Nursing and the national policy of education for health care professionals for the Brazilian national Health System

Abstracts

O presente artigo tem por objetivo identificar aspectos e características da formulação e implementação da política nacional de gestão da educação na saúde, ao longo dos últimos 6 anos, destacando a participação e o papel central da graduação e da profissão da Enfermagem como campo de conhecimento estruturante da gestão do cuidado e do processo de trabalho na saúde. Ressaltam-se os avanços e desafios atualmente colocados para a consolidação do SUS e o papel da articulação entre os gestores da saúde e da educação, e do estabelecimento da articulação interfederativa para o sucesso das iniciativas em curso.

Educação superior; Educação em enfermagem; Sistema Único de Saúde; Atenção Primária à Saúde; Recursos humanos em saúde

REFLECTION

Nursing and the national policy of education for health care professionals for the Brazilian national Health System^*

La enfermería y la Política Nacional de Formación de Profesionales de Salud para el SUS

Ana Estela Haddad

Ph.D., Professor of the Department of Orthodontics and Pediatric Dentistry, Faculty of Dentistry, University of São Paulo. Director of the Programs of the Ministry of Health, Department of Health Work and Education Management. São Paulo, SP, Brazil. [e-mail]

^{Correspondence addressed to}

ABSTRACT

The objective of the present article is to identify the aspects and characteristic of creating and implementing the national policy for the administration of health education, over the last six years, with particular emphasis on the central role of nursing undergraduate studied and the profession as a field of knowledge that structures the management of care and the working process in health. The advancements and the current challenges that are posed to implement the National Health System and the role of connecting health care and education administrators and establishing an interfederal network to assure the success of the ongoing initiatives.

Descriptors: Education, higher; Education, nursing; Unified Health System; Primary Health Care; Health manpower

RESUMEN

El presente artículo tiene por objetivo identificar aspectos y características de las formulaciones e implementación de la Política Nacional de Gestión de la Educación en Salud a lo largo de los últimos seis años, destacando la participación y el rol central de la carrera y la profesión de Enfermería como campo de conocimiento estructurador de la gestión del cuidado y del proceso de trabajo en la salud. Se resaltan los avances y desafíos enfrentados en la actualidad para la consolidación del SUS y el papel de la articulación entre los administradores de salud y de la educación, y del establecimiento de la articulación inter-federativa para el éxito de las iniciativas en curso.

Descriptores: Educación superior; Educación en enfermería; Sistema Único de Salud; Atención Primaria de Salud; Recursos humanos em salud

The current government of president Dilma Roussef has established the priority of eradicating absolute poverty, allied to social and economical development, to the defense of citizenship and human rights and to the improvement of infrastructure across the country, through the Growth Acceleration Program (Programa de Aceleração do Crescimento - PAC). Achieving the established objectives depends on the state's capacity to formulate, produce and manage social and economical advancements and transformations.

Health stands in the central agenda of the new government. In May 2011, an especial edition of The Lancet was published, containing a series of exclusive articles regarding health in Brazil and the results, advances and challenges of the National Health System (Sistema Único de Saúde - SUS). The editors introduced the subject reporting that the country, since this January, has for the first time been governed by a woman, President Dilma Rousseff. Furthermore, they address the outstanding position that Brazil has assumed, i.e., the position of the 5^th economy of the world, with an economical growth rate that has achieved 7.5% last year⁽¹⁾. The editorial also mentions that, in 1989, Brazil was one of the countries with the largest inequality rates in the world, and that over the last two decades, the SUS has significantly improved people's accessibility to primary and emergency health care.

Regarding the Millennium Development Goals (MDG), the referred journal reports there was a 50% decline in the number of children born at a low birthweight and a two-thirds reduction in the mortality rate of children aged five years or younger. The editors weighed that there are still many challenges ahead, e.g. the relationship between the public health system and private systems associated with supplementary health, the high rates of caesareans, the unreasonable use of high technologies, which, among other consequences, increase the cost of the health system. They conclude that the strong emphasis on health as a political right, allied to the level of engagement of civil society, were decisive factors for the achievements of the SUS, which can inspire other countries in solving their health issues. Furthermore, that health sectors and researchers should carefully look at Brazil as a country that was capable of implementing deep reforms, and managed to place the equity of health care in the core of the national policy.

