THE INSERTION OF THE UNIVERSITY INTO THE FOUR PILLARS OF CONTINUOUS EDUCATION IN HEALTH : EXPERIENCE REPORT

Continuous Health Education has been recognized as an important dimension of the management of the Brazilian health system, with the purpose of ensuring that the individuals involved receive the necessary support to ensure the effectiveness of its principles and guidelines. This report presents the experience of a public university participating in a Permanent Commission for Education-Service Integration through the involvement of a nursing program. Clear benefits arise from greater proximity between the university and regional demands and the ability to engage students and professors in nursing research and extension efforts. The challenges are related to poor adherence of the representatives of the segments that are part of the Commission, especially concerning social control. Among the future requirements suggested are actions that evaluate the processes of Continuous Health Education and investment in the development and consolidation of this policy at the regional level. DESCRIPTORS: Education, continuing. Teaching. Education, nursing. Human resources formation. LA INSERCIÓN DE LA UNIVERSIDAD EN EL CUADRILÁTERO DE LA EDUCACIÓN EN ENFERMERÍA: RELATO DE LA EXPERIENCIA RESUMEN: La Educación Permanente en Salud es una dimensión importante de la gestión del sistema de salud de Brasil, que objetiva asegurar a las personas involucradas, el apoyo necesario para la efectividad de sus principios. Este relato tiene como objetivo presentar la experiencia de una universidad pública en conjunto con una Comisión Permanente para la Enseñanza e Integración a través de la participación del curso de enfermería. Son claras las ventajas con respecto a la aproximación de la universidad con las demandas regionales y la capacidad de involucrar a los estudiantes y profesores de enfermería en la investigación y la extensión docente. Los desafíos están relacionados con el déficit de adherencia de los representantes de los sectores que forman parte de la Comisión, en especial de control social. Entre las futuras demandas son acciones sugeridas para la evaluación de los procesos de Educación Permanente en Salud y la inversión en el desarrollo y la consolidación de esta política a nivel regional. DESCRIPTORES: Educación continua. Enseñanza. Educación en enfermería. Formación de recursos humanos. http://dx.doi.org/10.1590/0104-07072016002530013


INTRODUCTION
One of the most important advancements encouraged by the 8 th National Conference of Health in 1986 that took place in Brazil is an enlarged conception of health, because the discussions that arose from it resulted in the creation of the Unified Health System (SUS).Because Primary Health Care (PHC) is the system's main axis to meet the health needs of Brazilians, alternative proposals seeking to induce a paradigm shift entered the agenda, among them, the Family Health Strategy (ESF), which is considered the core element of the Brazilian Policy of Primary Health Care.This strategy is intended to strengthen and organize PHC in Brazil and focuses on the care provided to families within their area of residence, favoring increased access and the reorientation of practices toward interdisciplinary actions, integral care, and health promotion.The Family Health Strategy proposes a change in the conception of the healthdisease continuum, departing from the traditional model of care, focused on the disease, and investing in actions that couple health with quality of life. 1 There was, in the 2000s, a large expansion in the number of professionals working for ESF and, aiming to meet the operational guidelines established by the SUS, city managers sought initiatives linked to Continuing Education in Health (EPS)to direct the education of workers toward the problemsolving rationale, which takes into account the community's environment and lifestyle and focuses on the quality of services.These investments imply reaffirming the constitutional principles established for the SUS, namely universal access, equity and the integrality of actions. 2 Therefore, projects intended to change the education of professionals point to the need for a new profile, one that absorbs transformations in the world of labor and new human competencies desired in the health field, in opposition to the hegemonic model of biological training, strongly reinforced since the 1960s in the American coutries and which is centered on disease and hospital care. 3th the gradual consolidation of the SUS and the constitutional requirement of maintaining the organization and training of human resources in the health field within the system's sphere, the Brazilian Ministries of Health and Education established strategies to conduct the training and professional qualification processes in the health field in partnership, involving both formal education and EPS. 2 Aiming to overcome the traditional conceptions of education in the health field, in November 2003, the ministries presented the National Policy of Continuous Education in Health (PNEPS) through Decree No. 198/04.PNEPS was a proposal of strategic action to transform and qualify health practices, the organization of actions and services, educational processes, and pedagogical practices, in order to qualify health workers.5] In this sense, the current PNEPS, which was reformulated in 2007 through Regulation No. 1996/07, in order to meet the peculiarities and inequalities present in the country, requires strategies to integrate education and service with greater commitment on the part of health and education sectors, workers from the SUS, researchers, professors and students.The goal is to construct a national policy of education and qualification of professionals that is consistent with the guidelines and principles of this new health care model. 6S is seen as service-learning, with the incorporation of learning and teaching into the routine of organizations and the labor process to ensure significant learning and the possibility of transforming professional practice.To this end, service-learning is based on problems faced in the real context and takes into account the individuals' previous knowledge and experiences by problematizing the working process and acknowledging that the need for education and the qualification of workers are both based on the individuals' and populations' health needs. 6The training/qualification processes require actions in the spheres of working organization, interaction with management networks and healthcare services, and social control in the sector, in agreement with the SUS and with the real needs of the population.
