SUS Ombudsman offices and the Brazilian Public Health School Network: a novel experience

This experience report aimed to analyze the vocational education of ombudsmen in the Unified Health System (SUS). This project was a partnership between the Sergio Arouca National School of Public Health (ENSP/FIOCRUZ), the Brazilian Network of Public Health Schools (RedEscola), and the SUS Strategic and Participatory Management Secretary (SGEP/MS). Considered pioneering, the vocational education was developed within the logic of a participatory process which involved municipal, state and national actors from SUS Ombudsman offices, state public health institutions/schools, the National Council of Municipal Health Secretaries (CONASEMS), and the RedEscola’s Technical and Executive Secretary in a consensual governance articulation resulting in the qualification of 451 ombudsmen.


Introduction
The purpose of recording this experience is to analyze the training process of ombudsmen working for the Brazilian National Health System (SUS).Its inspiration is related to the proposal of Bondía 1 who, when exploring the concept of experience, presents itself as an event that passes by us or an event capable of training and transforming us.
The Sergio Arouca National School of Public Health of the Oswaldo Cruz Foundation (ENSP/FIOCRUZ) has at the heart of its mission to train professionals, generate and share knowledge and practices to promote the right to health and improve the population's living conditions.It is in this context that the reported experience is anchored, the result of a cooperation between ENSP/FIOCRUZ and the Ministry of Health (MS) with the participation of the Pan-American Health Organization (PAHO), under the national coordination of the Brazilian Network of Schools of Public Health (RedEscola).

The Brazilian Network of Public Health Schools
The creation of the Network of Schools and Training Centers in Public Health, now RedEscola, was driven by the findings of the RegeSUS project -Innovations in Public Health Education with Dialog and Partnership 2 -as a result of an agreement between the Secretary of Work and Health Education Management of the Ministry of Health and ENSP/FIOCRUZ.This project involved eighteen public health schools and training centers that made up the Network proposed by ENSP/FIOCRUZ in which its Technical and Executive Secretary (STE) is based.
The network comprises 59 health education institutions in Brazil.It is a space for permanent dialogue and its mission is to articulate and strengthen strategies for the development of education public policies in the country.Its focus is on the qualification of SUS workers, according to its constitutive principles and guidelines 3 .
The training institutions of RedEscola are distributed all over the country and linked to the three levels of public management: federal, state, and municipal.Networking organizations have been referred to as fundamental to the execution and consolidation of actions essential to education and work within SUS.Since its creation, RedEscola has provided a flow of information, dissemination of methodologies, and the sharing of knowledge and practices for the effective implementation of public health education policies.
The Secretary for Participatory Management (SGP), on the other hand, was created in 2003 under the leadership of Sergio Arouca, its first secretary.It was driven by the ideals of the Brazilian Sanitary Reform.In 2006, it was renamed as the Secretary for Strategic and Participatory Management (SGEP).It was conceived as an institutional instrument capable of strengthening the principles and guidelines of universality, equity, integrality and community participation in the control of public health policies 3 .
The rapid decentralization of the health system in the country -and as a result, the increase in local management responsibilities and capacities, both in services and in financial execution -required the improvement of strategic management instruments.In 2006, the SGP incorporated the SUS National Audit Department (DENASUS), the SUS Monitoring and Evaluation Department (DEMAGS), and reshaped the Department for Monitoring Health Reform and the Department of Support to Participatory Management (DEGEP), originating the Secretary for Strategic and Participatory Management (SGEP) 4 .Currently, the SUS General Ombudsman office is linked to the Integrity Board (DINTEG) created by Decree nº 9,795/2019.
In July 2007, the National Policy on Strategic and Participatory Management (PARTICIPASUS) 4 was launched by SGEP and implemented by Ordinance nº 3,027 4 with the purpose of bringing together various structures responsible for supporting strategic and participatory management functions in SUS.Far beyond the development of instruments capable of collaborating in the SUS management, PARTICIPASUS is meant to amplify and give voice to SUS users and also its workers and managers as a practice of transparency and inclusive and participatory citizenship.This task required specific health education actions, capable of developing the necessary technical knowledge without ever losing sight of the involvement of critical and political meaning of the multiple issues and possibilities to be addressed 5 .
Under this framework, the SUS National Qualification Course for Audits and Ombudsmen was developed within the scope of the SUS Audits and Ombudsman Qualification Project.In this sense, the strengthening of strategic areas was carried out between 2012 and 2016 by ENSP/FIOCRUZ in partnership with the SUS Ombudsman General Department (DOGES/SGEP/MS), the DENASUS/SGEP/ MS and national coordination of RedEscola 5 .

