Strengthening the leadership of the Commission on Education-Service Integration for permanent health education

Abstract

OBJECTIVE

To know the performance of universities in the Permanent Commission of Education-Service Integration in the West Region of Santa Catarina, with a view to strengthening its role in the development of continuing education initiatives in health.

METHODOLOGY

Convergent Care Research developed in the first half of 2014, involving interviews with university professors, workshops with the Technical Board of the Permanent Commission of Education-Service Integration and participation in meeting with representatives of the Region.

RESULTS

Three categories were identified concerning the role of universities in the development of health education actions, as well as the role of the Commission as a favourable space to the articulation of these institutions.

FINAL THOUGHTS

Universities play a key role in the development of permanent education actions in health, considering the reality of the territory and services, as well as demands and potential of the actors involved, which favours the teaching-service integration in the Region.

Keywords:
Continuing education; Nursing research; Teaching-care integration services; Higher education

Resumo

OBJETIVO

Conhecer a atuação de universidades junto à Comissão Permanente de Integração Ensino-Serviço da Região Oeste de Santa Catarina, com vistas a fortalecer seu protagonismo no desenvolvimento de iniciativas de educação permanente em saúde.

METODOLOGIA

Pesquisa Convergente Assistencial desenvolvida no primeiro semestre de 2014 envolvendo entrevistas com professores universitários, oficinas com a Câmara Técnica da Comissão de Integração Ensino-Serviço e participação em encontro com representantes da região.

RESULTADOS

Foram identificadas três categorias relativas ao papel das universidades no desenvolvimento das ações de educação em saúde, bem como ao papel da Comissão de Integração Ensino-Serviço como espaço favorável à articulação dessas instituições.

CONSIDERAÇÕES FINAIS

As universidades assumem papel fundamental no desenvolvimento de ações de educação permanente em saúde, considerando a realidade do território e dos serviços, bem como demandas e potenciais dos atores envolvidos, o que favorece a articulação ensino-serviço na região.

Palavras-chave:
Educação continuada; Pesquisa em enfermagem; Serviços de integração docente-assistencial; Educação superior.

Resumen

OBJETIVO

Conocer la participación de universidades junto a la Comisión Permanente de Integración Enseñanza-Servicio de la Región Oeste de Santa Catarina, para fortalecer su protagonismo en el desarrollo de iniciativas de formación permanente en materia de salud.

METODOLOGÍA

Investigación Convergente Asistencial desarrollada en 2014, incluyendoentrevistas a profesores universitarios, talleres con el Consejo Técnico de la Comisión de Integración Enseñanza-Servicio y participación en reunión con representantes de la Región.

RESULTADOS

Se identificaron tres categorías relativas a la función de las universidades en el desarrollo de acciones de educación para la salud, así como el papel de la Comisión de Integración Enseñanza-Servicio como espacio favorable para la articulación de estas instituciones.

CONSIDERACIONES FINALES

Las universidades desempeñan un papel fundamentalen el desarrollo de acciones de educación permanente en salud, considerando la realidad del territorio y de los servicios, así como demandas y el potencial de los actores involucrados, lo que favorece la integración enseñanza-servicio en la región.

Palabras clave:
Educación continua; Investigación en enfermería; Servicios de integración docente asistencial; Educación superior.

Introduction

In Brazil, permanent education is approached differently in the health field from 2004 on, when the Ministry of Health, through Decree 198, implants a specific policy regarding the theme: the National Policy for Permanent Education in Health (PNEPS). This policy expresses the debates conducted regarding the training of human resources for the health field, following a constitutional direction concerning the responsibility of the Unified Health System (SUS) to guide training in this area. The focus of this policy was strengthening the articulation between health services and teaching institutions, to generate more adequate answers to the needs of the Brazilian population^1-2.

According to Lemos¹, the PNEPS guided the implementation of changes in the work process at SUS in three different axis: the world of work as a space of conformation to new subjectivities; the wheel as a device for shared, horizontal and solidaristic management; and meaningful learning, that which puts the student and the worker in the driver’s seat of the learning process.

