Evaluation of the implementation of ‘Qualifica Cerest’: Contributions to Workers’ Health in Porto Alegre (2020-2023)ABSTRACT
This study examines the implementation of the ‘Qualifica Cerest’ questionnaire from 2020 to 2023 in Porto Alegre, Rio Grande do Sul. ‘Qualifica Cerest’ is a tool for measuring the quality of the performance of Workers’ Health Reference Centers, through the application of an electronic questionnaire that evaluates nine criteria, the set of which indicates whether CEREST’s performance is satisfactory. The National Health Plan 2020-2023 establishes the goal of 60% of CERESTs in Brazil to present satisfactory performance. The research, of a descriptive and analytical nature, was designed to provide a broad and detailed analysis of the topic, combining two strategies: the presentation of the evaluation matrix, its criteria and attributable points; and the analysis of the results obtained. In the evaluation, CEREST in Porto Alegre reached the percentile established for each year, evidencing performance aligned with the perspective of comprehensive worker health. However, the strengthening of social participation, the implementation of educational activities and the provision of support deserve attention. The study allowed reflection on the instrument evaluated, raising questions about its implementation, and dialogues with discussions and research focused on the theme of strengthening the National Network for Comprehensive Care for Workers’ Health at the municipal level.
KEYWORDS
Health surveillance; Surveillance of the Workers Health; Health evaluation; Healthcare work process; Quality indicators; health care.
RESUMO
Este estudo examina a implementação do questionário ‘Qualifica Cerest’ no período de 2020 a 2023, em Porto Alegre-RS. O ‘Qualifica Cerest’ é uma ferramenta de mensuração da qualidade da atuação dos Centros de Referência em Saúde do Trabalhador, por meio da aplicação de um questionário eletrônico que avalia nove critérios, cujo conjunto indica se a atuação do Cerest é satisfatória. O Plano Nacional de Saúde 2020-2023 estabelece como meta que 60% dos Cerest no Brasil apresentem desempenho satisfatório. A pesquisa, de natureza descritiva e analítica, foi concebida para proporcionar uma análise ampla e detalhada do tema, combinando duas estratégias: a apresentação da matriz de avaliação, seus critérios e pontos atribuíveis; e a análise dos resultados obtidos. Na avaliação, o Cerest de Porto Alegre alcançou o percentil estabelecido para cada ano, evidenciando uma atuação alinhada com a perspectiva da integralidade da Saúde do Trabalhador. Contudo, o fortalecimento da participação social, a realização de atividades educativas e a realização de apoio merecem atenção. O estudo permitiu a reflexão sobre o instrumento avaliado, suscitando questionamentos acerca de sua implementação, e dialoga com discussões e pesquisas voltadas ao tema do fortalecimento da Rede Nacional de Atenção Integral à Saúde do Trabalhador em nível municipal.
PALAVRAS-CHAVE
Vigilância em saúde; Vigilância em Saúde do Trabalhador; Avaliação em saúde; Processo de trabalho em saúde; Indicadores de qualidade em assistência à; saúde.
RESUMEN
Este estudio examina la implementación del cuestionario ‘Qualifica Cerest’ entre 2020 y 2023, en Porto Alegre, Rio Grande do Sul. ‘Qualifica Cerest’ es una herramienta de medición de la calidad del desempeño de los Centros de Referencia de Salud Laboral, mediante la aplicación de un cuestionario electrónico que evalúa nueve criterios, cuyo conjunto indica si la actuación del Cerest es satisfactoria. El Plan Nacional de Salud 2020-2023 establece la meta de que el 60% de los Cerest en Brasil presenten un desempeño satisfactorio. Esta investigación, descriptiva y analítica, se diseñó para proporcionar un análisis amplio y detallado del tema, combinando dos estrategias: presentación de la matriz de evaluación, sus criterios y puntos atribuibles; y análisis de los resultados obtenidos. En la evaluación, el Cerest de Porto Alegre alcanzó el percentil establecido para cada año, demostrando una actuación alineada con la perspectiva de la integralidad de la Salud Laboral. Sin embargo, el fortalecimiento de la participación social, la realización de actividades educativas y la prestación de apoyo son factores que merecen la atención. El estudio permitió reflexionar sobre el instrumento evaluado, planteando cuestionamentos sobre su implementación y dialoga con discusiones e investigaciones enfocadas en la temática del fortalecimiento de la Red Nacional de Atención Integral a la Salud Laboral en el ámbito municipal.
PALABRAS CLAVE
Vigilancia en salud; Vigilancia de la Salud del Trabajador; Evaluación en salud; Proceso de trabajo en salud; Indicadores de calidad de la atención de salud.