The regulation that revised and established new guidelines and strategies for the PNEPS implementation to adapt it to the SUS's operational guidelines, stipulates that the regional leadership of the policy is established by Regional Management Boards.These boards are composed of city health managers from a given region and, through new regulation, were appointed as Regional Inter-Manager Commissions. 7These commissions, in turn, are supported by Permanent Commissions of Service-Learning Integration (CIESs), which are provided in the regulation and participate in the development, execution, monitoring and assessment of actions implemented by EPS.CIESs as an inter-sector and regional device should be composed of health managers, education managers, SUS workers, and teaching institutions and should provide programs in the health field, through their different segments and social movements that are linked to the management of public health policies and the SUS' social control. 6thors 8 emphasize that the concept and consolidation of these "four pillars" (education, management, care delivery, and social control) depend on the quality of education, which results from reflection on relevant criteria for technicalprofessional development and planning of the healthcare network, taking into account patients' uniqueness.
In order to meet the Master Plan for Regionalization from 2002 and the Regulation No. 1.996/07, the state of Santa Catarina recomposed CIESs taking into account the basis already established by the Continuous Education Centers structured beginning in 2004, as processes oriented toward the PNEPS' objectives. The PNEPS '  From this perspective, this report's aim was to present the experience of a public university with representation in the CIES from the West Macroregion of Santa Catarina in participating and cooperating with the Commission, between 2011 and 2013, to share the experience and contribute to its dissemination and the construction of consultation materials for managers (from both education and service), healthcare workers, Higher Education Institutions (HEI) with programs in the health field, and the community in general.

Conceptualizing Continuing Education in Health in the West of Santa Catarina
The implementation process concerning the Regional Development Plan in 2008 in Santa Catarina revealed the need to revise the Regional Inter-Manager Commissions, thus, the state is currently composed of 16 Regional Inter-Manager Commissions (CIRs) and 15 Permanent Commissions of Service-Learning Integration (CIESs) that encompass all the health macro-regions and, consequently, all the cities within the state.Coordination and leading of the PNEPS within the States is a responsibility of the State Health Departments, which in Santa Catarina, are supported by the State Departments of Regional Development (SDRs). 5 With the regionalization process proposed by the Ministry of Health (MH), the Health Region consists of a territorial base for the planning of healthcare delivery, to be defined by the State Health Department according to local specificities. 11In this context, the West Macro-Region of Santa Catarina is composed of 26 municipalities governed by one CIR and, in regard to EPS, assisted by one CIES.The demands concerning continuous education actions presented by the municipalities that compose this Region of CIR and CIES should be organized, as provided in Appendix II of the Regulation GM/MS No. 1.996/07, on the bases of the development of a Regional Actions Plan for Continuous Education in Health (PAREPS). 6e macro-region CIES, since 2008, has the support of one coordinator/organizer, of representative members of the four pillars of each of the 26 municipalities that compose the Macro-region, in addition to representatives of non-governmental organizations, HEI with programs in the health field, municipal associations, health managers and social control managers.Initially, the connection among these was performed by the representative of the SDR Health management in Chapecó, a municipality considered to be the hub in the Macro-region.Beginning in 2011, this connection started being performed by a representative of the education segment, together with the nursing program of one university, supported by the SDR's deputyorganizer.This decision took place in the assemblies of the regional institutions (CIR and CIES), due to the integration of education and service in the development of the Continuous Education Policy.The responsibilities of the CIES' organizers consist of organizing and planning this Policy at the regional level, meeting what was established by PAREPS and other regional demands.