Permanent education health processes must contribute to the changing of professional practices and to institutional improvement relative to the organization of work. This demands educational processes that promote the problematization of the work process, observing health needs that individuals and populations face in their day-to-day lives, considering their knowledge and experiences³. Staying coherent to the principles and guidelines of the Unified Health System (SUS), permanent health education aims to support the organization of the work targeted at integral health attention and at the building of chains of progressive health care, consolidating the idea of attention networks that articulate health services in all attention levels, “recognizing life contexts and stories and ensuring proper reception and accountability of the health problems of people and populations”³. As the practices of health care workers are being guided thus, such educational processes favor them to transcend their comprehension and activities, contributing to a production of knowledge that is more favorable to the articulation of curative, preventive, and health promotion activities⁴.

In 2005, the changes that took place in the administrative structure of the Ministry of Health, and as a consequence, in the Secretariat of Work Management and Health Education (SGTES), the organ responsible for coordinating and making viable the implementation of the PNEPS, brought substantial changes, that reverberated in its guidance^1-2,5). In 2007, through Decree GM/MS nº 1996, the PNEPS redefined its guidelines and strategies, to be aligned with the Pact for Health², which established a greater commitment of the shared management of SUS, partnered with other social and institutional actors in the definition of priorities and strategies for the development of permanent education in the different spaces, for the social construction of health³. However, some authors indicate that important losses and discontinuities were generated by initiatives aimed at reorganizing this Policy, among which the decentralized management of resources and the role attributed to managing instances, which were no longer deliberative, but consultative instances^1,5.

The Decree GM/MS Nº 1996/2007 reiterates permanent education as “a pedagogical concept, in the health sector, to conduct organic relationships between teaching, actions and services, between teaching and health care, which was broadened, in the Brazilian Sanitary Reform, to embark relationships between training and sectoral management, institutional development and social control in health”³. From this perspective, it involves a square formed of four sides that represent different social subjects, that in turn are involved in the process of teaching and health care: managers, workers, educators and social control, promoting the construction of shared management of health education that integrates the management of the health system⁶.

The new PNEPS Decree instituted the Regional Inter-management Committee (CIR), formed by a group of managers of the cities in a specific region, responsible for the coordination of the elaboration of the Plans of Regional Action for Permanent Health Education (PAREPS), partnered with the different social segments³. In turn, the CIRs must promote the creation and support the actions of Permanent Commission of Teaching- Service Integration (CIES), which have among their attributions the need to offer support to the CIR in the building of the PAREPS, articulate institutions to propose intervention strategies on the field for the training and development of workers, and contribute to the follow-up, monitoring and evaluation of permanent education actions in health, to be implemented in the covered region³.

The CIES is composed by the state and municipal health and education managers, workers of the SUS, teaching institutions with courses on the health area, and social movements connected to the management of public health policies and social control at SUS. The CIES is supposed to work as an interinstitutional and regional instance for the co-management of the PNEPS, in the elaboration of projects for the change in the training and development of the workers, to improve the assistance offered and the reorganization of health services³.

To plan and execute educational actions, the PNEPS states that regional specificities should be considered, “needs for training and development for health work and the already installed capabilities of institutional offers of formal actions of health education”³. On the other hand, so that education can bring effective change to the practices and to the organization of health services, an articulation between these services and teaching institutions is paramount, so they can ensure an approximation between the reality of work and the contents of an education in health^2,5.

In this sense, the question that guides this study refers to the contributions of universities in the implementation of PNEPS, and aims to describe the actions of universities in the development of permanent education actions in health, and how these are articulated with the CIES in the West Health Region of the State of Santa Catarina.

Methodology

This study was born from the End of Course Paper (TCC)⁷ presented to the Nursing Course of a community university of the West Region of the State of Santa Catarina, which aimed at strengthening the management of permanent health education in the Region under the coverage of the Western CIR of Santa Catarina. The work being considered was developed in the first semester of 2014, and the methodology it adopted was the Convergent Research of Care (PCA), whose aim is to get to know the reality under study, seeking to contribute with the production of changes and the introduction of innovations in health practices. From this perspective, the researcher is committed, together with subjects that are implicated in the reality being studied, to generate interested knowledge, so that it can support changes in the process of care, regarding possible types of action and the established interaction relationships⁸.

When it is used by nursing, the PCA includes, managerial, educational, and care-related activities as a part of its investigative process. To be consolidated, however, it requires the application of a group of techniques of data generation and collection, following the strict rules and other criteria of scientific researches. The implementation of the PCA is developed in five phases: conception, instrumentation, scrutiny, analysis and interpretation⁸.

