Reflections on equity and its applicability to the nursing work process

Reflexiones sobre la equidad y su aplicabilidad al proceso de trabajo en enfermería

ABSTRACT

Objectives:

to reflect on the principle of equity from the perspective of social justice and its applicability in the dimensions of the nursing work process.

Methods:

theoretical essay on the challenges for the practice with equity in the dimensions of the Nursing work process: teaching, care, research, political participation and administration.

Results:

the principle of equity should: in education be transversal in the training of future professionals; in assistance to occur without privilege or discrimination, treating the unequal unequally and the equals equally; in research be the target in the creation of new knowledge; in political participation to count on the contribution of social movements; and in the administration to count on the creation of specific executable policies.

Final Considerations:

there are still inequalities in access to services by part of the Brazilian population. Nursing should promote in its work process the implementation of equity promotion policies with a view to social justice.

Descriptors:
Health Equity; Social Justice; Nursing; Unified Health System; Equity in Access to Health Services

RESUMEN

Objetivos:

reflexionar sobre el principio de equidad en la perspectiva de la justicia social y su aplicabilidad en las dimensiones del proceso de trabajo en enfermería.

Métodos:

ensayo teórico sobre los desafíos a la práctica con equidad en las dimensiones del proceso de trabajo de enfermería: enseñanza, atención, investigación, participación política y administración.

Resultados:

en la enseñanza, la equidad debe transversalizarse en la capacitación de los futuros profesionales; en la atención, aplicarse sin privilegios ni discriminación, tratando desigualmente al desigual e igualmente al igual; en investigación, ser objeto de producción de nuevos conocimientos; en participación política, contar con respaldo de los movimientos sociales; y en administración, gozar de la construcción de políticas específicas aplicables.

Consideraciones Finales:

existen aún desigualdades de acceso a los servicios para segmentos poblacionales brasileños. La enfermería debe promover en su proceso de trabajo la implementación de políticas promotoras de la equidad, apuntando a la justicia social.

Descriptores:
Equidad en Salud; Justicia Social; Enfermería; Sistema Único de Salud; Equidad de Acceso a los Servicios de Salud

RESUMO

Objetivos:

refletir sobre o princípio da equidade na perspectiva da justiça social e sua aplicabilidade nas dimensões do processo de trabalho em enfermagem.

Métodos:

ensaio teórico sobre os desafios para prática com equidade nas dimensões do processo de trabalho da Enfermagem: ensino, assistência, pesquisa, participação política e administração.

Resultados:

o princípio da equidade deve: no ensino ser transversalizado na formação dos futuros profissionais; na assistência ocorrer sem privilégios ou discriminação, tratando os desiguais de forma desigual e os iguais de forma igual; na pesquisa ser alvo da produção de novos conhecimentos; na participação política contar com a contribuição dos movimentos sociais; e na administração contar com a construção de políticas específicas exequíveis.

Considerações Finais:

ainda há desigualdades de acesso aos serviços por segmentos da população brasileira. A Enfermagem deve promover em seu processo de trabalho a implementação das políticas de promoção da equidade com vistas à justiça social.

Descritores:
Equidade em Saúde; Justiça Social; Enfermagem; Sistema Único de Saúde; Equidade de Acesso aos Serviços de Saúde

INTRODUCTION

At the moment when Brazil debated the theme “Democracy and Health”, in the 16^th National Health Conference (8^th + 8), Nursing, as in previous occasions, joins this purpose by placing on the agenda of its largest event, the 71^st Brazilian Congress of Nursing, the principle of Equity.

When debating democracy and health, it necessarily goes through the doctrinal/philosophical principles of the Unified Health System (SUS), among them, Equity, which, without Social Justice is not promoted. Equity, in addition to Universality, Integrality and Social Control, is the structuring and articulating axis of the SUS. Equity, when looking at the differences between individuals, groups, families and communities, qualifies both the universality of care and the completeness of actions.

In this context, Social Control, from the organized movements of Civil Society, makes an important contribution in pointing out existing inequalities and in demanding public policies that consider different treatment for those who are different, while demanding what, in fact, is a necessity for the groups, as far as their needs are concerned. It is important to say that this movement is born with the Sanitary Movement, which built the Sanitary Reform process, based on values such as citizenship, democratization of health and human rights⁽¹⁾.

Given the inability of equality to treat unequal people unequally, equity has been conforming over the years, due to organized social movements, as a qualifier of equality, with the outcome being equality, itself. Depending on the pressure of heterogeneous groups, ministerial policies have been adopted to recognize and address the differences of minority groups⁽²⁾.