SUS Ombudsman Offices
The experience lived under the perspective of the SUS ombudsmen vocational education and the resulting articulations with DOGES and State and Municipal Health Ombudsman offices culminated in the implementation of the SUS National System of Ombudsmen, an interconnected network of ombudsmen operating in the Union, states and municipalities.They operate in a decentralized manner, respecting the autonomy of each federation entity, under the central strategic guidance of DOGES.In the scope of SUS, DOGES was also responsible for proposing, coordinating, implementing and encouraging practices to expand user access to the evaluation process of public health actions and services 3 .
In fact, Ombudsman offices were supported by the 1988 Federal Constitution 6 .Its Article 37 determines that the Executive Branch must institute and maintain services to deal with complaints and suggestions from the population about public and private services provided, ensuring spaces and mechanisms for doing so.SUS Ombudsman's offices receive complaints, accusations, compliments, criticisms, and suggestions related to services and care provided at municipal, state, and federal levels, interconnected by the SUS National System of Ombudsman offices.They are democratic channels capable of strengthening SUS and the right to health and citizenship, aiming to bring the reality of day-to-day services closer to the citizens' reality in order to improve management.

Material and methods
The initial and preparatory proposals for the course included meetings and workshops with the training institutions that are members of the Network in all states.The goal was to get closer to the target and to build municipal, state and national work agendas both to prepare the instructional material and to prepare learning facilitators, including all the structural logistics required for the courses.
Therefore, this text was written using analysis as a qualitative research technique based on reports and documents produced by the STE Network during two years, from the first meeting held in Brasilia between RedEscola and DOGES to the final evaluation workshop, including reports with the participants' perceptions.

The course
Initially, the course was intended to be only 40 hours covering specific content from SUS Ombudsman offices.However, after the first meeting between RedEscola/ENSP and SGEP representatives, it was agreed that it would be essential for the ombudsman workers to have access to a more in-depth knowledge about SUS, recognizing an asymmetry of information about it.This step meant the addition of 40 hours in the training program which amounted to 80 hours.
It included 27 federal units in face-to-face modality with 40 hours dedicated to the studies about State, Health and Society; and 40 hours dedicated to specific issues of SUS Ombudsman offices.
It is important to note that the evaluations conducted at the end of the training process revealed that the insertion of content on the SUS was essential to understand the role and importance of the Ombudsman within SUS.
Thus, the course produced teaching material composed of two Learning Units (UA): UA1 -State, Health and Society; and UA2 with topics related to the SUS Ombudsman office 7 .
The UA1 was made up of five modules: 1) Health policies in Brazil; 2) Conceptual and legal frameworks of SUS; 3) Institutional model and instances of decision in SUS; 4) SUS models of care and organization; and 5) Auditing and ombudsman offices as SUS management tools.
UA2 addressed the concept of ombudsman as well as its work processes, the importance of information management, and innovations SUS ombudsman offices operates.The teaching-learning process in this Unit was streamlined from texts, videos, debates, and concrete cases selected by the SUS General Ombudsman Office.