In the conception phase, the subjects and place of the study are defined, as well as the problem and the research questions, and the general and specific objectives. In this study, the subjects were members of the Technical Chamber of the Western CIES of Santa Catarina and seven teachers from three universities of the municipality, indicated by representatives of the institutions in the Technical Chamber of the CIES. The place chosen was the CIES Technical Chamber, as institutionalities, and the physical space the Regional Health Management (Gersa) of the West of SC. It should be highlighted that the Technical Chamber is formed by three representatives of three universities, the Gersa, the Association of Municipalities from the Microregion of Western Santa Catarina, by the Health Secretariat of two municipalities from the Region, and by health professionals, to a total of 13 participants. On the other hand, the CIES is constituted by representatives from 25 municipalities of the Region, representing the four sides: teaching, management, workers and users of the health system.

In the instrumentation phase took place meetings with the Technical Chamber of the CIES, interviews with the teachers and participation in the organization and conduction of a workshop with representatives from the CIES. In addition, observation and document readings were the performed techniques of data collection. The scrutiny phase is the application of techniques, starting by the reading of the Municipal Health Plans of the 25 municipalities, to identify the inclusion of the theme “permanent education” among their priority objectives and goals, as well as the reading of minutes and other CIES documents, relative to the period from 2008 to 2013, seeking to identify its historical path and the actions of the teaching institutions in this trajectory. After that, three meetings were conducted with the Technical Chamber, focused on the debate regarding challenges and potentialities of the actions of the CIES in the Region, on the definition of strategies for their strengthening, including the support to the organization and the conduction of a workshop for the definition of the Regional Action Plan for Permanent Health Education (PAREPS), in which 66 representatives of the municipalities that are a part of the Western SC CIR. In this activity, the observation technique was also used, focusing on the interactions established and on the role that teaching institutions have in the institutionalized CIES spaces. The third activity consisted of interviews with seven professors from the three universities, headquartered at the municipality of Chapecó, which offer courses in the field of health, aiming to understand how is it that permanent education is approached in teaching, research and extension activities in their institutions, and how these articulate with the CIES.

In the analysis phase the technique of thematic analysis, indicated by Minayo⁹, was applied, guided by the objectives proposed in the conception phase of the project. The thematic analysis consists in the floating reading of the data; the organization and systematization of meaningful registration units; the coding and organizing of groups of meaning, from which, finally, categories that are relevant to the study are extracted. According to the PCA data collection and analysis should happen simultaneously, integrated to the practice of care, in such a way that the researcher can intervene and/or offer interventions throughout the process, whenever problems or relevant potentialities are identified, or even gaps or failures that can offer space for the introduction of changes and/or innovations⁸. Finally, the interpretation phase is the synthesis, theorization and transference of results, to confer meaning to the findings and relate them to similar situations, as to highlight possible contributions they may offer to the qualification of health care.

In this article, one of the categories defined in the analytical process was chosen -subjects and organizations of the four sides of permanent health education in the Region -, which integrates three sub-categories related to the actions of the universities in this context: the role of the universities in the development of health education actions; health education actions developed by the universities through the CIES; the CIES as a space that favors the articulation of universities in the Western Health Region.

The project was approved by the Committee for Ethics in Researches Involving Human Beings of Unochapecó, under protocol nº 031/CEP/2014, and all the recommendations of the Resolution CEP/CNS 466, from December 12, 2012, were respected¹⁰. Aiming to respect the secrecy of the identity of the participants, the statements of the subjects are identified by acronyms upon which interviewers and interviewees agreed.

Results and Discussion

The CIES of the Western Macro-region II of Santa Catarina was constituted in June 2008, when a Center for Permanent Education in Health was created in the Region, according to the guidance of the management team responsible for the EPS in the State of SC. In the composition of the CIES there are: representatives of the four sides (health and education management, work, teaching and social control) from each of the 25 municipalities that compose the CIR; representatives of non-governmental organizations and universities of regional scope; representatives of the western Santa Catarina Regional Health Management (Gersa) and of the Association of the Municipalities of the Western Macro-region of Santa Catarina. It should be highlighted that Chapecó counts, currently, with four higher teaching institutions - two of them public and two community colleges - that offer courses in the health field, contemplating 11 of the 14 professional categories recognized by the Ministry of Education as belonging to this field. Until 2011, the coordination of the CIES was conducted by representatives of Gersa, when it started to be performed by representatives of the teaching field, with the help of a vice-articulator, a professional linked to Gersa¹¹.

