Programa de Formação Técnica em Enfermagem para Agentes de Saúde: when a professional trainning becomes another threat to SUS

In January, the Brazilian Ministry of Health (MS, from the Portuguese Ministério da Saúde) published ordinance n. 83/2018 (Brasil, 2018), whose aim is the professional training of community healthcare agents (ACSs, from the Portuguese agentes comunitários de saúde) and endemic disease combat agents (ACEs, from the Portuguese agentes de combate a endemias); it also creates the Technical Training Program in Nursing for Healthcare Agents, called PROFAGS. Summing up, it affects the attributions of the workers, and it institutes federal funding for teaching institutions, including private ones. PROFAGS will be executed in the biennium 2018-2019, and the process of development of the Program is supported by a meeting that took place wi-thin the realm of the Tripartite Intermanagers Comission, in December 2017.

The professional training of the ACSs has been an object of dispute ever since the institutionalization of this profession within the realm of the SUS. These disputes integrate the dynamics of the production of the healthcare policy that, being the product of class struggle, is not exempted from the interests of the workers, who defend the universality of the right to health and education; and from the interests of companies, which have historically made use of public funds, and which treat health and education as commodities (Nogueira, 2017).

The publication of the syllabus of the ACS Technical Course (CTACS, from the Portuguese Curso Técnico de Agente Comunitário de Saúde) in 2004 (Brasil, 2004) can be considered, in two senses, as an improvement toward the professional training of these workers. It represents the attempt to unite professional training and the ascent in schooling, and it was developed in a democratic process that included teaching institutions, representatives of the ACSs, and sectors of the MS.

Going against the process of development of the proposal of the CTACS, the proposal of the PROFAGS took place among managers, without the participation of the remaining players with expertise and historical representation in the enactment and development of professional education in healthcare policies, like the Technical Schools of the SUS (ETSUS, from the Portuguese Escolas Técnicas do Sistema Único de Saúde). The technical training in Nursing for ACSs restores the proposal of the merger of professional categories contained in the report of the 7th National Forum on Primary Healthcare Management. This merger implies the aggravation of the precarization of the work and of the risks of reduction of job posts, which in turn is aggravated by the proposal of the new National Primary Healthcare Policy (PNAB, from the Portuguese Política Nacional de Atenção Básica), which strengthens the healing biomedical practices and the focus on the Health of the Family Strategy (ESF, from the Portuguese Estratégia Saúde da Família).

Another potential repercussion of the PROFAGS is the impending deprivation of the characteristics of the profession that the training in nursing will produce in the work process of the agents. The work of the ACS comprises practices that include social mobilization, interlocution with the biomedical knowledge and the popular knowledge, demands for social rights, mapping and follow-up of the socio-sanitary conditions of the territories, which are determinants in the process of health and illness, in the production of information, in the establishment of networks of social support, and in the planning and execution of educational actions in health. These practices are being impacted by the managerial logicality, a process that is intensified with the implementation of systems to evaluate the work in healthcare that are based on individual performance criteria, competitiveness among teams, performance-based compensation, and gearing of the work based on quantitative goals focused on biomedical procedures (Nogueira, 2017). It was not by chance that ordinances n. 958 and 959, which were issued by the MS in 2016, and revoked due to the intense mobilization of the ACSs, were developed with the same reasoning restored in the PROFAGS, that is: the replacement of the ACSs by Nursing technicians with the aim of expanding the scope of practices in Primary Healthcare (AB, from the Portuguese Atenção Básica) and the so-called increase in its resolutivity. The PROFAGS will aggravate the bureaucratization of the work of the ACSs, as well as the secondarization of the work of popular education in health and the follow-up of the users in the territory. This process even tends to increase the epidemiological risk of the population through the shift in goals of the work of the ACSs and ACEs, which will happen with the overlap in the attributions of these workers, altering the characteristics of their fundamental attributions.

The work of the ACEs, which is guided by the perspective of integration of the fields of vigilance in healthcare (epidemiological, sanitary, environmental and worker’s health vigilance), anticipates the process of becoming ill, especially with the goal of promoting health, unlike the activities planned for the nursing technician, who works on intervention processes in situations in which the onset of diseases has already happened. It involves work processes that are complementary, and that are indispensable to the AB, and their integration cannot be mistaken with a merger, for this will have a negative impact on the practices of promotion and vigilance in health.

Concerning the professional training of the ACEs, the technical course in Nursing and the technical course in vigilance have similar syllabi. The training in vigilance, whose guidelines were issued in 2011, is an MS proposal that began in the late 1990’s, and is based on knowledge originated from the integration of the vigilances. These guidelines strengthen the AB in the perspective of the intervention in the social determinants, and has as its parameter the principles of the SUS, adopting social participation as a strategy. Moreover, the proposal of the PROFAGS does not take into consideration the work process of the ACEs, who are professionals who work on ‘the end,’ for exemple, combating arbovirus infections.

