Reflexões acerca da integralidade nas reformas sanitária e agrária

Trata-se de um ensaio reflexivo com o objetivo de discutir as reformas agraria e sanitaria do ponto de vista da integralidade da atencao a saude das familias assentadas. No desenvolvimento desta reflexao identificou-se que tanto a reforma agraria quanto a sanitaria apresentaram, desde sua concepcao, o desejo por diminuir as injusticas sociais, alcancar a integralidade e o bem-estar dos individuos e familias, seja no contexto da primeira, voltada para os individuos e familias sem terra, ou da segunda, voltada para todos os individuos e familias em geral. Entretanto observou-se nestes dois contextos de reforma politica e social acoes desintegradas e desarticuladas, pautadas em interesses economicos, corroborando para a marginalizacao da populacao rural no âmbito da atencao a saude e principalmente da integralidade desta.


INTRODUCTION
The concept of integrality is very complex and has been discussed by various authors in many healthcare settings.] Nonetheless, countless limitations are observed in relation to universal access to health services and the development of integral healthcare delivery, especially if we consider the social and economic differences in Brazil.
We propose a reflection concerning some conceptions of integrality and invite the reader to consider the history of the Brazilian Healthcare and Agrarian Reforms to identify the existing relationship between integrality and the Healthcare and Agrarian Reforms.Some questions are suggested to initiate a discussion about these issues.Was the Healthcare Reform able to develop or achieve its objective to reduce social injustice, and achieve universality and integrality for the entire Brazilian population?Did the Agrarian Reform achieve its objectives to end social exclusion, reduce social injustice and ensure the well being and health of rural workers?

Integrality
Integrality is a polysemic concept; a term with ethical, democratic and multi-dimension. 3ntegrality is revealed in the different types of knowledge and routine work practices and experiences of individuals in different contexts, also recognized as an integrating axis among health services when perceived from a systemic view. 4ogether with universality and equity, integrality constitutes a triple concept of the Healthcare Reform, which encompasses the ideal of citizenship, health as a right of all, and overcoming injustices. 5It is one of the pillars of SUS defined in the Federal Constitution of 1988; complying with it favors the quality of healthcare delivery, in which is included the coordinated implementation of health promotion, prevention of risk factors, assistance to rehabilitation. 6It is the only finalistic principle of SUS, as an attribute of what is expected from this system, that is, providing expanded care to groups and individuals. 3is pillar should be developed in two dimensions.The first is the result of efforts on the part of and convergence of different types of knowledge from a multidisciplinary staff in the concrete and singular space of health services in an encounter between users and the staff.This includes a commitment to better listen to the health needs of the service users, 5 based on humanization, problematization and interlocution among different types of knowledge and practices in a interpersonal dialogical relationship. 7At the same time, integrality should also be developed through the coordination of health services, considered at a macro level and in the service network, as an object to reflect upon new practices in order to reorganize the services and work processes in order to establish public policies focused on the complexity of the healthcare service. 7erefore, the delivery of integral healthcare goes through the organizational, hierarchical, and regionalized healthcare structures and achieves the quality of individual and collective healthcare, based on the users of the healthcare system. 8ong the meanings of integrality, this can be achieved in the scope of the practices of health workers through abandoning reductionism and fragmentation, and searching for a holistic and enlarged view that continues in the area of health services organization, seeking to more broadly define the perceptions held of groups' needs and the best way to meet such needs.Integrality should be achieved through the incorporation of promotion, prevention, treatment, and rehabilitation at all levels in the purview of health policies and governmental responses to the population's health needs. 98] It presents a plurality of actions that are not restricted to accessibility but goes beyond therapeutic planning, including the regulation of health public policies, reorientation of the relationship between the State and society, and attention to the subject-user, considering care in all dimensions of the human being. 7

HEALTHCARE REFORM AND THE CONCEPT OF INTEGRALITY