The continuity of the activities of the CIES was disrupted in several moments, depending on the comprehension of the managers regarding their role, especially that of who was responsible for the coordination of the Regional Inter-management Comission (CIR), as well as for the Gersa, whose space shelters the meetings. It stands out that the CIES is an interdependent instance, whose actions require pacts between the interested organizations, as well as the articulation with the state government instances, responsible for the approval of the PAREPS and the division of federal resources in the Stat, as effective support from the CIR and the municipal managers. According to those interviewed, during 2013 there were no encounters of the CIES or its Technical Chamber, due to a lack of support from the CIR, which did not make the realization of planned events viable, although there were resources available to that end. This lack of articulation was also evidenced in the analysis of the minutes, as well as by the findings that the Technical Chamber needed restructuring, one of the problems mentioned in the beginning of this study.

In a study conducted in the state of Rio Grande do Sul in 2010, the authors found the lack of evidence of participation and support from managers to be a limiting factor for the operationalization of permanent education actions proposed by the CIES. The lack of knowledge of the managers regarding what is permanent health education and the importance of educational practices to qualify health assistance has generated, often sub-repticiously, obstacles that weaken or prevent its implementation in the region^4,12.

In 2014, the west CIES of SC started its restructuring, with the support of three universities from the Region, whose important roles have been essential in this process.

It is paramount that the universities participate as they can qualify more and more these processes, which are group processes, which are collective, which are relational, much more than human or financial resources. (ATD)

The teaching institutions contribute in planning, in the setting of activities, in the teaching methodologies, because the issue of knowing how to do is an issue for everyone. (DZ)

The authors refer to the relevance of the role that representatives of the teaching segment have exerted in the process of consolidation of the Permanent Commission of Teaching- Service Integration, supporting a constructive debate regarding the negotiations in the definitions about priorities of the EPS. “In this context the teaching institutions constitute spaces of reciprocal support, when inserted in the space of services there are constant exchanges, teaching and learning, allowing for a change in the process of association between theory and practice”⁶.

The results are presented below, organized in three themes, to highlight the contribution of the PCA development in the process for the restructuring of the Technical Chamber and, consequently, in the strengthening of the actions of the CIES in the region.

The role of universities in the development of health education activities

As the potential of education to change health practices is recognized, health institutions assume an essential role in the qualification process of the subjects involved in the process of health care. In this process, one of the competences required is the development of pedagogical methodologies that can institute dialogical relationships, to value existing knowledge and experiences and promote a feeling of co-responsibility in the production of changes in the practices and in the organization of services⁵. In this perspective, the universities have been pointed as important spaces, as to methodologically provide tools to the EPS processes.

The teaching institutions have a lot to contribute in planning, in the setting of activities, in the teaching methodologies, to didactics. (DZ)

Regarding the methodology used for health education, how much it influences and will make people come or not to educational activities. (LC)

The methodologies used in the permanent health education process must break the tendency that treats the educational process as merely an inventory of techniques with little articulation with one another, considering social, epidemiological, and service contexts, from the problems of the day-to-day practices of organizations. The adaptation of strategies must reach a diversity of actors, like the workers of the services and community groups. The educational process must consider the identification of the problems, the characteristics, the obstacles and the opportunities of the context, as well as the available resources, considering the evaluation during the educational process¹³.

When they participate in the CIES, subjects connected to the teaching experience opportunities that integrate theory and practice, seeing a dialogue between what the theory advocates and what is evidenced in practice⁴. Thus, the teaching-service integration makes it possible to prepare the health professionals to act in a way that is closer to the needs of the population, and this process makes it so the graduation institutions can rethink their role in this setting⁵.

This requires the professors to be understanding and committed to raise the interest of the students, and develop with them all the abilities related to permanent education in health.

An important role is how the teaching institution is preparing the student so he understands that permanent education is an instrument to guarantee and improve health care. (MTS)

A fundamental thing is] the position of the professors regarding these students too, to really make them understand that health education is important for personal and professional formation. (JBS).

To stay coherent to the principles of the PNEPS, it is necessary to lead the process of professional education in another direction, instituting pedagogical practices that promote learning experiences in which the students have the role of protagonists, which requires from the professors permanent education, so they can adapt the adequate competences for this teaching-learning model¹⁴.

