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Saúde em Debate

Print version ISSN 0103-1104On-line version ISSN 2358-2898

Saúde debate vol.43 no.spe1 Rio de Janeiro Aug. 2019  Epub Sep 16, 2019

https://doi.org/10.1590/0103-11042019s102 

ORIGINAL ARTICLE

PET-Health/GraduaSUS in the perspective of service and teaching actors: contributions, limits, and suggestions

1Universidade do Estado do Rio de Janeiro (Uerj), Instituto de Medicina Social (IMS) - Rio de Janeiro (RJ) - Brasil. carinne.mag@gmail.com

2Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Departamento de Medicina Preventiva - Belo Horizonte (MG), Brasil.


ABSTRACT

This manuscript presents the results of an online survey conducted with the project and group coordinators of the last edition of the Education through Work for Health Program (PET-Health/GraduaSUS), which sought to identify the results achieved and to point out the limits and contributions of such edition for the production of changes. The survey was carried out in March and April 2018, with 445 coordinators, whose quantitative data were treated statistically; and qualitative data by content analysis, giving rise to four categories: The positive repercussions of PET-Health/GraduaSUS; The negative aspects of PET-Health/GraduaSUS; The coordination of the projects by the health service: controversial point; and Suggestions for changes. It was found that the PET-Health/GraduaSUS contributed to the professional development, expansion and diversification of the learning scenarios, strengthening primary care and interprofessional education in the curricula and benefited the local community. The main positive aspects of the edition were the coordination of the project by the health service and the reports of experiences in the Community of Practices; the numerical and uniprofessional composition of the groups, however, was pointed as a negative aspect.

KEYWORDS Teaching care integration services; Education, continuing; Education, higher; Public health policy; Staff development

RESUMO

Este manuscrito apresenta os resultados de um survey on-line conduzido com os coordenadores de projetos e de grupos da última edição do Programa de Educação pelo Trabalho para a Saúde (PET-Saúde/GraduaSUS), que buscou identificar os resultados alcançados e apontar os limites e as contribuições dessa edição na produção de mudanças. O survey foi realizado em março e abril de 2018, com 445 coordenadores, cujos dados quantitativos foram tratados estatisticamente; e os qualitativos, por análise de conteúdo, dando origem a quatro categorias: As repercussões positivas do PET-Saúde/GraduaSUS; Os aspectos negativos do PET-Saúde/GraduaSUS; A coordenação dos projetos pelo serviço de saúde: ponto controverso; e Sugestões de mudanças. Constatou-se que o PET-Saúde/GraduaSUS contribuiu para o desenvolvimento profissional, ampliação e diversificação dos cenários de aprendizagem, fortalecimento da atenção primária e da educação interprofissional nos currículos e beneficiou a comunidade local. Os principais aspectos positivos da edição foram a coordenação de projeto pelo serviço de saúde e os relatos de experiências na Comunidade de Práticas; já a composição numérica e uniprofissional dos grupos foi apontada como aspecto negativo.

PALAVRAS-CHAVE Serviços de integração docente-assistencial; Educação continuada; Educação superior; Políticas públicas de saúde; Desenvolvimento de pessoal

Introduction

Education through Work for Health Program (PET-Health/GraduaSUS), established in 2008 by the Ministry of Health (MH) in partnership with the Ministry of Education, has as main objective to induce changes in the training process of health professionals, in alignment to the needs of the Unified Health System (SUS) 1.

In this perspective, it assumes as driving force the development of activities based on the teaching-service-community integration and oriented by the National Curricular Guidelines (DCN), which stimulate the experience of the students in the health services through tutorial learning groups, composed of tutors, preceptors and academics 1,2.

Initially directed to the Family Health Strategy (FHS), PET-Health was subsequently extended, through thematic editions, to other areas considered as priorities for SUS: health surveillance; mental health and Health Care Networks 3. In 2015, when the GraduaSUS edition was launched, the program has taken as focus the curriculum of health degrees, the qualification of integration processes and the training of preceptors and teachers 4. Throughout these ten years of the program, 8 notices have been published and almost 800 projects have been developed in all regions of the country 3.