The historical movement of health policies is related to the political, social and economic movement of Brazilian society.The actors of the process of public health construction reproduced the logic of capital in all actions.Over the course of history, the conception and practice of health care integrality remained distant from the settings of legislation and practice. 10he view of the evolutionary process has always followed the advancement of capitalism, with strong influences from international capitalism.Health has not always been the focus of the Brazilian government, not in relation to the solution of important problems or in relation to the allotment of resources to the health sector. 10 The trajectory of the Brazilian health policy begins with the construction of purposes of struggling groups, which influence the shaping of the system. 5Hence, health problems, over a long time in this trajectory, became the focus of attention when they were epidemic and fell out of focus when they became endemic. 11ublic health activities in 1850 were restricted to the delegation of sanitary responsibilities to municipal communities and to the control of ships and health in ports.The main interest was minimum health control.The empire's political organization was a regimen of unitary and centralizing government. 11ith the republic, a political and legal organization that is typical of the capitalist state was established.The tradition of political control being in the hands of large landowners imposed standards for the exercise of power according to the primarily agrarian capitalist interests. 10he economy in the 20 th century was agriculture-based destined for exportation, supported on the monoculture of coffee.Accumulation of capital originated in international trade, a fact that boosted industrialization and consequently favored urbanization.In this context, severe diseases such as smallpox, malaria, yellow fever and others emerged and negatively affected Brazilian economic development.] Still in the 20 th century, Oswaldo Cruz organized the Public Health Office, implemented demographic records, and introduced laboratories for etiological diagnosis.Carlos Chagas restruc-tured the National Health Department linked to the Ministry of Justice in an attempt to improve health conditions without, however, abandoning political and economic interests.] It is worth mentioning that among the considerations provided in this law was the condition that this benefit not be extended to rural workers. 10he CAP'S were organized per company and depended on the workers' ability to organize and mobilize; workers also had to pay for the costs of these CAP'S.The Getulio Vargas' government, aiming to extend this benefit to all the categories of the working class, replaced the CAP'S with the Retirement and Pension Institute.] It is clear that by the end of the 1950s, medical care and welfare assistance were not relevant for the State or among its main objectives.Actions and measures were not totally effective and always excluded some group or part of the working class, as happened with rural workers.
The Ministry of Health and the National Department for Rural Endemic Diseases were cre-Brazil.We sought then to understand the healthdisease continuum in close relationship with the population's living and working conditions.Therefore, healthcare reform was reformulated with a view to break with the traditional corporate order and to reverse the tendency to privatization in the sector's policy. 10he Constitution of 1988 12 provides that health is a "right of all and a duty of the State", ensuring, through social and economic policies, reduced risk for diseases and other injuries, in addition to universal and equal access to actions and services aimed to promote, protect and recover health.:1 The view of health that refers us to the reform of healthcare models presents the need to collectively and socially construct health practices that take place through a dialectic process, where distinct practices are involved, linked to the political and technical dimensions.These dimensions, once combined according to their cost-effectiveness relationship, result in healthcare practices focused on the needs of individuals, families and communities.
Longing for the afore described care model defined in the health concept that expresses Law 8080, the Brazilian healthcare system has undergone, for two decades, a process of change that was initiated in the 1980s with the Healthcare Reform movement.Nonetheless, even today, we seek to create conditions for the healthcare system to effectively and permanently reach individuals and become more humane, supportive, and more importantly, more resolute.In other words, we are determined for the system to implement integrality provided as a principle of SUS.
Healthcare reform intended to print on healthcare delivery a more integral practice and perspective, using integrality and the construction of social justice as principles, but such a goal has not always being evidenced.On the contrary, what is actually apparent in the entire history of the SUS is a frayed system and incomplete healthcare reform. 14Universal access to services, professional coordination, and problem-solving capacity are not actually implemented in Health Units, which expose users to a fragmented, unqualified and unjust healthcare delivery. 15mong the various reasons that may have led to this sense of incompleteness is the inheritance of a health network focused on curative actions, on medical work, and on the division of tasks driven by an economic model and by the interest of the State, which has not always targeted prevention of diseases and health promotion.