Among the initiatives of the teachers of the universities towards this goal, the involvement of student permanent education actions can be noticed through extension programs and/or Course Conclusion Papers developed in the same Region. Likewise, the mobilization of students to participate in the workshop for the construction of the PAREPS, as well as in the development of courses for members of the policy management councils and municipal managers, developed as priorities by the PAREPS.

Regarding the role of universities in the development of health education activities in the Region, its importance to strengthen the CIES stands out, as the statement below highlights:

There has to be a social commitment to develop actions with partners [...], to participate in the different instances where there is a group of managers, like the CIR and the CIES, to understand what is the reality of the municipalities, the potential and weaknesses, and, together, [...] work as partners, to offer a broader number of services, improve basic attention. (CV)

The university [should] take the place of a partner in this process and build, with the other actors, a more inclusive health education process, to [recognize] what are the real health needs of the people, what are the priorities for formation, for training. (ATD)

Considering the weaknesses in the permanent education activities in recent times in the Macro-region, the development of the PCA mobilized different instances to strengthen the CIES, favoring the discussion between spaces then dormant, and leading EP actions to be reconsidered.

Currently, beyond participating in the composition of the Technical Chamber of the CIES, representatives from the universities are part of a work group, coordinated by the Health Secretary of the municipality of Chapecó, aiming to elaborate the Organizational Contract of Public Health-Teaching Action (COAPES), following the Interministerial Decree 1,124, August 4, 2015¹⁵.

Actions of health education developed by the universities through the CIES

Throughout the history of the CIES in the region, the universities had an important role in the development of permanent education actions, their offers targeted at managers, professionals and users of SUS, but also including the subjects linked to graduation and post-graduation education. The records of the Western CIES indicate that the first activity conducted with resources from the CIES was the Seminar for the Prevention of Dengue and Yellow Fever, promoted in 2009 and executed by Unochapecó.

In 2009 and 2010, in the scope of the CIES, the following activities were conducted, executed or mediated by higher education institutions: Course on urgency and emergency; Workshop for reviewing the Regional Action Plan for Permanent Health Education (PAREPS); Course of Mental Health in Primary Care; II Seminar for the Prevention of Dengue and Yellow Fever in the Macro-region Far West II of SC/ I Workshop of Zoonosis Training/ I Workshop of Capacitation regarding Accidents with Venomous Animals. In this period, the CIES participated in the process of elaboration of projects submitted and approved by the Unochapecó in the public notices of the Ministry of Health regarding the National Program for Professional Reorientation in Health (Pró-Saúde) and the Program of Education through Work in Health (PET-Saúde), in whose Local Management Commission it maintained representatives.

In 2011 and 2012, the universities developed, with the support of the CIES, the following activities: III Zoonosis Seminar and II Workshop of training about venomous animals and toxic plants in the Macro-region of the SC Far West II; II Seminar for Work Management; I Seminar of Permanent Health Education; I Academic Week of the Bachelor’s Course of Nursing of the Universidade Federal da Fronteira Sul (UFFS). In this period, the CIES maintained its commitment regarding the execution of interministerial strategies for Redirecting the Formation of Health Professionals (Pro-health and PET-Health) in local and regional levels.

In 2014, after a period of disarticulation, representatives of the Unochapecó, the Universidade do Estado de Santa Catarina (Udesc) and the Universidade Federal da Fronteira Sul (UFFS) participated in the organization and realization of the III Workshop for the revision of the Plan for Regional Actions of Permanent Education in Health (PAREPS), according to which are being developed, through a partnership, the activities of capacitation in the Region, highlighting the training of members of councils for the management of policies and municipal managers.

In addition to these activities, originated from demands which were defined in the dependencies of the CIES, the professors from these universities have conducted activities focused on permanent health education as a part of their regular teaching activities, whether they are connected to subjects of health courses (undergraduate or post-graduation studies), or to interinstitutional programs of research and extension. Many of these activities originate from demands of the service or are built in a partnership with different subjects in the practice settings, as it can be seen in the statement below:

In the [hospital X] the [University 2] aids in the restructuring of the continued education sector and they wrote a program for the formation of workers inside the hospital. The planning of the actions of the Program is conducted according to the demands that rise from the meetings of the managers of the hospital, from all the areas. (DZ)

The extension programs, especially from University 3, treat themes such as hypertension and diabetes, sexuality in adolescence, children health, pregnancy and prenatal, beyond the process of death and dying, as a dimension of the process of health care. This University also develops a research project on domestic violence with the community health agents.