The national health policy is being formulated and implemented with the first and utmost goal of offering accessibility and quality embracement to the SUS healthy system to the whole population. Considering the direction assumed, the established strategy was planned with the priority to advance in the implementation and consolidation of the health care networks, with primary care as the major entrance door and the one setting order in the network (Ordinance MS nº 4.279/2010)⁽²⁾. They should be strengthened and connected to the maternal-child, emergency, and psycho-social health care networks.

Decree number 7,508, promulgated this year, regulates part of the Organic Health Law (Law number 8,080/11990), and establishes essential elements to improve the work of the SUS and its principles and guidelines, focused on the importance of the interfederal pact⁽³⁾. The national health policy an the outlined strategic objectives should advance in the contexts of the health regions, based o the organizing organizational contracts for public action (contratos organizativos de ação pública - COAP), in the priorities identified considering the sanitation map, and be agreed upon at the intermanagers commissions.

One of the priority branches of the national health policy is the management of health and work education, which is characterized by its aspect of transversality compared to the other sectors. One milestone of the movement for the valorization of health workers in Brazil was the creation of the Health Work and Education Management Department (Secretaria de Gestão do Trabalho e da Educação na Saúde –SGTES), in 2003, through Decree 4,726 of June 9^th, 2003 in the regimental structure of the Ministry of Health, as one of the Purposive Departments in charge of formulating and implementing the national health policy.

The SGTES has the mission to develop policies and programs that seek to assure the universal and equal access to health care, implying the role of work education and management, the responsibility for the qualification of workers and for organizing health work, comprising new professional profiles able to answer the real health needs of the population and of the SUS⁽⁴⁾.

In the educational guidance plan, the bases for this policy follow the principles of the education policy and the contemporary tendencies of education that address the educational processes as a scientific technical, ethical and critical-operational movement for the social development, interaction and production where the dynamics of learning results from the multidimensional and interdisciplinary knowledge as well as the connection with the process of service provision.

The paradigmatic axes that aligns and organized the health education policy is the integration between education and the SUS system network instituted as a pedagogical act that brings health network professionals closer to the pedagogical practices and teachers closer to the health care processes, thus permitting the innovation and transformation the processes of teaching and health service provision⁽⁵⁾.

Allied to the re-orientation of education, the National Policy for Permanent Health Education (Política Nacional de Educação Permanente em Saúde - PNEPS) consists of one of the structure pillars of the organizational improvement of health services⁽⁶⁾. Permanent education is learning based on the working process, where teaching and learning are incorporated to the everyday routine of organizations and health work⁽⁷⁾. In August 2007, Ordinance GM/MS number 1.996 was published, stating the new guidelines and strategies for the development of the development of the National Policy for Permanent Health Education⁽⁸⁾. This Ordinance reinforces the strategic importance of decentralizing and regionalizing the System, and is aligned with the guidelines for the Health Pact. The financial resources are no longer centralized in the Ministry of Health and are now transferred in a regular and automatic fashion from the National Health Fund (Fundo Nacional de Saúde - FNS) to the respective State and Municipal Health Funds, according to the agreement among the management departments of the SUS, which include the Bipartite Intermanagers Commission (Comissão Intergestores Bipartite - CIB) and the Regional Management Commission (Colegiado de Gestão Regional - CGR). Furthermore, it should also be highlighted that the development of the health education management function is a tripartite responsibility, and that advancements and commitments must be made effective in each management domain of the SUS in order to assure the funding of this area⁽⁸⁾.