Such a fact currently presents a challenge for the integral delivery of healthcare, since work has been traditionally organized in an extremely fragmented manner, also hindering universalization.
After 20 years of Health Reform, great difficulties still remain in terms of access to health services and the continuity of care.Such difficulties are related to problems in the organization of services, the absence of a regionalized and hierarchical network, poor regulation and inadequate referral and counter-referral mechanisms. 16

AGRARIAN REFORM AND THE RURAL POPULATION'S ACCESS TO HEALTH SERVICES
The agrarian issue has always been present in the Brazilian development process and has evolved in innumerous manners and gone through various phases. 17Some authors consider that the struggle for land in Brazil begun with the occupation of the Portuguese and is marked by the end of slavery with the threat of the slaves themselves becoming owners.Land no longer was acquired by possession and, therefore, began to be sold.] The emergence of peasant leagues from the Northeast is observed at the end of the 1950s, which boosted the struggle for agrarian reform. * T.N.Latifundia refers to great landed estate that belongs to one single person, family or company and is characterized by insufficient exploration of resources.
At the end of the 1970s, conflicts in the country intensified, giving rise to occupations and social movements in favor for the struggle for land.] This excluding economic model speeds up the need for an Agrarian Reform Program and landholding interventions that give rise to the settlement project of the National Institute of Colonization and Agrarian Reform (INCRA). 18grarian Reform is a package of measures aimed to promote better distribution of land by changing ownership and use, generating social justice, progress and well being for rural workers and economic development for the country. 19A rural settlement is a family-based associate business unit, autonomous and managed by workers, that aims to promote the economic and social development of all the settlers. 19n this context, Brazil implements in the 1980s a policy to establish settlements in various regions in the country.Thereby, through INCRA, rural settlements are supported by its credit policy, which finances the implementation of significant resources for housing, sustenance for the settlement family during the first year, in addition to funding the costs of production and providing credit for production investment with terms and grace periods 18 The Constitution of 1988 12 provides a special chapter for Agrarian Reform, stating that it is the role of the federal government to expropriategiven social interest and seeking agrarian reform -a rural property that is not performing its social function (chapter III, article184).However, it also establishes mandatory payment of the expropriated property prior to expropriation (which has hindered the process).Additionally, so-called "productive properties" could not be expropriated due to social interest in implementing rural settlements.These aspects negatively impacted Agrarian Reform. 18here are currently in Brazil 8,763 settlements and approximately one million settled families. 20It is the family itself who organizes and performs productive activities in the settlements.Defined as family farming, the family owns the production means and at the same time works on the productive property. 18ven those promoting settlements acknowledge that Agrarian Reform does not only mean access to land, but a set of actions aimed to assist families to produce, generate income and also access essential rights such as health.
Scientific production in Brazil is still insufficient to explain complex relationships between the determinants of health and the health conditions of the rural population.A study organized by the Center of Agrarian Studies and Rural Development (NEAD) addressed the access of the settled population to health services.It was conducted in 16 Brazilian cities and observed that such access is still insufficient, considering the poor medical care provided to these families, the unfinished projects and care programs, inactive health units, lack of health workers, and difficult transportation for patients who require ambulatory medical care and/or hospital care, among others. 21t is important to note that access to health services does not only mean the entrance of users into the system, but the possibility of meeting the needs that led individuals to seek the service in the first place, which may occur at the primary care level, as happens in the Family Primary Heath Care Unit (UABSF) or at other levels.
The Rural Assistance Program (PRORURAL) was created in 1971 through the FUNRURAL.1] However, access was only possible in health institutions linked to the FUNRURAL; rural settlements, which did not exist at the time, were not included.
In 1980 INAMPS enabled access for rural workers in any of its healthcare facilities, which increased access for these workers, especially in hospitals. 11At the same time access improved, health policies were still unequal, both in terms of quantitative and qualitative access to those living in rural areas, compared to residents of urban areas, outlining a process that was consolidated in the 1980s and that was called "excluding universalization" of health policies. 21iscussions concerning the health of the rural population have drawn the attention of managers and politicians since the 1970s and 1980s, a time when Agrarian Reform was not yet established, as there were few rural settlements.