In the syllabi of the ACS and Vigilance in Health technical courses, the stimulus to participate in the ETSUS when the courses are being offered implies thinking of them as a right, for they are free and developed by public institutions for agents that are part of the SUS. In the case of the CTACS, the topics that are suggested as the bases for the syllabus emphasize the work in AB and education in health as crucial points (Brasil, 2004). Despite the fact that the contents of the Syllabus of the CTACS need updating, since they have been developed 14 years ago, we must point out the fact that the technical training in ACS contemplates many different facets of the work that are telling of the attributions of this professional category, such as the work with a multiprofessional team, the promotion of health, and the prevention of diseases in individuals and groups of people, and the actions geared towards environmental issues. The technical training in Nursinghas attributions and theoretical contents that prioritize the work in institutions that are not predominantly parts of the primary level of healthcare.

With the publication of the public tender of the PROFAGS, the intention not to prioritize the public teaching institutions in the process of acquiring funds from the MS is confirmed, even though in the Programmatic Functional Classification the funds for the execution of the Program burden the rubric of “Training of health technicians and strengthening of the technical schools and SUS training centers”. Thus, we identify the movement of allocating funds that should be intended to public institutions to the private network, which traditionally offers the Technical Training in Nursing.

Among the other serious inadequacies of the PROFAGS is the possibility of developing this training in semi-in-person classes, and, as published in the ordinance, administered preferably at night. This implies the accountability of the workers regarding the precarious professional training that the State has historically offered; moreover, it burdens the workers who are inarguably overloaded by their triple shifts, as is the case of the ACSs, a professional category composed mostly of women. Furthermore, at the PROFAGS, the worker who cannot manage to fulfill the minimum attendance required by the course is punished, and forced to give back to the government the full amount of money in reais (Brazilian currency), a commitment that will be taken on by the worker at the moment he signs an enrollment form that prescribes this responsibility.

Ordinance n. 83/208 is another measure of the federal government of focusing on the AB and taking away rights, and it was enacted after the vetoes to the House of Representatives Bill (PLC, from the Portuguese Projeto de Lei da Câmara) n. 56/17, which became Law n. 13.595/18. These vetoes concerned demands that are dear to the workers: technical training in ACS and ACE during their working hours, and the compulsory presence of the ACSs within the AB structure.

It is a known fact that the private and commercial interests that have a hegemony over the federal government have put pressure over the development of the PROFAGS. However, the ETSUS, and union representatives organized by the ACSs, the Brazilian Nursing Association (from the Portuguese Associação Brasileira de Enfermagem) and other entities are taking a stance against the Program. The establishment of the right to professional training of the ACSs and ACEs is paramount for the championing of the SUS, for these workers comprise categories that have been instituted, and that exist exclusively in the realm of public policies. It is a duty of the State to provide access to professional training for these workers, committing to a policy of training that does not motivate privatization and the dismantlement of the SUS. On the contrary, it is up to us to affirm the need to promote a specific professional training, geared towards the AB, the SUS, and one that takes place mainly in public teaching institutions.

The fact that the ETSUS and the agents will not join the Program should strengthen the championing for the establishment of a Professional Education policy that consolidates the realms of the work and the attributions of these workers. These political forces should maintain their activities to ensure that the SUS remains public and universal, with the goal of establishing a professional training policy stimulated by the critical analyses of the social determinations of the health and illness process, by the actions to promote health, by social mobilization, by popular education, and by vigilance in health.

Mariana Lima Nogueira
Professor and researcher at Oswaldo Cruz Foundation’s Joaquim Venâncio Polytechnic Health School
Ieda da Costa Barbosa
Professor and researcher at Oswaldo Cruz Foundation’s Joaquim Venâncio Polytechnic Health School

Referências

• BRASIL. Ministério da Saúde. Ministério da Educação. Referencial curricular para o curso técnico de agente comunitário de saúde: área profissional saúde. Brasília, DF: Ministério da Saúde, 2004. (Série A. Normas e Manuais Técnicos).
• BRASIL. Ministério da Saúde. Portaria n. 83, de 10 de janeiro de 2018. Institui o Programa de Formação Técnica para Agentes de Saúde (PROFAGS), para oferta de curso de formação técnica em enfermagem para agentes comunitários de saúde (ACS) e agentes de combate às endemias (ACE) no âmbito do SUS, para o biênio de 2018-2019. Brasília, DF, 2018. Disponível em: <http://bvsms.saude.gov.br/bvs/saudelegis/gm/2018/prt0083_12_01_2018.html> Acesso em: 13 jan. 2018.
  » http://bvsms.saude.gov.br/bvs/saudelegis/gm/2018/prt0083_12_01_2018.html>
• NOGUEIRA, Mariana L. O processo histórico da Confederação Nacional dos agentes comunitários de saúde: trabalho, educação e consciência política coletiva. 2017. 541f. Tese (Doutorado em Políticas Públicas e Formação Humana) – Programa de Pós-Graduação em Políticas Públicas e Formação Humana, Universidade do Estado do Rio de Janeiro, Rio de Janeiro.

Publication Dates

• Publication in this collection
  May-Aug 2018