Introduction
Health constitutes one of the fundamental pillars of human development, directly impacting individuals’ quality of life and productive capacity. The concept of health goes beyond the mere absence of disease, encompassing a state of physical, mental, and social well-being1, an understanding that, in Brazil, has been broadened by the inclusion of social, economic, and cultural determinants. This recognizes health as a social product, a result of quality of life, which in turn is influenced by the distribution of wealth. Thus, health results both from the capacity to produce social justice and from the provision of a health system that guarantees equitable access to comprehensive practices2.
According to the World Health Organization (WHO), work is a social determinant of health, as is the distribution of power, income, goods and services, living conditions, access to health care, education, and leisure, as well as the quality of housing and the environment. Work determines access to income, rights, and social protection, directly influencing the health-disease process. Precariousness, informality, and inequalities in labor relations exacerbate health inequities, especially among groups characterized by gender, race, and social class. This understanding demands that work be analyzed in its technical, social, and subjective complexity3.
In this context, public policies and health surveillance actions are key elements in promoting and protecting workers’ health, vital for facing the challenges imposed by work dynamics, especially in capitalist countries, where work is seen, notably, as a resource, and therefore, as an input for production processes.
In 2012, the Ministry of Health (MS) created the National Workers’ Health Policy (PNSTT)4, which is part of a broader understanding of the relationship between health and work, particularly its impact on workers’ health. The PNSTT aims to promote, direct, and support comprehensive Workers’ Health (ST) care, with an emphasis on surveillance measures to reduce work-related deaths, accidents, and illnesses.
The world of work, particularly in the last half-century, has undergone significant changes resulting from the development of productive forces, which invariably seek to expand value extraction. These factors have promoted profound transformations in the dynamics of workers’ inclusion in production processes and labor relations. The fact is that labor societies, instead of producing freedom, have transformed into machines of submission, renunciation, and precariousness of life, forcing workers to accept exploitation5. In this context, neglect of WH has been an intrinsic element of the capitalist production system6. This restructuring of the world of work is compounded by historic setbacks in labor relations, which increase illness in and through work in contexts of insecurity, helplessness, harassment, and other constraints. This results in a growing incidence of illness, which is not always welcomed and treated within the healthcare network7.
This situation contradicts the fundamental principles of the Brazilian Constitution, which stipulate that all Brazilian workers, formal or informal, active or inactive, must be protected. The document also assigns the Unified Health System (SUS) the responsibility for ensuring comprehensive health care, including protection, treatment, and recovery. In this context, the SUS is responsible for providing comprehensive health care to the population, taking into account interdisciplinarity and comprehensiveness8.
When it comes to ST, it is essential to consider work as a determinant of the health-disease process. Workers are exposed to various risks both inside and outside the workplace: the risk of accidents, illness, and death resulting from work activities, such as commuting; they suffer from exhausting jobs and precarious working conditions, subjected to exhausting work hours, generally undemocratic work management, and high productivity demands; and are often subject to moral and sexual harassment6.
The ST has appeared in several SUS planning instruments, such as the National Health Plan (PNS)9, a strategic guidance instrument for the federal manager of the SUS, which, in its interfederative relationship, has incorporated the issue of workers’ health since its creation in 2003. In the first edition, which covers the period from 2003 to 2007, the goal was to reduce the incidence rate of work-related diseases, but it did not foresee the implementation of a Workers’ Health Reference Center (CEREST).
CERESTs provide technical support in the execution, coordination and agreement of health actions in the SUS and in an intersectoral manner, including health assistance and surveillance, offering support to managers and social control, expanding and strengthening the ST in its entirety at all levels of care in the SUS8.
The following PNS, from 2009 to 2011, included the goal of expanding the creation of CERESTs, which, in the 2012-2015 PNS version, was qualified by the goal of increasing the percentage of CERESTs that develop Workers’ Health Surveillance (VISAT) actions. In the 2020-2023 PNS version9, this action was again qualified by the inclusion of the goal of 60% of CERESTs functioning properly, which was operationally defined by the Ministry of Health in 2020 and is now included in the PNS/MS/SUS Indicators panel10.
The inclusion of this goal in the PNS 2020-2023 is part of the effort to qualify the National Network for Comprehensive Care for Workers’ Health (RENAST), created in 2005, which is made up of CEREST.
The Department of Environmental Health Surveillance and Workers’ Health, General Coordination of Workers’ Health Surveillance, of the Ministry of Health (CGSAT/DSAST/SVSA/MS), created guidelines to assess the satisfactory performance of CEREST goal. The Ministry of Health developed a data collection tool called ‘Qualifica Cerest’, administered through an electronic questionnaire. This instrument consists of indicators monitored every four months, whose results allow for the measurement and monitoring of the health status of the Economically Active Employed Population (PEAO). Based on this assessment, VISAT teams can develop plans and actions to improve the quality of the actions implemented4.