Regarding University 1, activities developed by the groups connected to the PET-Saúde were highlighted in the statements, since they appeared to have strengthened initiatives of joint work involving teaching institutions and health service:

In the University we have the PET groups which have been doing permanent education. The Pró-Saúde itself [has projects towards that goal]. But, from the PET groups, there’s even a group today that discusses permanent education, which is diagnosing what is there in the health network in the city of Chapecó and that, from this diagnosis, is proposing PE workshops or courses. (MTS)

Although they evaluate the results of the initiatives developed by the universities as positive, whether or not they were partnerships mediated by the CIES, the professionals highlight, as a challenge, the understanding of the managers regarding the EPS, which is still very inclined towards the training of professionals to deal with specific health care demands.

A difficulty is the understanding the municipal management has of permanent education, that it [could] not [be] just training. (MTS)

This understanding is expressed in the health plans of the municipalities in the Region, in which permanent education takes place essentially as training courses targeted at themes such as women’s health, men’s health, urgency and emergency, among others. Although the municipal plans contemplate the training of the professionals, in practice, their actions are very incipient, when one considers that many of the municipalities in the Region do not have a structure/team to organize the training. This restates the importance of the universities to bring these actions into effect, not only in the main municipality, but also in the others that are part of the CIES.

In a research on the actions of the Permanent Commission of Teaching- Service Integration in Rio Grande do Sul, the authors found a tendency for the PAREPS to present educational conceptions with a strong predominance of focused practices, with technical bases. Although their importance is recognized, the authors problematize the tendency of these practices in preserving what was instituted, which works against movements that try to change work processes and service organization⁶. This restricts the potential permanent education processes have to mobilize the workers to “reflect on their work and, consequently, reconsider the organization of their work spaces and the health services”⁴, understanding their contradictions from a broadened point of view within a larger historical and social context¹.

On the other hand, among the difficulties expressed by managers of the West CIR of SC relative to the realization and/or expansion of permanent education actions in health in the municipalities, are the resistance of the users regarding the temporary dismissal of professionals from their activities in the service and the overload of work of the professionals, even in relation to the number of events offered, considering the restrict number of professionals in small cities.

From this perspective, some challenges for the universities stand out, such as the offering of educational actions that are closer and more integrated to the day-to-day of health services, especially with small cities, and the follow-up on the elaboration of municipal health plans, guaranteeing the inclusion of educational actions that are closer to the needs and potentials of the place/region. The potential of these actions could also be increased through a greater insertion of students in teaching, research, and extension activities in the Region.

The CIES as a favorable space for the articulation of universities in the Western Health Region

The articulation between universities and health services increase the potential of the formulation and implementation of answers to the concrete necessities of the population, as they contribute to the training of human resources, knowledge production and the offering of services aimed at responding to external demands².

All of those interviewed agree that the CIES is constituted as a space which favors the articulation of the universities of the Region, where subjects linked to it can meet, instituting spaces for discussion and for the formation of pacts in the perspective of permanent health education:

The CIES allows for the approximation between service and teaching and we have to strengthen that to effectively generate moments of reflection and try to do permanent education. (LC)

If the CIES was structured, it would be an [effective] instance for the approximation with universities. (CV)

The participants indicate an approximation between universities through the CIES, that is taking place in the Western Health Region:

The Plan of Regional Action for Permanent Health Education (PAREPS) itself, that happened not long ago [is an example]. The three universities go together and were proposing things in an articulated way. (LC)

Regarding the articulation between the universities that exist in the Region, three participants stated that there are movements for integration, especially from the teachers from the Nursing courses, with the two editions of the Nursing Week (2013/2014) and the realization of a State Forum of Nursing Colleges in the municipality, in 2012.

On the other hand, a participant related that this articulation is still reduced to the production of events. According to her,

[The institutions could be] really doing actions with more partnership, since in any spaces each one does in a way and it happens, sometimes, that a family receives many students from different courses, different situations and different schools. (JBS).

An alternative pointed out was the dialogue, an essential condition to bring to effect a process of education that respects and values the different subjects as people with important roles, be they students, users, professionals, professors, or even the managers of the institutions involved.