The major advancements in the implementation of the Permanent Health Education Policy, in terms of the aforementioned strategies are:

• emphasis on decentralization (in the processes of approving, implementing and funding this policy);

• establishing a participative management model for decisions and actions in health education;

• strengthening the role of state departments in the functions of policy management, coordination and supervision;

• focusing on local and regional specificities and needs;

• strengthening the current commitments in the 2006 Health Pact;

• adding the Permanent Health Education plan to the already existing SUS planning instruments (health plans, management report, etc), assuring the participation of social control in the construction of policy guidelines in the different management domains of the SUS, including in controlling its implementation.

Permanent education is being consolidated and incorporated to the health management agenda as the axis integrating education and work, supported by the function performed by the Teaching-Service Integration Commissions (Comissões de Integração Ensino-Serviço -CIES) implemented in the logic of regionalization.

While addressing Higher Level Education and Health in Brazil, an author⁽⁹⁾ states that the health workforce in Brazil consists of 1.5 million workers, most of which are public servants (52% of the nurses, 44% of the physicians, 27% of the dentists, 11% of the pharmacists, and 10% of the psychologists). Another study⁽¹⁰⁾ also states that there are 3,493 undergraduate courses in the health area in Brazil, 185 of which are medicine courses, with 97,994 enrolled students. The author mentions the challenges and difficulties that are dealt with in the education of health professionals in Brazil and states the following important overcoming factors: The Program for the Reform and Expansion of Federal Universities (Programa de Reestruturação e Expansão das Universidades Federais - REUNI), which brings Brazilian higher education closer to the guidelines established by the Bologna Process, and doubles the number of seats in public universities, among other improvements; and the Pró-Saúde (Pro-Health) Program – the National Program for the Redirection in the Education of Health Professionals (Programa Nacional de Reorientação da Formação Profissional em Saúde), which invests in the reorientation of education to meet the demands of the SUS by health professionals with a more humanist education, and who are committed with society, oriented towards the broader health concept, focused on primary health care.

Researchers⁽¹¹⁾ reaffirm the need for qualified health professionals to duly answer a complex health system as the SUS. In quantitative aspects, they refer to the data of year 2007, which report that Brazil had 1.7 physicians, 0.9 nurses, and 1.2 dentists for every 1,000 people, who were unequally distributed, with a high concentration in the southeast and south regions of the country. The authors mention that the accelerated growth in the number of enrollments, which, in 2008, accounted for 90,000 Medicine, 220,000 Nursing and 50,000 Dentistry students. They highlight that the Ministries of Health and Education are making strong investments to increase the focus of undergraduate courses on primary health care (in a reference to the Pró-Saúde Program and the Education Program for Health Work - Programa de Educação pelo Trabalho em Saúde - PET Saúde). They also state the investment that Brazil has made on the education and qualification of technical workers (primary and secondary level) through the National Program for the Education of Secondary Level Health Professionals (Programa Nacional para Formação de Profissionais de Nível Médio para a Saúde - PROFAPS). Among the challenges that need to be overcome, the authors understand that the major ones are: the bad distribution of the professionals across the many regions and cities, the high turnover of professionals at the services, the lack of career plans, and different salaries across the regions, states and cities.

Two studies performed during the early period preceding the implementation of the process of reorienting health education in, 2006, were benchmarks for their formulation and implementation: the study about the trajectory of health undergraduate courses and the study about the adherence of Medicine, Nursing, and Dentistry undergraduate courses to the National Curriculum Guidelines.

In the first study, performed between 2005 and 2006, the data from the Annual Census of Higher Level Education referring to the education of health professionals were highlighted and analyzed together by the Ministries of Health and Education, which resulted in the publication A Trajetória dos Cursos de Graduação na Área da Saúde (The Trajectory of Undergraduate Courses in the Health Area)^(10,12). Among the conclusions presented in this study, it is verified that:

• the demand for Health professionals can be understood in different dimensions, from their quantitative and qualitative aspects to the regional distributions of the professionals in the search to reduce the unequal accessibility to health services and actions;

• the need to reduce regional imbalances, in order to encourage the opening of slots, as well as to create work posts, observing both the established and desired capacity.