This article presents the results of a study that analyzed the implementation and developments of the ‘Qualifica Cerest’ program, carried out between 2020 and 2023 in the city of Porto Alegre, RS. This study was submitted to the Research Ethics Committee (CEP) of the Porto Alegre Municipal Health Department and approved by Certificate of Presentation of Ethical Appreciation (CAAE) No. 71594223.0.0000.5338 and Opinion No. 6,249,697. The investigation was motivated by the need to broaden the discussion on actions in the field of ST, which sought to contribute to health promotion, prevention of work-related diseases and injuries, as well as the rehabilitation of workers.
The Porto Alegre’s CEREST is comprised of a multidisciplinary team consisting of a manager, two occupational physicians, a psychiatrist, two nurses, an occupational therapist, a psychologist, an occupational safety technician, a nursing assistant, and four administrative assistants. The outpatient unit is located in the city’s historic center. The administrative area for ST services is located in the same building as the Health Surveillance Directorate (DVS). VISAT strengthens the PEAO care network, making it crucial to enhance research in this area of healthcare, particularly regarding ST11.
The article evaluates the implementation of ‘Qualifica Cerest’ and the results of the evaluation of the CEREST indicators in Porto Alegre, highlighting the weaknesses and challenges faced in the implementation of actions in the care of ST.
Material and methods
This descriptive and analytical study was designed to provide a broad and detailed analysis of ‘Qualifica Cerest’, a ST assessment instrument and methodology within the scope of RENAST. The study combined two work strategies: a summarized presentation of the ‘Qualifica Cerest’ logical framework, notably its criteria and attributable points from the questionnaire from 2020 to 2023; and an analysis of the results obtained for each criterion, considering the instrument’s logical framework. To illustrate and provide a better understanding of the indicators’ content, information obtained from the Management Reports of the Porto Alegre Municipal Health Department (SMS) for the same period was aggregated.
This methodological perspective sought to value the knowledge produced at the interface between practice and reflection, not limiting itself to the mere exposition of facts, which was circumvented by the analytical dimension that mobilized a reflective interpretation of the data, guided by categories constructed from the studied reality itself, as well as by careful evaluation of the data and an analysis supported by the principles of the SUS.
Normative No. 6/2021, issued by the CGSAST/DSASTE/SVS/MS12, guides the implementation of actions necessary to meet the criteria of the Workers’ Health Indicator established in the National Health Plan (PNS) 2020-2023, called ‘Percentage of regional and municipal CERESTs with satisfactory performance’. The document establishes specific criteria whose scores allow CERESTs to be classified as satisfactory if they achieve between 75% and 100% of the total score, equivalent to 120 to 160 points. In March 2021, this standard was amended by Normative No. 7/202113, which established a total score of 175 points, in response to the needs arising from the COVID-19 pandemic. The CGSAST/DSASTE/SVS/MS monitors the ‘Qualifica Cerest’ goal every four years, allowing for continuous monitoring of ST actions and conditions. The goal is verified annually.
The data used to verify the questionnaire’s evaluation criteria are obtained from national health systems, including the Notifiable Diseases Information System (SINAN), which collects data on diseases and conditions reported in Brazil; the Mortality Information System (SIM), which gathers data on deaths; and the SUS Outpatient Information System (SIA-SUS), which is used to record care provided in public health services.
Information Note (NI) No. 61/2018-DSAST/SVS/MS14 details the Worker Health Indicators to be monitored by CEREST on a quarterly basis; No. 94/2019-DSASTE/SVS/MS15 presents the new definitions of work-related injuries and diseases from SINAN.
Data is completed and submitted for analysis using the Research Electronic Data Capture (REDCap) platform, an electronic data collection and management tool widely used in clinical and health research. Data are recorded in this system and subsequently emailed to the Ministry of Health. Submission occurs at the end of each four-month period, meaning that information is collected and analyzed throughout each three-month period, allowing for continuous monitoring and updating of information, which must be done carefully due to the underreporting of work-related illnesses. ‘Qualifica Cerest’ involves robust data collection, guaranteed by the use of national health systems, official information notes, and digital platforms, enabling the monitoring of indicators and facilitating the planning of actions in the municipality.
Box 1 presents the nine criteria that make up the Worker Health Indicator, the attributable points and the source of information for the ‘Qualifica Cerest’ questionnaire.