The CIES' monthly assemblies occur on the same days the CIR meetings take place.These assemblies include discussions concerning EPS demands, detailed planning for future initiatives, and assessment of ongoing actions.Afterwards, discussions are submitted to the discretion of CIR meetings and approved according to the deliberation of the local health managers.

Actions developed and monitored by Permanent Comission of Service-Learning Integration: perspectives and challenges
Since 2011, has CIES actively monitored "inter-ministerial structuring actions" developed in the Universidade Comunitária Regional de Chapecó (Unochapecó) and in the Universidade Federal de Santa Catarina (UFSC).These actions are devices to re-organize education in the health field, considering the integration between education and service and are intended to improve educational programs in the health field in order to meet the National Curricular Guidelines (DCNs) and the SUS' principles and guidelines. 2,10In this sense, we highlight, within the sphere of CIES in the West of Santa Catarina, the monitoring of the National Program of Reorientation of Professional Education in Health (Pró-Saúde) [Pro Health] and the Program for Education for the Work in Health (PET-Saúde), developed through an integrated proposal by Unochapecó and the Health Department of this municipality, in addition to the SUS University of Alberta (UNA-SUS), the "Multidisciplinary Specialization in Family Health -Distance Learning" program of which is administered in the 26 cities in the region and other states in Santa Catarina.Considering the initiatives of these HEIs, it is evident that there is engagement of students in the process of continuous education as they develop "learning-to-learn" skills centered on an active learning process focused on competen-cies, evidence, and problem-solving to deal with the problems within the community.We also note the diversification in the contexts of practice and the inclusion of students within the SUS in the beginning of their training, encouraging them to create and devise proposals intended to change and improve working conditions. 12-Universidade Comunitária Regional de Chapecó13 In 2011, CIES concluded the first assessment survey of one of the courses "Introduction to Family Health Teams", the results of which were analyzed by professors and students with scholarships from a nursing program of one of the active universities within CIES and later submitted to a Brazilian periodical.In convergence with this initiative, it is worth noting that nursing education, as well as research in this field, has been characterized in recent years by a series of transformations in the search for knowledge and qualification, generating intellectual growth in care practice.This is confirmed by noting the curricular change within the nursing programs committed to courses that focus on research. 14ong other things, we observed that, even though the methodology of the Introduction course, based on the problematization of the service's routine, seems to favor the incorporation of content into the practices of teams, further studies are needed to measure its impact on the qualification of the work process.These findings, as well as the active participation of the HEIs in the EPS process, has encouraged other studies involving professors, students and healthcare workers.
In 2012, sensitization activities were promoted among SUS professionals and managers aiming to improve the quality of prenatal care, and care delivered during labor and post-delivery in the region, due to the need to consolidate the Rede Cegonha This network is an MH strategy, grounded on the principles of humanization of care, and implemented by the SUS in order to improve the access to and quality of care provided at the time of birth in the public health network.The guidelines of this network include the qualification of healthcare workers to provide safe and humanized care, the creation of mother and infant centers to assist high-risk pregnancies, and vaginal-delivery centers to meet the demands of humanized births for the low-risk cases. 15om this perspective, in agreement with the fields elected by the MH as being priorities for SUS intervention, this initiative was considered one of the demands relevant to educational processes among managers and professionals, taking into consideration the investment of the MH to improving indexes and qualification/humanization of this type of care.In developing countries such as Brazil, a considerable number of women die due to pregnancy-related complications, such as Hypertensive Disorders of Pregnancy (HDP), a fact that exposes failures in healthcare delivery. 16e 8 th annual Nursing Week in 2012, and the 9 th annual Nursing Week, organized by the Brazilian Association of Nursing (ABEn) in Chapecó Center in 2013, also participated in CIES in consideration of a profession that has increasingly become qualified, has grown and is inserted into a transformative process in diverse contexts of practice in the health field. 17ong the challenges identified in the process of including the university in the monitoring and coordination of EPS actions in the Macro-region, we highlight the incipient participation of the segments representing the EPS' four pillars in the 26 cities that compose CIES, especially the pillar concerning social control, despite the numerous contacts and invitations.A possible explanation for this poor participation is that it is a relatively recent policy and experience shows that actors involved in newly implemented policies need time to process and became sensitized to them.Nonetheless, studies addressing health boards 18 , such as inter-sector institutions that favor the social construction of citizenship and the emergence of social agents prepared to influence the management and production of policies and actions, show the need for a continuous educational process, enabling individuals to fulfill their roles with confidence and autonomy.In agreement with such clarifications, a demand emerges within CIES to provide educational actions focused on the subjects that compose EPS' four pillars, in order to sensitize these individuals and prepare them to participate in and become co-responsible for this policy.