The GraduaSUS edition, object of study of this manuscript, was configured to bring PET-Health closer to the other national health education policies in force and to overcome the challenges identified in previous editions. In view of this, this edition establishes, among other points, that the coordination of projects is carried out by the health secretariats, a function relegated to educational institutions in previous editions; the compulsory participation of the medical course; and the constitution of tutorial groups by graduation course, as opposed to the multiprofessional logic previously foreseen. In two years of operation, it involved 5.893 actors scholarship holders and volunteers, among students, health professionals and teachers of 105 different projects collectively built 3,4.

Considering the completion of the validity of the last edition and the lack of analytical research on the program, this manuscript presents the results of a survey conducted with project coordinators and groups of the PET-Health/GraduaSUS. Developed with the intention of attending to the item related to the monitoring and evaluation of projects contained in the notice which governs the edition 4, the survey sought to identify the results achieved with the development of the proposals and to point out the limits and contributions of the PET-Health/GraduaSUS in the production of changes in health training and in the qualification of health services.

Methods

It is a descriptive and exploratory study, with a mixed approach, developed in March and April of 2018, through an online survey. This data collection method is often used in large-scale researches to obtain the opinions of a particular target audience through a questionnaire, in this case, self-administered and virtually available.

The study population consisted of all the coordinators of PET-HEalth/GraduaSUS, with 105 project coordinators, who are obligatorily linked to health services, and 394 group coordinators, a function performed by professionals from Higher Education Institutions (IES). The invitation to participate in the research was made to all, through electronic mail containing the access link to the survey and the deadline for its completion.

All 445 (89.1%) respondents constituted the sample, of which 103 project coordinators (98.1%) and 388 group coordinators (88.1%), reaching coverage levels above 80% in all regions where the health secretariats and the IES which have joined the PET-Health/GraduaSUS are located.

For the elaboration of the survey, an instrument previously used by the Health Education Management Department of the Secretariat of Labor and Education Management for Health of the MH (Deges/SGTES/MS) to monitor PET-Health was adapted to the context of the GraduaSUS 5 edition, giving rise to a structured questionnaire with 34 questions grouped in four blocks, later configured in electronic form in the FormSUS. In addition to these issues, a free entry field was left at the end of the instrument for the voluntary registration of the respondents as to their impressions on the issue in question.

The questions of block 1 sought to identify schooling, training and time in the institution of the subjects surveyed. Block 2 grouped questions pertinent to the adequacy of the physical structure of the health services for the development of the project activities, the types of activities developed, and the mechanisms used for the selection of the participants of the PET-Health/GraduaSUS. Block 3 was composed of questions that sought to identify the main results achieved by the projects vis-à-vis the objectives of the program foreseen in the edict. Finally, block 4 aimed to know the opinions of the coordinators on the suitability of the format of the edition of PET-Health/GraduaSUS in relation to the other editions and to allow the registration of positive points, negatives, suggestions for changes and difficulties faced in conducting the program.

The quantitative data were analyzed by descriptive statistics via Microsoft Excel® and are presented in the format of tables. The qualitative data, derived from the free entry field, were submitted to the content analysis proposed by Bardin 6. For this purpose, the records were organized, subjected to exhaustive reading and later coded and categorized by semantic similarity, resulting in four analytical categories: The positive repercussions of PET-Health/GraduaSUS; The negative aspects of PET-Health/GraduaSUS; The coordination of the projects by the health service: controversial point; and Suggestions for changes.

In compliance with the norms established in Resolution nº 466/2012 of the National Health Council, the project was submitted and approved by the Research Ethics Committee of the Institute of Social Medicine of the State University of Rio de Janeiro, under Opinion n° 2.503.706.