But, after all, how important is it to address the issue of equity in the current context? The reasons are not few, a combination of factors led the Brazilian Nursing Association (ABEn) to approach equity, such as the growing mobilization around human rights, political activism of social movements, intolerance, the struggle for respect for individual differences, increasing social inequalities between individuals, groups, geographical regions, feminism, postmodernism and eco-sustainability⁽²⁾. To where we are going matters, if we do not reflect and change behaviors that only contribute to a more hostile, inhumane, less supportive world, less committed to economic, social and environmental issues. Considering our adherence to the social-democratic ideology⁽³⁾, the posture could be different, but that of refuting the iniquities and give way to equity.

A concern that emerged almost five decades ago, with the discussion on human rights, revisited in the last twenty years by the health sector and three Brazilian Nursing Congresses, Equity enters the agenda as a possibility to promote social justice with a view on the current and future generations⁽²⁾. However, inequalities will still continue, due to existing inequalities, such as poor housing conditions, income concentration, precarious education and increasing violence, generating an impact on the disease and on which the health sector is powerless to address. When these inequalities are absent or minimized, they optimize health equity. But, these absences, despite being a challenge for nursing, should not be an obstacle for nurses to perform their work.

In this scenario, of the 71^st Brazilian Congress of Nursing, the discussion on the consolidation of the SUS principles, particularly equity, as a way of guaranteeing the Democratic Rule of Law, that is, respect for Human Rights and respect for Fundamental Guarantees.

From the methodological point of view this theoretical reflection is structured in three chapters. The first chapter presents a conceptual approach to social justice and its applicability to equity. The second chapter presents considerations on health equity. And the third chapter leads the reader to reflect on the challenges and possible ways to practice with equity, based on the five dimensions of the nursing work process.

In light of this, the objective of this article is to reflect on the principle of equity from the perspective of social justice and its applicability in the dimensions of the nursing work process.

EQUITY AND SOCIAL JUSTICE

Equity is a polysemic term that goes through all social practices, including health^(1-2,4-5). When combined with different social practices, equity has the potential to promote positive outcomes for its purposes in a mutual aid type.

Equity as justice, initially, was the study object of the Romans, who saw it in a linear way, and later by the Greeks, who added elements giving it strength to incorporate social justice⁽⁶⁾.

Equity is not unanimous in society. For liberal-conservative countries, equity has no applicability, since each citizen is responsible for themselves, their options, their choices, even becoming a state intrusion into the private life of individuals. In being responsible for themselves, individuals bear the burden and bonus of their choices. Consequently, for the conservative liberal current there is no interference with the needs of individuals, which are ignored by the state, supported by the fact that freedom and individualism are fundamental rights. Therefore, equity is not a government concern⁽³⁾.

In countries that adopt the social-democratic ideology, the needs of individuals and groups are a State’s concern, and access to the use of health goods and services is independent of their financial or social status. The needs of individuals are considered by the government. Here, the concept of equity tends to operate, because social, economic and individual differences do not determine the pattern of health consumption but the condition of vulnerability of individuals and groups⁽³⁾.

It should be noted, however, that these two ideologies do not operate as conceived. The first, perhaps due to the biological risks produced by the unequal, the second, due to the investment that the state has to make increasing its dimension in terms of social benefits⁽³⁾.

For some authors^(2,5), there should be no difference in the organization or pattern of care between groups or subgroups of society due to their demography or geography, a question of difficult resolution in our country, of continental dimensions and great differences in geographical areas; some authors^(1,3) also agree that there is a similarity between the words equity and equality from the point of view of the meaning and origin of the word, but that despite the semantic and etymological proximity to equity, both are opposed to inequality, Equity qualifies Equality. There are also those who consider that there are differences between health needs and health service needs, being distinct objects, the first related to unequal living and health conditions and the second related to the conditions of access and use of health services⁽¹⁾. In this sense, equity can be understood as a strategy that allows achieving an ideal of justice and full citizenship to equalize all citizens. If it is not a practice that takes differences into account, it will not be equity^(1,4,7).

The dialogue between law and philosophy considers Aristotle’s classical equity to be the one that addresses the correction of the law in cases where it is imperfect, considering that the law is general, the cases are peculiar. Modern equity, a concept formulated by Kant, argues that equity is not for the courts but for conscience⁽⁶⁾. Thus it can be said that both law and conscience are necessary for the practice of equity in the sense of promoting human rights.

Still in the philosophical field, Aristotle, in his Theory of Justice, points out that obedience to the laws is not enough, but human actions must go towards the benefit of society, in the universal sense. For this philosopher, equity is the correction of equality, defended by the law, which because it is universal can promote iniquity. Aristotle argues that Justice and injustice are ambiguous terms, the first one being defined as “doing what is right”, the second “doing/acting wrong and desiring what is unrighteous”⁽⁸⁾.