Another aspect related to this view has to do with the conceptual interpretations of continuous education on the part of those involved in the local organization of this policy.It is known that educational processes need to be dynamic and continuous and promote social advancements, in addition to promoting the qualification of people involved.Continuous educational programs are restricted to recycling specific types of knowledge, the operationalization of which takes place after a general reading of problems and topics to be addressed, usually under the format of coursework. 19The logic of continuous education is based on decentralized, ascendant and multidisciplinary practices, taking into account the needs that emerge from the work processes of health staffs. 5e main objective of continuous education is the effective transformation of practices and "critical knots" identified and dealt with in care delivery or management, which enables the establishment of contextualized strategies that promote a dialogue between the general policies and the uniqueness of spaces and subjects.Such assumptions follow the conceptual definitions presented by the Pan-American Health Organization (PAHO) 20 in the 1980s, based on practices defined by knowledge and work relations, elements that make sense for those involved and that, when problematized, can promote transformation in the work process. 4,8,20The initiatives of CIES in the West Macro-region has usually been based on actions that may be classified as continuous education in the format of coursework and focused on the development of specific skills.
Despite conceptual mistakes and the poor participation of those that compose CIES, i.e., the organization of practices falling under the responsibility of individuals who are not very active, the EPS Policy is gradually becoming consistent in this Macro-region.Such a fact becomes apparent in meetings within CIR, in which a broader agenda involving EPS-related issues, as well as the support of managers for the proposed actions, is perceived.It is believed that integration between education and service is another factor that is becoming consolidated as a favorable point moving toward valorization of the subject (professor, worker, manager or patient) in the process of providing care with a view to improve the quality of healthcare delivery.
It is worth noting that during the period in which CIES and the university started cooperating, only a small portion of the financial resource provided by the MH to the Commission for 2012 was used due to a delay in making the resources available, bureaucratization, and difficulty in operationalizing the money transfer.This last event, among others, shows some of the difficulties faced and the need to place value in the policy, especially in regard to its operationalization and development.

FINAL CONSIDERATIONS
The positive aspects of the EPS Policy in the Macro-region include the partnerships established with the cities and the Health Department, mainly represented by the SDR Health Management in Chapecó, in addition to considering it relevant among the service managers and education in the health field.Among the challenges, the following stand out: difficulty meeting the specific demands of the different municipalities, of establishing more solid bonds among the sectors represented within the Commission, as well as weak investment in the policy's development.
In regard to the experience of cooperation between CIES and the university, there are clear benefits in regard to a greater proximity between academia and regional demands and the possibility of involving nursing professors and students in research and related extension activities.Additionally, it was possible to establish greater integration and more partnerships with other HEIs and programs in the health field in Chapecó and other cities in the state, shortening geographic distances.
Among future demands for CIES in the West Macro-region of the state, we suggest actions directed to the assessment of EPS processes and investment in its enlargement, development and consolidation.Among these broad goals, two stand out: the continuous sensitization of managers in regard to their participation, and fostering cooperation with other sectors, especially social control within CIES and strengthening EPS at the city level.
management in Santa Catarina has been coordinated at the state level through the Directorate of Continuing Education in Health, which has a Division of Continuous Education with this specific responsibility.The State CIES was established during the 2 nd State Seminar of Work Management and Education in Health, which occurred in August 2010.The State CIES was structured with its own statute and a monthly meeting agenda.It is a space where experiences and decisions related to the EPS' actions can be shared among the 16 CIESs that composed the state level.The individuals composing the 16 CIESs participate in the State CIES, together with technicians from the State Health Department, representatives of Public Health Schools, Health Education School (EFOS), Technical School of Blumenau, Universities, and also representatives from the State Health Council, State Board of Education, and the Council of City Health Departments (COSEMS). 10