Results and discussion

The high preponderance of those who hold a nursing degree in the coordination of projects (n=40; 38.8%) and groups (n=88; 25.7%) was emphasized; and the low participation of doctors in the coordination of the groups (n=43; 12.6%), despite the obligation of this course to approve the projects.

Furthermore, it was verified a high schooling among the respondents (n=445), of which 83.4% had a master’s degree or doctorate as the highest level of education. In terms of length of service, most of the project coordinators (54.4%) and course coordinators (43.3%) have been inserted for more than ten years, respectively, in the health secretariats and IESs participating in the PET-Health.

It is verified, in table 1 that the physical structure of the health services was considered adequate for the development of program activities by 91.8% of the group coordinators and for more than 55% of the project coordinators, being teaching activities the most developed; and assistance, the least developed. These findings are in line with what is suggested by most of the studies that focus on the topic of health education, which point out that the inadequate infrastructure of practice scenarios is one of the main factors limiting the conduction of teaching-learning activities in reality of SUS 7-9.

Table 1 Aspects related to the development of the activities of projects and mechanisms of selection of the participants of the Education through Work for Health Program edition 

Variables analyzed Project Coordinators Group Coordinators
n=103 % n=342 %
Adequacy of the physical structure of the health services for the activities
No 6 5.8 2 0.6
Partially 39 37.9 26 7.6
Yes 58 56.3 314 91.8
Types of activities developed
Care 70 68.0 209 61.1
Education 97 94.2 320 93.6
Extension 88 85.4 305 89.2
Research 85 82.5 273 79.8
Development of activities not foreseen in the project, by necessity of the health/community services
I do not know how to answer 0 0.0 6 1.8
No, activities were restricted to the original project and in accordance with the curriculum 5 4.9 25 7.3
Yes, eventually 38 36.9 144 42.1
Yes, frequently 60 58.3 167 48.8
Joint development of activities by the health service and educational institutions
Yes 88 85.4 280 81.9
Partially 14 13.6 62 18.1
No 1 1 0 0
Mechanisms used to select students scholarship holders
Selective process through Notice 91 88.3 312 91.2
Coefficient of school performance 10 9.7 64 18.7
By membership 7 6.8 33 9.6
Indication 11 10.7 16 4.7
I do not know how to answer 5 4.9 0 0.0
Mechanisms used to select tutors/preceptors
Indication 52 50.5 119 34.8
Recognition/professional experience 61 59.2 227 66.4
Selective process through Notice 32 31.1 97 28.4
By membership 26 25.2 111 32.5
Neither of the options above 1 1.0 3 0.9
I do not know how to answer 2 1.9 4 1.2
Mechanisms used to select group coordinators
Indication 41 39.8 109 31.9
Recognition/professional experience 70 68.0 252 73.7
By membership 27 26.2 100 29.2
Selective process through Notice 6 5.8 13 3.8
Neither of the options above 2 1.9 6 1.8
I do not know how to answer 3 2.9 4 1.2
Existence of volunteers
Student 101 98.1 329 96.2
Preceptor 53 51.5 136 39.8
Tutor 53 51.5 136 39.8
There are no volunteers 2 1.9 7 2.0

Source: Own elaboration based on the research data, 2018.

The accomplishment of activities on demand for service/community, even if not initially foreseen in the project, was pointed out by more than 90% of the project and group coordinators; and more than 80% of them stated that the activities were carried out jointly by IES and health services (table 1).

Regarding the selection modalities of scholarship holders participating in the PET-Health/GraduaSUS, the most frequently used options, according to the set of respondents, were the selective process mediated by notice for the student selection; and professional recognition/experience for the selection of group coordinators and tutors/preceptors. For most of them, the projects also had students and tutors/preceptors on a voluntary basis (table 1).