Equity can also be analyzed from two other aspects, namely: vertical equity, referred to inequality between the unequal, and horizontal equity, which refers to equity between equals, thus enabling an equal distribution between people with equal circumstances^(5,9). In practice we can clearly see such situations. If we take a group of older people as an example, we can have both horizontal equity if everyone is in a better socioeconomic and health condition, and vertical equity if these indicators move apart. Thus, we will have a different treatment for the same group.

These nuances allow us to understand why there is a complex operationalization in equity and it ispoorly discussed, although presented in a practical way in the daily life of health professionals in different scenarios of prevention, promotion, protection and recovery of health. It also allows us to be aware of the challenges of making it real in our nursing practices. In this sense, it is imperative to ask: How to establish strategies and criteria in which equals should be treated equally and unequal in an unequal manner? How to mitigate inequalities and promote equality? What are the criteria and indicators for measuring fairness and to whom it is fair in health care? What defines inequality as unfair?

EQUITY AND HEALTH

The decentralization process of health policy, with the implementation of SUS, created a favorable situation for the promotion of equity, even though it was not a reality for all Brazilian municipalities⁽⁴⁾.

Named, initially, Health Care Policy of Vulnerable Groups, the Health Equity Promotion Policy began around the 1970s. Supporting this process, there were the strengthening of social movements, the consolidation of the democratic process after military government, and the Federal Government’s effort to guarantee human rights by spreading access to goods and services to vulnerable groups⁽²⁾.

In the health field, equity promotion policies are strengthened in the National Health Conferences and in the policies of the Ministry of Health, through the Strategic and Participatory Management Office (SGEP). Over the past ten years, Brazil has improved the use of health services by promoting horizontal equity, that is, equality between equals. The Family Health Strategy (ESF) improved access and use of services, users had a better chance of accessing the services offered by expanding the coverage of services and actions, although insufficient to meet all demand and all their needs, requiring professionals to make subjective decisions in the distribution of care⁽²⁾.

The strategy used to make equity practicable has been the agreement of attributions with the managers, the development of joint actions and the partnership with the social parties. Three directions of action have been used as strategies to make equity promotion possible: the transversality of actions, the training of professionals and participatory management⁽²⁾.

Recognizing the transformation potential of education, the Support for Participatory Management and Social Control Department of the Strategic and Participatory Management Office

of the Ministry of Health (DAGEP/SGEP/MS) has been developing seminars for managers and distance learning courses for professionals in order to broaden the approach to vulnerable groups and promote equity policy, however, such measures are timid in view of the presented scenario⁽²⁾.

The National Human Rights Plans (PNDH) and the feeling of belonging to some segment that showed differences contributed to the principle of equality of SUS, in its genesis, would turn into the principle of equity, making inequalities visible through the lens of differences. However, contact with some health departments has shown that there are still many difficulties to be overcome, whether due to the reduced staff and the time to adhere to a policy, demanding changes in the individual and collective worldview, and in accepting the differences⁽²⁾. Add to these difficulties the absence of epidemiological profile and living conditions of populations and issues of gender and race⁽⁴⁾.

Regarding the differentiated needs of the groups, we must not lose sight of the fact that everyone has different degrees of vulnerability, so it is central to look at everyone, regardless of their peculiarities.

Egry⁽¹⁰⁾, in the light of Stephen Moore, emphasizes the conceptual and operational aspects of equity considering that the variable chance of life, by referring more to the social and economic determinants, gives a more positive response to the operationalization of actions than the risk variable that relates to biological determinants.

Equity is a challenge not only for nursing, but also for other professional categories and for the SUS⁽¹¹⁾, given its magnitude in extrapolating access to health services, to incorporate other elements, such as social, economic and environmentaldeterminants. In this way equity also articulates with the principle of integrality.

Regarding sustainability, Paim⁽¹⁾ conducted a study showing regional inequalities, the results showed favorable aspects for the southeastern region, in relation to the northern and northeastern regions of Brazil,with differences up to 50%, in both low and high complexity. Similarly, these inequalities reproduced in racial ethnic issues, where black and indigenous populations were also disadvantaged in access to health services compared to other populations.

It should be considered that this scenario has motivated several initiatives to reduce inequalities in the Brazilian health system, for example, the implementation of the Primary Care Budget (PAB), and, more recently, the new National Primary Care Policy (PNAB), which enacts the situation already legitimized by the Amazonian populations in response to their geographical differences, such as the Basic Health Units (UBS), the “ambulanchas” (ambulance boat), in an attempt to provide access to SUS principles, in different scenarios.

There could be a discussion here about eco sustainability and equity, about aspects always referred to thedifferences of the northern region, and its challenges, to which SérgioArouca suggests a green SUS, that articulates different ways of assisting the population without violating the principles of the Brazilian health system. Naturally, measures must be adopted for the rational use of existing resources and the conscious and rational use of the environment, which will guarantee future generations an environment in better conditions than negative predictions point out so far. The subject is complex and requires a deepening, but different limitations do not allow it at this time.