With the creation of RENAST, the need for structuring, organizing, and standardizing ST-related strategies and actions intensified, particularly their integration into the Health Care Networks (RAS), a role to be played by CEREST, among others. The ‘Qualifica Cerest’ program includes indicators that reflect the main guidelines and competencies of these services, such as recording notifications of work-related injuries, which is the responsibility of CEREST, which must work to improve the quality and regularity of these records. Evaluation criteria include regularity in recording Work-Related Diseases and Injuries (DART) in SINAN and the provision of medical or other higher-level consultations in specialized care (SIA-SUS). Also considered are the issuance of a Causal Nexus Opinion and the performance of health inspections in work-related illnesses. Furthermore, it includes institutional and matrix support in Primary Health Care (PHC), Specialized Care, and Urgency/Emergency, as well as monitoring of indicators in accordance with NI 61/2018-DSAST/SVS/MS14. Finally, it provides for the implementation of epidemiological dissemination actions, continuing education activities in the RAS, and educational activities aimed at the population.
Results and discussion
Ordinance No. 1,206, of October 24, 201316, changed the registration of CERESTs in the National Health Establishment System (SCNES), which is now considered a specialized ST care establishment, which has a VISAT service, in addition to providing technical-pedagogical and clinical-assistance support to the SUS service network for comprehensive health care for urban and rural workers, which includes promotion, prevention, surveillance, diagnosis, treatment and rehabilitation actions.
According to the PNSTT, CEREST planning actions must be coordinated at the regional and municipal levels. In line with this principle, Municipal Ordinance No. 1,186/201817 was published, regulating the Municipal Workers’ Policy of Porto Alegre, RS. The goals and indicators for evaluating and monitoring this policy must be included in the management instruments established by the SUS planning system. Furthermore, its development must be participatory, following a model of coordinated and systemic action on an ongoing basis.
In 2020, Resolution CIB-202018 of the Bipartite Intermanagerial Commission/RS (CIB/RS) approved a change in the scope of the Porto Alegre-RS Regional CEREST, restricting its services exclusively to health services in the municipality of Porto Alegre, thus ceasing to be a regional CEREST and becoming a municipal CEREST. As of February 2020, the CEREST team no longer compiled data on indicators for other municipalities.
With the implementation of ‘Qualifica Cerest’ in 2020, combined with VISAT’s action planning during the pandemic, it was possible to more accurately identify specific needs related to ST. Therefore, it became necessary to expand the team, including professionals and technicians, to implement strategies to combat the pandemic within the scope of occupational health for workers.
The publication of NI No. 7/2021-DSASTE/SVS/MS13 redirected VISAT’s actions to meet the ‘Qualifica Cerest’ criteria, presenting relevant considerations for addressing the health crisis currently being experienced due to the COVID-19 pandemic. The working class was at great risk due to the maintenance of economic activities, even though WHO guidelines called for compliance with health measures, which were not always observed, particularly in Brazil. In this scenario, VISAT’s actions began to be adjusted to adapt to health restrictions while still performing its functions. The CEREST team in Porto Alegre began using new strategies for data collection and remote training19, which enabled the implementation of ‘Qualifica Cerest’.
Normative No. 6/2021/MS12 considers CERESTs that achieve between 75% and 100% of the total score, corresponding to a range of 112.5 to 150 points, to be functioning as satisfactory. For the years 2021 to 2023, Normative No. 7/2021/MS changes the maximum score to 165 points, with a minimum score of 100 points being considered satisfactory13. Table 1 below describes the ‘Qualifica Cerest’ scores in the city of Porto Alegre-RS in the years studied.
In criterion 1 - Existence of monthly records of work-related diseases and conditions subject to mandatory notification in SINAN, the city of Porto Alegre reported 6,359 work-related diseases and conditions in 2020, obtaining a total of 30 points, demonstrating an increase in the number of reported cases of DART. In 2021, 6,888 cases of DART were reported, classified, and investigated, reaching a rate of 46.64 notifications per 10,000 inhabitants in Porto Alegre, the highest in the last six years, reflecting the use of digital notifications. Reports filled out only with ICD 10 of B34.2 totaled 2,386 notifications, since, in the previous year, there were no notifications with a presumed causal link in the workplace with ICD 10 of B342.21620.
In 2022, reports of DARTS increased by 11.2% compared to the previous year. An analysis of this year’s SMS Management Report revealed twice as many cases of work-related mental disorders reported in 2022. Furthermore, Repetitive Strain Injuries and Work-Related Musculoskeletal Disorders (RSI/WMSDs) increased by 182% in 2022 compared to 202121.
In 2023, 1,916 notifications were made for COVID-19, a reduction of 28.5%, with a significant decrease in notifications with ICD B34.2 with presumed causal link, when, in 2022, it was 4,28222.