The political-pedagogical project
This format was agreed upon by the ENSP/ FIOCRUZ representatives and the STE interlocutors of RedEscola and SGEP with the specific objective of updating the knowledge of the course participants, reinforcing the importance of the Ombudsman office as a strategic instrument for the health system management.
The collective creation of the pedagogical material was guided by the National Policy of Permanent Education in Health 8 (PNEPS).It is characterized as an educational aspect with capabilities linked to mechanisms and issues that make it possible to generate reflection on the work process, self-management, institutional change, and transformation of in-service practices through the proposal of learning how to learn, working in teams, building daily routines and becoming an object of individual, collective, and institutional learning.
When addressing Permanent Education in Health training, it is assumed that all service, work, care, education, quality, and citizenship are intended to contribute to meet the population' individual and collective needs.Considering such political-pedagogical principles, the course's educational material was inspired by the competency-based learning to guide the teaching-learning process in the model of knowledge, skills, and attitudes.This model was chosen for valuing the workers' experience, identifying and reflecting their knowledges through their daily practices The qualitative analysis of work processes in an increasingly complex labor world allows the development of skills and attitudes more coherent with the day-to-day reality of institutions 10 .
Accordingly, competency-based management education can allow students to reflect on the diverse world of labor in which they are inserted through strategies favoring the dialogue and socialization of different knowledge and experiences.Thus, it is possible to overcome the dichotomy between knowing and practice by sharing lived experiences, which leads to the recognition of work processes problems and interpersonal relationships able to overcome gaps in the daily life of institutions.
The concept of competency-based learning has been studied by several authors and considered as a set of knowledge deployed in the workplace in concrete situations, triggering various knowledges and emphasizing the triad of knowing, know-how and know how to be.However, Le Boterf 12 warns that "competence does not lie in the resources (knowledge, skills, abilities, and capabilities) to be mobilized, but in the very mobilization of these resources".The workshops and meetings with members of the governance team training the ombudsmen also considered the Paulo Freire's 14 reflection of the subjects as protagonists of their own educational process, capable to reflect actively and continuously on their reality and the actors within it -community, managers, workers, and users.
Every stage of the course was widely discussed.The pedagogical material was submitted to testing and validation sessions conducted in a simulation format as a kind of pre-test.This allowed the creation of a classroom environment attended by professionals from the ombudsman's offices -federal, state and municipal.All of them with extensive experience not only pedagogically, but also in ombudsmanship practice.These aspects highlight the cooperation and participatory management and represent an important legacy in terms of knowledge and know-how dissemination, and the guiding principles for the deployment of Ombudsman offices.
The communicational and interactive nature of the educational material is also emphasized as it had the collaboration of content experts invited for their experience in the proposed themes and the expertise of ENSP/ FIOCRUZ in the design of pedagogical and educational materials.
Prior to the application itself, the material was sent to several reviewers to analyze it especially in terms of: language, clarity and objectivity; content, based on the theme consistency and aligned with the pedagogical material; and schedule, by comparing the time required to teach the content and carry out the complementary activities contained in the program.
The subsequent step, to validate the content and pedagogical strategies of the analyzed material, consisted of welcoming suggestions and recommendations arisen from the pedagogical simulation.The authors made adjustments to meet the course needs, taking as guiding points the target audiences and the training process objectives in line with the dialogic and communicative proposal that permeated the entire elaboration process.
This organized, edited, and published material was previously sent to the educational institutions by STE of RedEscola to be distributed to participants before the beginning of the training.It is also available for free access on the RedEscola website.
At the end of each Unit, evaluation questionnaires with open and closed questions and space for criticism, praise, and suggestions were applied to students, facilitators, and coordinators.

The training of the facilitators
The learning facilitators of UA1 were selected primarily by the Network schools in their respective states.The facilitators of the municipal and state SUS ombudsmen, on the other hand, were appointed by DOGES/SGEP/MS.The facilitators participated in four training workshops promoted by the national coordination aiming to refine the educational processes and use the pedagogical material.
The objectives of the facilitators' workshops can be summarized as follows: to know the different conceptions and approaches used in the pedagogical process; understand the importance of active methodologies in professional training processes; and recognize the potential of the management by competences principles in these processes.
Moving forward in this perspective, the questioning of traditional teaching practices and those that are more transformative of educational models was privileged with the objective of, as Davini 15 states, promoting reflection and offering contributions enabling more consistent pedagogical options in dialogue with the models and their authors.Thus, three pedagogical models were selected to illustrate this statement.According to Davini 15 , in addition to the course objectives, the problematization pedagogy is committed to the transformation of practice.In this case, it is also through practice that it is verified if the problems were, in fact, solved.
Another aspect considered, at the core of this experience, was work as a key dimension to meet theory and practice forming a space of convergence in the ombudsman's performance.
The idea of a transformative and emancipatory practice, according to Paulo Freire 16 , has ruled the conception of the educational material, reinforced in the training and/or updating of the learning facilitators throughout the training process.
The selection of the participating municipalities was based on the following criteria: adherence to the Public Action Organizational Contract (COAP) 17 or to the SISPACTO 18 .This system allows the registration of goals agreed upon by municipalities, health regions, states, and the Federal District with priority given to municipalities that did not have an ombudsman office in place.
The appointment of the trainees in accordance with the number of vacancies occurred upon formalized release by the state and municipal health secretaries aiming to guarantee the participation of the ombudsman.The minimum attendance required was 70%.
As a contribution to the course planning and implementation by the state coordination, a Workbook was prepared with guidelines for the course's operation covering: governance structure, actors involved and their respective attributions, organization, operation, didactic and pedagogical material, and organization dynamics.