• the demographic and epidemiologic transition has been changing the population's needs and demands for health care, indicating the importance to connect professional education and the organization of the health system;

• the need to seek the approximation between health services and institutions that prepare professionals with higher level education; the expansion and consolidation of the implementation of the National Curriculum Guidelines of Graduate Courses, permitting to make changes in the concept and profile of the professionals, graduates from Higher Education Institutions, directed to the comprehensive care for people, families, social groups, and communities.

Analyzing the data from the Higher Education Census of the Anísio Teixeira Institute of Educational Studies and Research (Instituto de Estudos e Pesquisas Educacionais Anísio Teixeira - INEP), in 2004, it is verified that nursing undergraduate courses, from 1996 to 2004, had the second greatest growth in number of enrollments, among 14 health professions, following the Physiotherapy courses (Table 1).

Another study, performed by the Department of Health Education Management in the Health Work and Education Management Department of the Ministry of Health (DEGES/SGTES/MS) through a partnership with the Ministry of Education by means of the INEP, had the purpose to analyze the adherence of Nursing, Medicine and Dentistry undergraduate courses to the National Curriculum Guidelines⁽¹³⁾. The initiative was considered timely at the time that the Pró-Saúde Program was beginning to be implemented in these courses, and the study could serve as a baseline reference, about the current stage of this group of courses, in a way that, in the future, after the implementation period of the projects had been completed, it would be possible to perform a better evaluation of its impact. For the study, a group of professors and researchers from the three areas analyzed the pedagogical projects and the evaluation reports (National Evaluation System for Higher Education - Sistema Nacional de Avaliação da Educação Superior – SINAES/INEP/MEC) of the undergraduate courses in these areas, implemented after the introduction of the National Curriculum Guidelines, i.e., 2001 for Medicine and Nursing, and 2002 for Dentistry. Based on the analysis compared between the political-pedagogical projects and the evaluation reports of the courses, it was concluded that, in most cases, the National Curriculum Guidelines, despite being referred in the pedagogical projects, in general, were not yet incorporated or reflected in the implementation of the courses. These findings reinforce and served as evidence to justify the political decision that was made regarding the prioritization of the implementation of the Pró-Saúde Program.

Five years after the development and implementation of the actions and programs to reorient the professional education in health, it is observed that Nursing emerges as the profession that has the most central connection with healthcare management.

In the Pró-Saúde Program, of the total 379 undergraduate courses among the 14 health professions participating in the program, 70 courses are in Nursing, which is, thus, the profession with the highest number of participating courses.

In the Family Health PET Program, Nursing increased from 73 participating courses in 2009 to 96 courses approved through the second request for proposal (RFP), valid for 2010 and 2011.

In the Health Surveillance PET and the Mental Health PET Programs, Nursing is the course with the highest participation, 62 and 64 courses, respectively^(4,14).

One recent initiative associated with the pedagogical orientation axis of the Pró-Saúde Program, through a partnership with the Coordination for the Improvement of Higher Education Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES/MEC), referred to as the Pró-Ensino Program (Pro-Teaching) –the National Program for the Development of Faculty in Health (Programa Nacional de Desenvolvimento Docente em Saúde), consists of the support to the education and training of professors, strengthening the lines of research that involve the teaching-learning process in the health area.

Figura 1

Figura 2

The Pró-Ensino Program resulted from the evaluation and supervision of the implementation of the Pró-Saúde and PET Health Programs, particularly from the perception of the great challenge posed for the faculty, which was not prepared to deal with the new dimensions included in the reorientation of education, represented by the teaching-service integration, the active methodologies of the teaching-learning process, by the multiprofessional teamwork since graduation, among others.

Regarding the education of professors and researchers, graduate programs are academic activities of unquestionable legitimacy and acknowledgement in Brazil. Therefore, it is essential that this domain of activity also be committed to the consolidation with the SUS.