To understand the distribution and determinants of ST-related events, it is essential to analyze work and its impacts comprehensively. This analysis must go beyond the conditions traditionally addressed, also considering organizational, ergonomic, and psychosocial aspects23. According to Seligmann-Silva24, it is also necessary to consider the underreporting of work-related illnesses and injuries in the analysis of indicators, which can lead to distortions and limitations in discussions and the development of action plans.
Due to the nature of their activities, healthcare workers have been extensively exposed to SARS-CoV-2 infection, generating significant global health concerns, as healthcare and public safety professionals continue to perform their duties. This context has enabled the establishment of a causal link between COVID-19 and work, allowing it to be classified as an occupational accident, as defined in Brazil by Law No. 8,213/199125.
Criteria 2 and 3 - Medical consultations in ST and/or consultations with higher-level professionals (except physicians) performed and recorded by CEREST; and Issuance of an opinion on causal link performed by CEREST and/or RAS or DART notifications, achieved the maximum score in 2020. A total of 213 medical consultations were performed, representing a 66.7% decrease compared to the previous year, when consultations were conducted without social distancing restrictions. This information was extracted from the SIA-SUS database of procedures for Medical Consultations in ST, with the issuance of an Opinion on Causal Link12.
In 2021, the number of cases referred for medical consultation by the PHC at CEREST was 401, followed by 135 consultations with a causal link and 18 consultations in 2022 by the PHC with a causal link. Medical consultations and consultations with higher-level professionals, other than physicians, decreased by 13% compared to the previous year. It is worth noting that, during this period, social distancing was in effect, as well as a reduction in the number of CEREST employees. In 2023, 104 medical consultations with a causal link were carried out. Through DART notifications, it is possible to plan the development of care pathways involving the RAS, responsible for caring for the workers, which ranges from early diagnosis to identifying the relationship between illness and work, to treatment, rehabilitation, and follow-up.
According to the Ministry of Health (MS)26, the clinical consultation is the most important tool for establishing a causal relationship between work and the worker’s complaint or illness. In this context, Garboggini27 considers that the medical consultation and the diagnosis of a causal link should be considered a moment of vulnerability, which demands the attention of the healthcare professional in solving the problem. This primarily involves the construction of a multidisciplinary care network, including referral to specialized healthcare.
According to criterion 4 - Conduct health inspections in ST through CEREST, according to SIA-SUS data, in 2020, the VISAT team conducted 650 inspections related to COVID-19 mitigation in workplaces19. In 2022, 190 inspections were conducted, and in 2023, 90 inspections were obtained22. Criterion 4 does not specify the types of health inspections in ST; they can be carried out by spontaneous demand, active search, or by complaint, with the objective of identifying hazards, recognizing and assessing potential risks, and, consequently, determining and implementing the necessary corrective and preventive control measures to prevent accidents, health problems, discomfort, or damage to property.
Considering the challenge of implementing VISAT actions in all municipal work environments, which is a highly complex task, planning is essential to establish priorities, ensuring interventions with greater impact and educational and disciplinary effects on the sector. Therefore, the adoption of surveillance actions and strategies is recommended18. According to Moura-Correa et al.28, with the incorporation of VISAT’s responsibilities into the SUS’s scope of competence and the adoption of the expanded concept of health, new challenges arise for health services, which have expanded their responsibility to develop approaches that integrate various areas of knowledge in health analysis and intervention to ensure the effectiveness of VISAT actions.
Aiming to fully meet the assumptions of the SUS and the specific regulations that regulate ST, VISAT constitutes a set of health practices, registered as a typical function of the State, and its public nature must be centered on the prevention of harm and the promotion of health, acting on determining factors of the health-disease process, observing the principles of the SUS, social control, among others28.
Improving work environments to promote and protect workers’ health is imperative for VISAT’s actions. Inspections may require complex solutions and costly investments for employers, but they can also be implemented with simple, low-cost measures, considering that many of them are established in current legislation, technical standards, and regulations, or even based on epidemiological analyses conducted by the Internal Accident Prevention Committee (CIPA) or the Specialized Occupational Safety and Medicine Service (SESMT) when there is an increased incidence of a disease or injury in a given activity within the production process. However, it has been commonly observed that many of these measures are neglected or non-existent, which causes concrete harm to workers’ health29.
Regarding criteria 5 and 6 - Providing institutional/matrix support in ST with PHC teams; and with specialized care and emergency managers/teams, related to case discussions, the CEREST team conducted 37 case discussions with PHC, Specialized Care, and Urgency and Emergency teams in 2020, during a period when the pandemic weakened the team’s work. During this pandemic, the available documentation to demonstrate matrix support actions was limited, and even so, the maximum score was not achieved in these two criteria. According to Qualifica’s criteria, such actions would have needed to be documented in photos, attendance lists, etc., which, due to the COVID-19 pandemic, was not possible. In the following three years, the minimum points were achieved to meet these criteria. The work methodology used was online, which optimized planning, communication, time savings, and increased the scope of training for RAS teams23.
