no medication).In the second collection, although there was also opposition, the answers were in the same level of consideration about the comprehensiveness principle and health promotion (beyond the prevention), highlighting issues of psycho emotional order and citing the social dimension.Figure 3 shows the discussed ideas.

DISCUSSION
According to the questions presented in Category 1, the emphasis on the health-disease biological process, reinforced during years in speech therapy course gave way to a biopsicoemocional approach.The disease is explained as an individual's internal homeostasis break attributed to the experienced stress as a factor that determinate the health changes, corroborating with authors who affirmed 13 that it's the requirement of adaptation, positive or negative, called stressor.Such stressors may be external or internal, and the first can occur independently of the personal internal world, such as: change of leadership, political changes in the country, accidents and other situations that happen outside the individual's body and mind.The second is determined by the individual, such as: anxiety, shyness, depression also including beliefs, lack of assertiveness and difficulty to express feelings.
The maximum approach social achieved was the corroboration with the study 14 where health and disease are two extremes of a constant dynamic performed by the individual and the environment where he/she lives, the normal-abnormal, inspirationexpiration, sleep-alert, life-death.The community conditions and determines the health and illness on the relationship between individuals and the environmental systems in which they live to interact with living and nonliving.It is through this interaction that action and reaction effects are triggered interfering in the physical and environment construction and producing (un) sustainable means to survival and preservation 15,16 .This dynamic is different for each individual and the difference becomes crucial according to each one's ability to deal with the aggressions one faces, called resilience 17 ,and thus, in a subjective way, is reflected in the quality of life indicated by the students.
However, no student quoted the definition of the 8th National Health Conference, 1986, or discussed the notion of health as a social right and achievement, thus, the social and regional inequalities that act as limiting factors to the full development of a satisfactory level of health and it's organization.Although the graduate students training has been mainly directed to the health knowledge in a comprehensive, holistic way, in support to the quality of life and for some values that simultaneously instituted and are instituted by the citizenship definition ambivalence, it did not allow a relationship between individual and society, and of caring and responsible citizens.Nowadays one of the public policies challenges has been exactly to reconcile the universalization to the citizenship term acquired in the contemporary concept, with claims for the right to preserve the differences to ensure equity.
In relation to Category 2, the excluding universality seems to keep growing, making the private sector funding mechanisms increasingly similar to the American system, "in which State action is residual" 18 .Currently social classes C and D have been in a scenario of struggle between the supplementary healthcare operators, due to their purchasing power increase.Data 19 highlighted 1,100 active supplementary healthcare companies operators in the country, among insurers, medical cooperatives or medicine group companies and "almost all social classes A and B are already within the healthcare supplementary."Given these explanation it can be verified that the management on the health principle is guided by notions of effectiveness (best x worst) and efficiency (investment x benefits), lined by the little time that students have in the business hours, more especially those studying full time, and by media reports that most of the times points to local public health places with long queues, independent of the procrastination that occurs within private clinics and the time for exams through the supplementary healthcare.While the comments also occur in cities where public health is well evaluated by the population, in Bauru-SP there are negative headlines every day, in the spoken or written media, for political reasons or because it states the truth about the system.Fortunately most students pointed to seek some professional help.
Concerning the self-medication procedure, there was, mainly, the disregard of nosological diagnosis and the signs and symptoms of more serious diseases that could be concealed by drugs, which are available without prescription, have strong commercial appeal, can be used for a specified time (antipyretic, for example) or are considered "without side effects."Similar results are found in a research 20 that verified the use of self-medication by the future health professionals, from different courses.The authors noted that 42% of students had used drugs prescribed by doctors, and 58% used selfmedication.Another study 21 found the presence of self-medication in 40% of nursing students.These authors stated that the educational practices incorporation for not trivializing the use of drugs should be performed, including health students, so they can properly guide their future patients.
In some studies 22 the medication has been referred as symbolic commodity and discussed from the social point of view of the physician prescribing the medication and of the individual, in which complex sets of relationships such as "hegemony, alliances, transgression, submission, power and counter power and other."The discussions concluded that health reified is embedded in a commodity consumption relationship having the need to break with this concept for a shift of health as a right.On the other hand, authors 23 emphasized that, when consumed, they induces the individual to meet the need of change from a "bad" state to a "good" one, from a state of no-health, dissatisfaction, to a state of health / satisfaction, as extensively proclaimed by healthcare professionals.
Moreover, there are barriers to the medicines rational use: the lack of guidance for the users on the part of prescribers, direct advertising to the final consumer and the consumer misuse 24 .In this sense, self-medication and / or inappropriate prescribing may lead the individual to experience side effects, develop iatrogenic diseases and mask progressive diseases, therefore, it represents a problem to be prevented 25 .
Regarding the use of homemade medicines one should observe that the Ministry of Health, in the Interministerial Order 2.960/2008 introduced the National Medicinal Plants and Herbal Medicines Program, with a focus on primary care.The program, among its objectives, proposes to introduce or expand the medicinal plants supply, herbal remedies and services related to Herbal Medicine, in line with the NHS guidelines, and also to promote and recognize the popular and traditional practices of herbal and homemade medicines use 26 .
It is this context that future health professionals should take into consideration regarding the selfmedication process so that the repercussion and orientation in this activity be clarified and performed in a safe way.