The Ministry of Health and the Ministry of Education were, through a partnership, responsible for the regulation and acknowledgment of the multiprofessional and specialist residencies in the health area. Based on Law number 11,129 of 2005, several measures were implemented, following a continuous process of interlocution with organized civil society, which resulted in the institution of the National Commission of Multiprofesional Residency in Health (Comissão Nacional de Residência Multiprofissional em Saúde - CNRMS), connected to the MEC, responsible for the regulation, evaluation and supervision of this modality of education in the country. At the same time, the Ministries comprise funding lines made available though RFPs for the programs, based on the priority health policies, the population's health needs, also considering the local-regional specificities.

Figura 3

Figura 4

The set of actions listed herein, together with the other measures that comprise the multiple strategies of the management of health work and education, are founded on the integration between teaching and service, on the multidisciplinary teamwork, connected intra and inter-institutionally, based on interdisciplinary and sociocultural knowledge. Thus, the purpose is to develop projects and programs that associated the epistemological basis of health and education, introduce curriculum plans aimed at the priorities expressed on the epidemiological and demographic profiles and the social determinants of each region in the country, and induce the preparation of learning environments in inter-sector settings. This construction, political and technical, of health education takes place as of the inter-ministry connection between the Ministry of Health and the Ministry of Education⁽¹⁵⁾, establishing and meeting common agendas, such as: health and education managers, representatives of the health and education institutions (Technical Schools with the SUS, Higher Education and Research Institutions); health professional organizations and representatives of organized social movements.

REFERENCES

Received: 11/02/2011

Approved: 11/10/2011

Acknowledgement

To the management, evaluation and consulting teams of the Ministry of Health Department of Health Work and Education Management and all other management teams of the Ministry of Health, Ministry of Education, CONASS, and CONASEMS, from 2005 to 2011, which were, together, responsible for the formulation, implementation, supervision and evaluation of the national policy for health education management.

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• ²
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• ³
  Brasil. Decreto n. 7.508, de 28 de junho de 2011. Regulamenta a Lei n. 8.080, de 19 de setembro de 1990, para dispor sobre a organização do Sistema Único de Saúde - SUS, o planejamento da saúde, a assistência à saúde e a articulação interfederativa [Internet]. Brasília; 2011 [citado 2011 jul. 28]. Disponível em: http://www.planalto.gov.br/ccivil_03/_ato2011-2014/2011/decreto/D7508.htm
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• ⁸
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• 13. Haddad AE, Ristoff D, Passarella TM. A aderência dos Cursos de Graduação em Enfermagem, Medicina e Odontologia às Diretrizes Curriculares Nacionais. Brasília: Ministério da Saúde; 2006.
• 14. Haddad AE. A Odontologia na Política de Formação dos Profissionais de Saúde: o papel da teleodontologia como ferramenta do processo de ensino-aprendizagem e a criação do Núcleo de Teleodontologia da FOUSP [tese livre-docência]. São Paulo: Faculdade de Odontologia, Universidade de São Paulo; 2011.
• ¹⁵
  Brasil. Decreto-Lei n. 263, de 20 de junho de 2007. Institui a Comissão Interministerial de Gestão do Trabalho e da Educação na Saúde [Internet]. Brasília; 2007 [citado 2011 jul. 20]. Disponível em: http://dre.pt/pdf1sdip/2007/07/13900/0461504634.PDF

Correspondence addressed to:

Ana Estela Haddad

Av. Prof. Lineu Prestes 2227 - Cidade Universitária - Butantã

CEP 05508-900 - São Paulo, SP, Brazil

*

Study presented at the Round Table "O Ensino e a Pesquisa de Enfermagem em Saúde Coletiva frente à Consolidação do SUS", 2º Simpósio Internacional de Políticas e Práticas em Saúde Coletiva na Perspectiva da Enfermagem – SINPESC, School of Nursing, University of São Paulo, São Paulo, October 9th-11th, 2011.

Publication Dates

• Publication in this collection
  04 May 2012
• Date of issue
  Dec 2011

History

• Received
  02 Nov 2011
• Accepted
  10 Nov 2011