The course governance
To make this large-scale initiative a reality, it was necessary to design the governance structure and elaborate operational guidelines to offer the responsible actors greater security, transparency, and objectivity in the implementation of specific attributions.
The The experience acquired with the implementation of the first course offer and the evaluation carried out with the eight course coordinators led to a new governance scheme based on the lessons of organizational learning and inspired by the search for a culture of innovation.
With the political-pedagogical assumption of learning how to learn, it was noticed that the first experience has shown the need to include the municipal health secretaries and councils when choosing the municipalities for the program.For the second offer, this understanding led to the creation of a Support Group in the governance structure which involved eighteen Brazilian states and the Federal District.
Thus, new actors such as the Council of Municipal Health Secretarys (COSEMS) and representatives of the technical areas of the State Health Secretaries were incorporated to constitute Support Groups in each state.This has allowed a more collegiate and participatory approach in the selection of municipalities and the indication of course participants as well as the integration of academic activities.This new governance structure was considered a powerful management strategy, a strong point of the project.
Another measure adopted consisted of working in a more regionalized way with the Network's training schools offering more support in managing the course breaking with the random simultaneity among the course classes observed in the first offer.
The lessons learned from the first course also resulted in measures implemented in the second one such as the expansion in the number of places from 20 to 25.
Figure 2 shows the schematic design of the governance structure of the first course offered in 2014, and the second in 2015 with the creation of the Support Group.Regarding the students' profile, here are some characteristics to be considered.Figure 3 shows the distribution of students by activity level observing that 75% were municipal ombudsman offices workers while 13% were from state ombudsman offices, and 1% from the national ombudsman office.However, 13% did not answer.
The figure also shows the length of service among the trained workers revealing that the vast majority of participants had worked one to five years in the Ombudsman's office followed by those who had worked for less than a year, and this practically tied with the participants who had never worked in SUS Ombudsman's offices.
Figure 4 refers to the participants' education, showing that 49% of the students had a college degree followed by 28% with a specialization, 13% had a high school degree, 2% had a master's degree, and the same percentage for the doctorate.

Results and discussion
The course graduated 451 students from Brazilian regions: 37% in the Northeast, 22% in the North, 16% in the Centre-West, the same percentage in the Southeast, and 9% in the South.Based on figure 5, comparing the number of enrolled students and graduates, we can notice that Southeast had a 90% success rate followed by Northeast with 84%, Centre-West with 81%, North with 73%, and South with 71%.In an evaluation carried out with the total number of ombudsmen who completed the course by the training institutions involved, 89% of them considered the pedagogical method as good or very good.As for the didactic-pedagogical material, 93% of the students considered it good or very good.
As for the qualitative results, it was noticed that it was necessary and possible to overcome many challenges and that the actors involved in the process felt, in some way, empowered and with positive prospects for the future.This perception derives from the reports received through the evaluation records, such as: We suggest more meetings of this kind so that we technicians have a single purpose: to offer quality health care and a solution to all SUS users with transparency and universality.This course made me see that SUS has hope.I fell in love with the ombudsman office because through it I will be able to contribute to the improvement of management and better services for citizens.
The presented process allows us to know the weaknesses of the health work.It serves as a mirror for our health planning and direction.

Now I have arguments to defend SUS.
I arrived here small, empty, and I had no idea of the exact importance of my work.I can only thank everyone who made me stronger.