The shared development of clinical and health guidelines between a reference team and professionals providing matrix support can prevent the fragmentation of work processes in the RAS. Furthermore, according to Campos and Domitti30, this methodology enables the exchange of knowledge among professionals at different levels of care, contributing to the positive transformation of situations and/or health problems of individuals and communities, thus expanding the possibilities for diagnosis and treatment.
On the other hand, the fragility of the coordination of ST actions in the RAS is well-known, as it was not yet effectively incorporated into the SUS agenda. Although progress has been made in the municipal SUS, intersectoral actions are timid and isolated, reflecting the predominance of the care dimension to the detriment of surveillance actions and undermining the comprehensive approach31.
Regarding criterion 7 - Quarterly monitoring of the indicators recommended in NI No. 61/2018-DSAST/SVS/MS, the production and dissemination of materials with epidemiological analyses, such as bulletins, reports, clippings, leaflets, cards, infographics, etc., were not carried out in 2020. The lack of publication of a quarterly newsletter resulted in a lack of satisfactory scores during the year. According to the annual management report, the lack of human resources and the pandemic period justify this absence22, a situation that was reversed with the publication of indicator analyses in 2022 and 2023, published in quarterly epidemiological/information bulletins.
According to PNSTT guidelines, CEREST plays a central role in monitoring ST indicators, which allows for social and political visibility of the impacts resulting from production processes and economic-social development models adopted in the territories32.
Criterion 8 - Conducting continuing education activities in ST for RAS professionals during the four-month period - observed a lack of activity in 2020, but from 2021 to 2023, the criteria received a maximum score. During this period, continuing education activities with the RAS were reorganized and conducted remotely17.
For Vieira et al.33, continuing education initiatives during the pandemic were essential for training and organizing the workforce, as healthcare workers are responsible for ensuring qualified care to meet the population’s health needs. It was recognized that there was a need for these workers to be trained, which increased the demand for training to adapt services during the pandemic, which also required the reorganization of healthcare activities.
Regarding criterion 9 - Recording of Educational Activities for the population carried out by CEREST, in 2020 and 2023, the score was unsatisfactory. Only in 2021 and 2022 were educational activities recorded for the population, achieving a maximum score. The absence or insufficiency of educational activities highlights a weakness in CEREST’s actions, which needs to be examined more closely in VISAT’s action planning, given that educational activities are fundamental to promoting active citizenship in defense of workers’ health. Furthermore, according to Ordinance No. 2,728/2009/GM32, CEREST must promote the integration of ST into the SUS, incorporating ST into the routine services. This has been highlighted as one of the weaknesses of the SUS, with the low presence of health education, prevention, and training actions, still undervalued by health professionals.
In the publication of the evaluation results for the years 2020 to 2023 (table 1), in all years, CEREST in Porto Alegre reached the desired percentile for each year in the ‘Qualifica Cerest’ targets, that is, from the perspective of comprehensive care for ST.
Conclusions
This study analyzed the implementation of the results of the ‘Qualifica Cerest’ program for the years 2020 to 2023 in the city of Porto Alegre, highlighting that Workers’ Health remains quite fragile. ‘Qualifica Cerest’ is a tool that assists teams in evaluating VISAT’s work and its planning processes. Thus, it enables the identification of elements that are sensitive to workers’ health, indicating the direction that strategies and actions should take, and providing support for improving health actions in the workplace. However, to be effective and increase its resolution, it is essential to guarantee and strengthen CEREST’s infrastructure, invest in the training of its professional staff, and promote stronger coordination between the different levels of management within the SUS.
The continuity and improvement of these actions are essential to ensure better working conditions and health protection for the working population, enforcing the PNSTT and enabling progress in the detection of occupational diseases and the promotion of healthier work environments.
However, gaps remain, such as ensuring equitable access to specialized services, expanding educational initiatives aimed at workers, and strengthening civic engagement, which requires closer ties with society, such as through Health Councils. However, this study did not record significant actions in this direction, which constitutes an agenda to be addressed in the management and operation of CEREST in Porto Alegre, as it resulted in the absence of social oversight as a fundamental component of health policy.
In addition to synthesizing the results and discussions of ‘Qualifica Cerest’, this study sought to promote reflections around the VISAT qualification agenda, increasingly necessary given the degradation of working conditions in general, particularly in a scenario of precariousness promoted by the deregulation of work, which poses enormous challenges for the fulfillment of CEREST’s responsibilities.