The reflections made so far allow us to infer that despite the breadth and diversity of health services provided by SUS, there are still inequalities in access to services by segments of the Brazilian population, lacking the example of the education sector with positive discrimination measures. It is understood that this is a multifactorial problem that involves structure, professional qualification, working conditions, population factor, territorial extension, sense of belonging, cultural and geographical differences, geographical access and political commitment.

EQUITY IN NURSING PRACTICE

In the light of the reflections raised, we chose as a starting point the following questions for nursing: to which ideology of equity are we affiliated, liberal/conservative or social/democratic? Does equity for us extrapolate the radicalism of the eye for the eye, the tooth for the tooth, or does it challenge us to relativize, to exercise solidarity, and to give voice to consciousness? How have we faced our differences? What brings us closer and what makes us apart geographically and demographically between regions? What is the contribution of nursing in the face of these challenges?

The dimensions of the Nursing Work Process, educating, assisting, researching, participating politically and managing, suggested by Sanna⁽¹²⁾, help us in facing the challenges for a practice with equity.

In the field of health education, the challenge of nursing is on that Vicent Valla says “not to blame the victim”, that is, individuals and the community, due to their socioeconomic and sanitary condition, their ethnic racialorigin and gender attributing responsibilities without access to equity of opportunities, without offering equal conditions, which justifies the adoption of positive discrimination mechanisms⁽¹⁰⁾.

In the field of training human resources for health, as teachers and students, to detach from prejudices introduced since childhood about what is different, what causes us strangeness, which leads to a discriminatory judgment, that is, diminishing: race, ethnicity, lifestyle, sexual orientation, gender identity, are some by examples.

In the field of care, providing quality nursing care without being aware of the differences that will require unequal treatment for the unequal and equal for the same. Contribute to the construction of equity promotion policies by aggregating knowledge of the specificities of groups and their heterogeneity. Provide care to clients without paternalism, discrimination or privileges. Sensitize peers to good equity care practices by offering more care to those most in need and less to those requiring less care.

In the field of research there is a need for nursing to address the issue in order to substantiate its practices, both from the point of view of the using the knowledge already produced, as well as research for the production of new knowledge, based scientific evidence and nursing advanced practices. Asystematic observation showed how equity is poorly researched and how little it is identified in daily nursing practice. The investigation of this theme is necessary, since the research qualifies the health practices. An example of this essentiality is referred to research on sex and gender because they are health determinants⁽¹³⁾.

In the field of political participation, there is much to do. Of the five dimensions of the nurse’s work process, this is the least applied. The issues that include equity are both passionate and controversial, because they involve values, self-esteem, prejudice, feelings of superiority and inferiority. On the other hand, those who treat it as politics are challenging because they develop the ability to think critically, to make changes; also demotivating and excusing, but necessary in the process of building the Democratic Rule of Law. It is in the field of political participation that the guidelines for reducing inequalities in the formulation of equity promotion policiesare forged.

In the managing field, the nurse as the leader of the nursing team should be alert in order to understand the difference between equals and unequal, contributing to meet needs equitably andthrough permanent education by the team members for that view. In addition to their work with the nursing staff, they must know, execute and contribute to the formulation of policies to promote health equity with their peers and at higher levels.

In all dimensions of the Nursing work process, there is the need to know individuals and families under our care, in order to enable us to identify situations of vulnerability and our potential for intervention that results in positive discrimination.

FINAL CONSIDERATIONS

Returning to what we set out for the purpose of this study, we consider equity as a matter of social justice, highlighting some challenges that we believe to be common to all fields of knowledge. These challenges encourage us to look at the philosophical principles of Aristotle and Kant, withthe attention they deserve: equity qualifies equality/is the correction of justice and is out of court, being a matter of consciousness.

To look at equity from the perspective of social justice is to consider the differences in heterogeneity, multiplicity, plurality of society, which makes us more human. To look at equity from the point of view of consciousnessis to give up our self-centeredness, paternalism, protectionism and to walk miles beyond what is proposed to us.

The principle of equity is articulated by the SUS, being a sensitive indicator of health policies, effectively one of the most desirable, across all social policies. It has applicability in all dimensions of the nursing work process, namely: assisting, managing, teaching, researching and participating politically.

In this sense, nursing needs to act based on the implementation of policies to promote equity to address vulnerability situations, contribute to other social policies and other fields of knowledge, as well as training professionals with this view to daily carewith heterogeneous groups, individuals, family and community.

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Edited by

EDITOR IN CHIEF: Dulce Aparecida Barbosa

ASSOCIATE EDITOR: Antonio José de Almeida Filho

Publication Dates

• Publication in this collection
  22 Apr 2020
• Date of issue
  2020

History

• Received
  06 June 2019
• Accepted
  04 Nov 2019