In the Category 3, thinking about the cure of diseases / changes / disorders related to Speech Language and Hearing Sciences, according to the questions presented, it was observed that students exercised their skills, abilities and attitudes in a critical and reflective way as suggested in and Base Law of The National Education Guidelines, especially those focused in primary health care knowledge, decision-making, leadership and administration, and management.On this approach the disorders affect the individual health, seen from two angles: first as the absence of the restricted sense of disease, that is, as quality of life, whose characteristic is adopted in health promotion, in which help be given to the subject so that he/she can find an inner balance, their empowerment through knowledge, stabilization of the aspects (psycho emotional) that surround the morbidities and therefore dispenses medical/ medication treatment or uses it as a supporting treatment.The second, in which the disease is taken as a starting point and whose treatment, medical or surgical, is performed by medical professionals, but that requires a speech, language and hearing pathologist intervention prior, during and / or after the procedure, to recovery or rehabilitation.In both models what counts is how much one suffers with the difficulty of communication that might be or that is present in the subject daily life, and the impossibility for the professionals to deal directly with the disease but which acts on the morbidity or injury implications.
Thus, these factors may signal the speech, language and hearing pathology forms of intervention on the causes and consequences of diseases considering what generates the psycho affective and social problems, which are difficult to measure by means of examination and / or improved by intake of medications.These disorders affect the professional aspects, self-confidence, happiness and safety of an indivíduo 27 .
At first, students indicated the use of medication as a means of providing a cure, however this statement does not appear in in the second collection, which has its focus on the aspect regarding the maintenance of health and the participation of professionals in the process of mental, physical and social healing.Authors 28 advocate that aspects of speech, language and hearing should be health attributes, since they affect the competence and communicative performance in verbal and non-verbal, intra and interpersonal, and even that they do not cause physical pain, do not have signs and symptoms that can be expressed in laboratories, cannot be cured by ingestion of drugs nor lead to death, they do cause suffering.Although other areas have not been mentioned by the authors, one cannot ignore the role of the speech, language and hearing pathologist at all levels of prevention, when there is reference of certain diseases that can lead to death, as it is the case of neurological dysphagia, or in consequences of cases of advanced laryngeal cancer, as characteristics of morbidities that deserve special attention when it mentions the communication factor.Another study highlighted 29 that the speech, language and hearing pathologist works in research, prevention, assessment and therapy in different areas that concern the profession, but there is need to invest in improving the quality of life through the training of professionals with the perspective of health promotion 30 .
In contrast, the health care professional who has his/her training directed towards working in NHS conducts individual and collective promotion, protection and recovery of human communication, providing comprehensive care to individuals and collectivities accompanying empowerment regarding their health.It is noteworthy, therefore, that health professionals act as facilitators in the process of health education, and that the idea of integrated care in health implies a knowledge developed collectively by professionals, teachers, managers and users / patients, co-responsible for health 31 production.
Thus, the construction of the current ethical and humanistic values as fairness and equality, democracy, and community empowerment, diversity and choice, and intervention or non-intervention of the state, which lead to policies of social groups transformation, to conformation of a set of priorities, the pursuit of satisfaction of citizens and the collective learning of both parties -healthcare professional and individual (or collective), were the guiding principles of the health management module on this course of Speech-Language and Hearing Sciences.
Based on the above considerations, it was possible to observe that the human being, complex and multiple, is a product and the producer of health practices, and the individuals in the care actions, are transformed into the subject of health action, according to their individual, social, economic and cultural peculiarities.Thus, individuals and groups must be empowered with knowledge in order to identify their aspirations, to satisfy their needs, favorably modifying the environment in which they live in 32 .In this sense, management deals with polarities.This gives us opportunities to face the challenge of questioning instances that emphasize the imbalance between autonomy and control, benefits and harms, production and reproduction, disease and health, and caregiver and one who receives care, among outras 33 .
Thus, the students emphasized that the Speech-Language and Hearing Sciences participates in a cycle that seeks to provide improved quality of life of the individual, considering an interdisciplinary work of NHS principles: comprehensiveness as an essential fact in the development of the therapeutic process of a patient or community.Study 34 confirms the need for full implementation of the health care services from the organization of services to the professional training at undergraduate level.And in the case of professional training, agents such as: teachers, school leaders, students, education managers and managers of NHS must be present.

CONCLUSION
Given the found data it can be concluded that the graduate students training in SLH Sciences prompted the partial understanding of the healthdisease process as a primary guideline for exploring the territories of unique powers in the social practices field (health).However, it enhanced the learning progress regarding comprehensiveness process, when adopted in its praxis, theoretical positions focused on the quality of life and health promotion, simultaneously investing on disease prevention, in a broad and interdisciplinary sense.Thus, the challenge will be to establish the production of new instabilities and provide integral conditions for the capillarity of this knowledge with the specific Speech-Language and Hearing Sciences disciplines.Procedures can be adopted focusing on restructuring the methodology of teaching and learning by observing the contributions and limitations of the activities performed and the topics covered with students frequent dialogues in order to verify their suggestions, criticism and the thought directed to a better assimilation of the content offered.

Figure 1 -
Figure 1 -Ideas association according to the category health-disease process