Final considerations
Given the results achieved, it can be said that the course represented an opportunity to redefine the work processes of SUS Ombudsman offices, especially in the active search for listening to users of the health system and in the production of guiding reports reinforcing the Ombudsman offices as a driving force of participatory and democratic management.
The course also boosted the expansion of academic production on the SUS Ombudsman office relatively scarce until then.It also redefined the role of SUS Ombudsman offices as a management tool contributing to solve problems.The publication about UA2, for example, was the first educational material prepared exclusively for the SUS Ombudsman office.
The complex and participatory governance structure also represented, especially to state and municipal managers, the pedagogical character of the Ombudsman as an allied management tool, strengthening its insertion in an institutional way, as a daily management practice maintaining the ongoing knowledge construction in these areas and its continuity.
The character of this experience proved to be similar to that of the national policy of strategic and participatory management since it dialogues directly with the principles and guidelines of PARTICIPASUS: collective construction, social participation, inclusion, solidarity, and the effective implementation of an increasingly equitable SUS.
The methodological connection was clear.Those involved were able to create important bonds for the Ombudsman offices in their respective states and municipalities favoring collaborative actions among the participants.
Thus, offering a national training represented the first step in a new trajectory for SUS ombudsman offices and the enrichment of the technical debate about their role.The great challenge ahead is the immense responsibility of maintaining the training regularity.
This initiative also strengthened the State Schools of Public Health, all of which are committed and deeply involved with the course's political-pedagogical approach, and are, therefore, strong allies in the continuity of training and strengthening of both PNESP and PARTICIPASUS.
Finally, the course leaves other important legacies: pedagogical material considered unprecedented for its pioneering nature and a book entitled 'Qualification of SUS Ombudsman Offices: a dialogical experience' 18 which reports in detail the experience lived in this collective adventure through public policies for education and SUS management.It is also worth noting the proposed distance education course (EAD) created in conjunction with the Educational Development and Distance Learning Coordination (CDEAD/ ENSP) to offer greater scope for ombudsmen training and to expand the implementation of ombudsman offices in the country.
However, it is worth pointing out that according to the updated data from the SUS Ombudsman Network Coordination (COREDE/OUVSUS/DINTEG/MS), at the end of 2015, the country had 1,439 municipal ombudsman offices.In 2021, there were 1,665.In almost six years, a growth of 15.7% was registered.Considering the 5,570 Brazilian municipalities, it is noted that only 29.90% of them have ombudsman offices.No doubt, this highlights a great challenge especially in the current scenario of dismantling of constitutional public health policies enshrined by the Brazilian Sanitary Reform.
Despite the observed inflections and following up on the training processes, the DINTEG/MS established in 2019 a partnership with ENSP/FIOCRUZ aiming to create an Ombudsman Training Program in order to develop educational actions to qualify professionals and workers such as ombudsmen, technicians, and managers throughout the national territory with the following goals: 2,000 available seats for training in the modality of EAD and in the face-to-face modality for more than 900 institutions.
This initiative is strongly supported by the purpose, results, and learning from the experience reported here.We also highlight as key success factors, the support of DOGES/ SGEP/MS, the actions of PAHO, the role of ENSP/FIOCRUZ, the active participation of the STE-RedEscola, the engagement of educational institutions, and all actors involved in this initiative.
Finally, sharing this unique experience which is instigating, challenging and full of challenges and new questions, is an invitation to continue seeking to accomplish the aspirations of guaranteeing the full rights of citizenship to the Brazilian population.

Collaborators
Souza RMP (0000-0003-3204-0835)* contributed to the conception, planning, writing of the manuscript, methodological and thematic orientation, critical review of the content, and approval of the final version of the manuscript.Costa PP (0000-0003-3527-6974)* contributed to conception, planning, writing of the manuscript, methodological and thematic guidance, critical review of the content, and final approval of the manuscript.Muñoz FGS (0000-0002-3243-3498)* contributed to conception and planning of the proposal, content review, and approval of the final version of the manuscript.s *Orcid (Open Researcher and Contributor ID).

Figure 1
Figure 1 illustrates the three dimensions of competency-based training.

Figure 1 .
Figure 1.The three dimensions of competencies

Figure 2 .
Figure 2. Governance structure second offer

Figure 3 .
Figure 3. Distribution of Ombudsman students by sphere of government and working time

Figure 4 .
Figure 4. Distribution of students by level of schooling in Ombudsman offices

Figure 5 .
Figure 5. Consolidated number of students graduating in the five regions governance structure for the first offer of the course was composed of a national coordination, with the participation of the Vice-Director of the ENSP/FIOCRUZ School of Government in Health, the Executive Secretary of the Public Health Schools and