Power relationships are established, yes, but each time you sit around a table they become a group of equal people. And it should be placed in the role of the articulator of a proposition between formation, management and professional actions. It will always happen from an educational perspective. (ATD)

The professors that represent that institution in that place, they need to interact with one another, so they can conduct actions that really are according to the reality of the place, which help the student to have this knowledge [..] and aid this community in an effective way. To do that it is necessary to talk, to communicate, and sometimes that doesn’t happen. (JBS).

From the process of teaching service integration, there is an emergence of “institutional and communicational conflicts in the service network and in the universities, disputes between the professional health categories, market pressures [...] and the precariousness of the SUS career”⁵. The pressures and conflicts that emerge from this interaction reproduce disputes and the diversity of interests that exist in our society. In this sense, they require cultural transformation and the commitment of actors from all four sides in the debate and in the movements of redirection, reinvention and production of subjects⁵.

The experience of one of the PET-Saúde groups from Unochapecó can exemplify this possibility as a potential. In this experience, the actions of the coordinator of a primary health unit, one of the preceptors of the group, was paramount, as she performed the role of articulator in the definition of pedagogical actions, together with the responsible teachers, for the insertion of students from three universities in the unit and in its surrounding territory. A meaningful number of actions - involving teaching, researching and extension - were planned and developed in a dialogical and integrated form, making it possible for students to experience team work situations, avoiding overlapping actions in the unit and in the community.

To improve the articulation of the universities that act in these territories, some paths were indicated by the participants:

[...] having a better defined commission of teaching-service integration which plans the actions in a more articulated way, between the universities and, sometimes, between the courses themselves. [...] Organizing - a little for each territory - the universities, which in a medium to long term you can see the impact, the difference that the [University 3] or the [University 1] make in that territory, throughout time. (LC)

With the organization of the COAPES¹⁵, the universities should be organized by territory, partnering on actions that are according to the epidemiological and health profile of each territory. This action has been developed, at first, in the municipality of Chapecó, and will gradually be expanded to the other municipalities, according to the interministerial Decree 1,127, from 08/04/15.

Finally, it is necessary to understand that permanent health education does not merely implicates in changes of pedagogical or practical nature. It requires, beyond daily work, intervention in political spaces, organized collective articulations, that can strengthen the consolidation of the Unified Health System¹ in a way that is coherent to its principles and directives.

Final Considerations

This study aimed at identifying the role of the universities with the CIES in the Western Macro-region of Santa Catarina, in the fostering of permanent health education actions. Despite its non-continuity and the many challenges confronted to bring to effect the PNEPS in the region, the universities have been contributing with different partners to initiatives for the development of permanent health education in the Region, which has been very important for the strengthening of the Permanent Commission for the Integration of Teaching and Service.

The initiative contributed to systematize the actions developed by the CIES throughout the last two years, and favored the self-evaluation of the universities regarding their role in the strengthening of permanent education in the Macro-region. It contributed for managers and professionals from SUS to reflect upon the EPS actions, how they are defined in the municipal health plans, and how they had been or not executed.

It stands out that the process of building and implementing the PNEPS in the Region follows the tendency of other policies that integrate the SUS, regarding the challenges to consolidate it as the guiding force of government actions, and, simultaneously, constitute itself as an effective space for the democratization of public management. Possibly, the creation of different ministerial devices in the scope of health education in Brazil, not explicitly indicating articulations with the PNEPS, may have contributed for its weakening and de-characterization. It is paramount to recover the central idea of the wheel, implicated in the formulation of the PNEPS, which proposes circular and horizontal dialogue movement, involving teaching, management, care and social control, both as segments that think, propose and execute educational actions in a cooperative way, and as subjects that are compromised with effective changes in the ways to teach, manage, care and participate in health.

The development of Convergent Research of Care (PCA), involving subjects that have a main role in the historical trajectory of the CIES in the Region, contributed to the restructuring the Technical Chamber in the first semester of 2014, from which a workshop was promoted, which defined and deliberated the regional PAREPS, whose actions are currently being developed. It should be highlighted that the development of these actions has been happening with a strong collaboration between subjects from the involved universities.

The Convergent Research of Care showed itself to be appropriate for the production of knowledge which is integrated to the production of new practices in health and nursing. Similarly, it contributes to strengthen processes of approximation between educational institutions and health services, according to what is recommended by the National Policy of Permanent Health Education.

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Publication Dates

• Publication in this collection
  2017

History

• Received
  06 Dec 2016
• Accepted
  24 July 2017