Data analysis revealed weaknesses in the source of information for the indicators, since SIA-SUS is structured in procedure tables, while continuing education and matrix support actions are recorded in forms that do not belong to official systems.
On a positive note, the Qualifica results showed that the CEREST team in Porto Alegre promoted reorganizations of work processes, resulting in the incorporation of actions with work methodologies that ensured effective actions in a context of restrictions and the pandemic crisis. However, it is necessary to strengthen the ST in Porto Alegre, considering the multiple aspects that impact ST and, thus, support interventions capable of mitigating the risks to which the working class is exposed and which threaten their health. The research found, despite the challenges posed, the strengthening and consolidation of RENAST at the municipal level. A limitation of the study is the difficulty in accessing management reports, as well as the scarcity of bibliography on the research topic.
Finally, it is worth noting that there is still a lack of understanding regarding the role of the SUS as responsible for the PNSTT, which requires workers, users, and management to consider this area as an integral part of health policy. This lack of understanding, if not addressed, tends to weaken the VISAT, whose agenda tends to be ineffective and to have a reduced impact on the social, economic, and political determinants of working-class health.
To ensure that CEREST’s actions are implemented effectively, further research and studies must be carried out to identify existing weaknesses and to identify initiatives that have been implemented and that have effectively contributed to the implementation of the PNSTT, particularly at the municipal level.
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Financial support:
Fundação Oswaldo Cruz (Fiocruz)
Data availability:
Research data are contained in the manuscript itself
References
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6 Hennington ÉA, Sant’Anna FCR, Pasche DF. Democracia faz bem à saúde? Gestão do trabalho e a vigilância em saúde do trabalhador (da saúde) [Internet]. In: Machado JMH, organizador. Saúde do trabalhador em tempos de desconstrução: caminhos de luta e resistência. Rio de Janeiro: Cebes; 2021 [acesso em 2025 mar 20]. p. 174-7. Disponível em: https://renastonline.ensp.fiocruz.br/sites/default/files/arquivos/recursos/almanaque_st.pdf
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7 Antunes R, Praun M. A sociedade dos adoecimentos no trabalho. Serv Soc Soc. 2015;(123):407-27. DOI: https://doi.org/10.1590/0101-6628.030
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8 Rede Nacional de Saúde do Trabalhador [Internet]. Meta de Saúde do Trabalhador no Plano Nacional de Saúde 2020/2023. Página Oficial da Web. Biblioteca; 2020 [acesso em 2025 fev 25]. Disponível em: https://renastonline.ensp.fiocruz.br/recursos/meta-saude-trabalhador-plano-nacional-saude-20202023
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9 Ministério da Saúde (BR). Plano Nacional de Saúde (PNS). Gov.br [Internet]. 2021 jun 14 [atualizado em 2025 jun 2; acesso em 2025 mar 15]. Disponível em: https://www.gov.br/saude/pt-br/acesso-a-informacao/gestao-do-sus/instrumentos-de-planejamento/pns
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11 Secretaria Municipal de Saúde (SP). Planejamento e monitoramento dos indicadores em saúde do trabalhador [Internet]. São Paulo: Prefeitura Municipal; 2021 [acesso em 2025 mar 6]. (Cadernos de Saúde do Trabalhador, n. 8). Disponível em: https://www.prefeitura.sp.gov.br/cidade/secretarias/upload/saude/8_2_cadernos_saude_trabalhador_qualifica_cerest_08_10_21.pdf
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12 Ministério da Saúde (BR), Secretaria de Vigilância em Saúde, Departamento de Saúde Ambiental, do Trabalhador e Vigilância das Emergências em Saúde Pública, Coordenação Geral de Saúde do Trabalhador. Nota Informativa nº 6/2021 CGSAT/DSASTE/SVS/MS: orienta a realização das ações para atender aos critérios constantes no Indicador de Saúde do Trabalhador no Plano Nacional de Saúde - PNS 2020/2023 “Percentual de Cerest regionais e municipais com atuação satisfatória” [Internet]. Brasília, DF: Ministério da Saúde; 2021 [acesso em 2024 jan 13]. Disponível em: https://www.cevs.rs.gov.br/upload/arquivos/202103/22165240-nota-informativa-n-06-2021-cgsat-1.pdf