Current discussions concerning the health of the rural population was boosted by the 12 th National Health Conference in 2004, which indicated that one of the main current challenges is to ensure rural populations have effective access to the health system. 22ince then, the Ministry of Health has discussed the construction of a Health Policy for the Rural Population based on the National Plan of Agrarian Reform, the National Health Plan, the National Policy of the Humanization of Management and Healthcare, on the Amazonia Project, Policies to Promote Racial Equality, on the National Policy of Regional Development and on the National Policy of Territorial Planning.
Such a policy should be integrated into a set of public policies designed to raise the living standards of the population through inter-sector actions with a view to generate jobs and income, to promote environmental sanitation, housing, rural electricity, education, culture, leisure, access to land, and safe transportation.

CONSIDERATIONS CONCERNING INTEGRALITY IN HEALTH REFORM AND AGRARIAN REFORM
It became apparent that in recent years, due to the course of the Health and Agrarian Reforms, Brazil has tried to change the current and hegemonic health care model marked by fragmented actions and overvaluation of biomedical aspects.At the same time, an ideological struggle to reduce social inequality has also escalated.The reason is that the Health Reform and re-democratization movements in Brazil have always been associated with social justice and equity. 23onetheless, we observe in both Health and the Agrarian Reforms that the rural population has always been left outside the main health measures, while integrality and equity have never been achieved.During most of the last century, universality of health rights was ensured only to the social security beneficiaries, maintained by the Social Security Ministry, generating the delivery of curative healthcare, strongly excluding the rural population, and favoring the development of social inequality and differences in access to health services, especially if we consider the large urban centers and wealthier economies.
We note that despite the efforts toward these reforms, they present similar phases; such struggle occurred in a disconnected manner, supported on political and economic issues, and interests focused on an economic model that resulted in uncoordinated political actions.The health services and programs corroborate this situation, which in general, were and still are almost exclusively designed for the urban population. 24At the same time, the settlement process occurs through fragmented and uncoordinated public policies. 25udies addressing the living and health conditions of the settled population are rare, but the existing ones portray disconnection and detachment from the implementation of integrality.Most settlements present conditions that put the health of the population at risk such as a lack of running water, cesspools, and burned or buried garbage. 24Health needs can be organized into four large groups: the first comprises living conditions and the second refers to access to health technology. 6Access to healthcare is linked to living conditions, nutrition, housing, and accessibility of health services. 13In terms of access to health services, some settlements have family health units within the settlement itself, though in some cases, these units open only twice a week.In other cases, the settlement population needs to seek the health units available in the nearest town. 21,24This search for services in other health units overcrowd those services causing an excess of clients in relation to the number of personnel and disrupts the organization of healthcare delivery. 27hese situations are aggravated by the poor referral and counter-referral systems, which as shown by another study, hinders the continuity of care at the different levels of healthcare. 15onsidering the issues previously discussed, we observed that the rural population, specifically the settlement population, is at a disadvantage in terms of healthcare because it is not favored by the principles of universality nor by the practice of integrality.Such exclusion occurs due to the historical process previously described in which health practices are disconnected and the development of reform is fragmented also due to the configuration of professional and organizational practice of the health services.
Facing this reality and considering integrality as a result of professional knowledge and competence, cooperation between health workers and health services and among the health services and other organizations is needed to structure health services in order to meet the various health needs of the population seeking equity, whether in terms of spontaneous demand (when individuals express their suffering) or in the development of promotion and prevention actions.Hence, health managers and workers, especially physicians and nurses, should work in a coordinated manner in the management of health actions focused on the settlement-based rural population to meet their health needs, taking into account the local and regional histories of each settlement, their social, economic and cultural formation with the active participation of the community.
Despite its limitations, this paper discusses the importance of health actions and/or agrarian reform actions to be implemented while taking into account inter-sector and interdisciplinary actions so that integrality is not simply a guideline provided by the SUS but its practice and constitutes a battle flag of the reforms presented here.