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13 Ministério da Saúde (BR), Secretaria de Vigilância em Saúde, Departamento de Saúde Ambiental, do Trabalhador e Vigilância das Emergências em Saúde Pública, Coordenação Geral de Saúde do Trabalhador. Nota Informativa nº 7/2021 CGSAT/DSASTE/SVS/MS: reorienta a realização das ações para atender aos critérios contidos no Indicador de Saúde do Trabalhador no Plano Nacional de Saúde - PNS 2020/2023 “Percentual de Cerest regionais e municipais com atuação satisfatória” [Internet]. Brasília, DF: Ministério da Saúde; 2021 [acesso em 2024 jan 13]. Disponível em: https://www.cevs.rs.gov.br/upload/arquivos/202106/29101142-sei-ms-0020971888-nota-informativa.pdf
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14 Ministério da Saúde (BR), Secretaria de Vigilância em Saúde, Departamento de Vigilância em Saúde Ambiental e Saúde do Trabalhador - DSAST. Nota Informativa nº 61/2018 DSAST/SVS/MS: informa sobre os indicadores de saúde do trabalhador a serem monitorados pelos Cerest quadrimestralmente [Internet]. Brasília, DF: Ministério da Saúde; 2018 [acesso em 2024 jan 13]. Disponível em: https://cevs.rs.gov.br/upload/arquivos/202003/10115821-nota-informativa-61.pdf
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15 Ministério da Saúde (BR), Secretaria de Vigilância em Saúde, Departamento de Saúde Ambiental, do Trabalhador e Vigilância das Emergências em Saúde Pública. Nota Informativa nº 94/2019 DSASTE/SVS/MS: orientação sobre as novas definições dos agravos e doenças relacionados ao trabalho do Sistema de Informação de Agravos de Notificação (Sinan) [Internet]. Brasília, DF: Ministério da Saúde; 2019 [acesso em 2024 jan 13]. Disponível em: https://www.saude.ba.gov.br/wp-content/uploads/2019/09/NOTA-INFORMATIVA-N.-942019-DSASTESVSMS.pdf
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17 Porto Alegre (RS), Secretaria Municipal de Saúde. Portaria 1.186/2018. Regulamenta a Política Municipal de Saúde do Trabalhador e da Trabalhadora de Porto Alegre. Diário Oficial de Porto Alegre [Internet], Porto Alegre, 2018 jan 10 [acesso em 2025 mar 25]; Edição 5913:17. Disponível em: https://dopaonlineupload.procempa.com.br/dopaonlineupload/2740_ce_20190110_executivo.pdf
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18 Rio Grande do Sul (RS), Secretaria da Saúde. Resolução nº 019/20RS. Altera a abrangência do CEREST Metropolitano para atendimento exclusivo para o município de Porto Alegre. Diário Oficial do Estado do Rio Grande do Sul [Internet], Porto Alegre, RS. 2020 jan 20 [acesso em 2025 mar 25]; Edição 13:63. Disponível em: https://www.diariooficial.rs.gov.br/diario?td=DOE&dt=2020-01-20&pg=63
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26 Ministério da Saúde (BR), Secretaria de Atenção à Saúde, Secretaria de Vigilância em Saúde. Saúde do trabalhador e da trabalhadora [Internet]. Brasília, DF: Ministério da Saúde; 2018 [acesso em 2025 mar 1]. 136 p. (Cadernos de Atenção Básica, n. 41). Disponível em: http://renastonline.ensp.fiocruz.br/recursos/caderno-atencao-basica-41-saude-trabalhador-trabalhador
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29 Ministério da Saúde (BR), Secretaria de Vigilância em Saúde, Departamento de Vigilância em Saúde Ambiental e Saúde do Trabalhador. Coleção Visat: Vigilância em Saúde do Trabalhador [Internet]. Brasília, DF: Ministério da Saúde; 2023 [acesso em 2025 jan 26]. Disponível em: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/svsa/saude-do-trabalhador/colecao-visat-volume-1.pdf
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32 Ministério da Saúde (BR), Gabinete do Ministro. Portaria nº 2.728, de 11 de novembro de 2009. Dispõe sobre a Rede Nacional de Atenção Integral à Saúde do Trabalhador (RENAST) e dá outras providências. Diário Oficial da União [Internet], Brasília, DF. 2009 nov 12 [acesso em 2025 mar 15]; Edição 216; Seção I:76. Disponível em: https://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?data=12/11/2009&jornal=1&pagina=76&totalArquivos=128
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33 Vieira SL, Souza SG, Figueiredo CF, et al. Ações de educação permanente em saúde em tempos de pandemia: prioridades nos planos estaduais e nacional de contingência. Ciênc saúde coletiva. 2023;28(5):1377-86. DOI: https://doi.org/10.1590/1413-81232023285.1125202
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Editor in charge: Ronaldo Teodoro
Publication Dates
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Publication in this collection
06 Oct 2025 -
Date of issue
2025
History
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Received
09 Apr 2025 -
Accepted
01 July 2025