It is interesting to note that during the two years of operation of the GraduaSUS edition, about 1.700 students participated as volunteers of the program, that is, their participation was not conditioned or motivated only to receive the offered scholarship. The magnitude of this adhesion demonstrates the importance of the program in the student community, as well as among health professionals and teachers, who also worked in the program as preceptors (n=307) and voluntary tutors (n=191) 3.

In table 2, it is verified that, according to most of the respondents, the primary objectives of PET-Health/GraduaSUS were achieved, especially the one which indicates ‘to promote the qualification of teaching-service-community integration’, considered a pillar of the changes in the training of health professionals in Brazil.

Table 2 Results achieved by the projects of the Education through Work for Health Program edition GraduaSUS, according to the coordinators. Brazil, 2018 

Variables Project coordinators Group coordinators
n=103 % n=342 %
Objectives achieved with PET-Health/GraduaSUS
Favored curricular changes in line with the National Curricular Guidelines 79 76.7 266 77.8
Promoted the qualification of the teaching-service-community integration process 101 98.1 324 94.7
Promoted articulations with other teaching-service-community integration projects in the territories 95 92.2 298 87.1
Contributes to professional development and training
Very positively 78 75.7 271 79.2
Positively 24 23.3 71 20.8
Does not interfere 1 1.0 0 0.0
Hampers 0 0.0 0 0.0
Promoted the expansion/diversification of teaching-learning scenarios
Yes 88 85.4 298 87.1
Partially 14 13.6 40 11.7
No 1 1.0 4 1.2
Contributed to the services of the Unified Health System
Yes 82 79.6 279 81.6
Partially 20 19.4 58 17.0
No 0 0.0 4 1.2
I don't know how to answer 1 1.0 1 0.3
Strengthened primary care in curricular units of educational institutions
Yes 69 67.0 247 72.2
Partially 28 27.2 88 25.7
No 1 1.0 3 0.9
I don't know how to answer 5 4.9 4 1.2
Benefited the local community
Yes 92 89.3 307 89.8
Partially 10 9.7 31 9.1
No 1 1.0 2 0.6
I don't know how to answer 0 0.0 2 0.6
Contributed to the process of discussion or implementation of the Public Health Action Organizational Contract (Coap)
Yes, we are at the discussion process 62 60.2 173 50.6
Yes, we implemented the Coapes 15 14.6 50 14.6
No. We have already used another legal contracting instrument 12 11.7 19 5.6
No. We only adopted the commitment term signed for the development of PET-Health/GraduaSUS 7 6.8 48 14.0
I don't know how to answer 7 6.8 52 15.2
Contributed to the development of interprofessional education and collaborative practices
Yes 83 80.6 282 82.5
Partially 19 18.4 53 15.5
No 1 1.0 3 0.9
I don't know how to answer 0 0.0 4 1.2
Involvement of control/social participation in the development of the project
Yes 40 38.8 109 31.9
Partially 44 42.7 147 43.0
No 16 15.5 71 20.8
I don't know how to answer 3 2.9 15 4.4

Source: Own elaboration based on the research data, 2018.

The teaching-service-community integration is understood as a collective work, that integrates the different actors in the quadrilateral of health education 10, towards the development of activities that are articulated and coherent with the local reality, that at the same time lead to the qualification of the care provided to the user, to the excellence of training and to the permanent education of health workers. It is, therefore, a foundation for the construction of new ways of learning, teaching and making health, contributing to increase the critical and reflective capacity of the actors and improve the quality of life of the population 11,12.

From this perspective, with the exception of one, all respondents stated that the GraduaSUS edition contributed positively or very positively to professional development; and more than 80% of project and group coordinators stated that the activities developed within the scope of PET-Health/GraduaSUS contributed to the development of interprofessional education and collaborative practices, promoted the expansion and/or diversification of learning scenarios and benefited the local community (table 2).

According to the respondents, there were also positive repercussions in SUS services and in curricular units of educational institutions. Furthermore, community involvement during the project was observed or partially observed, in this order, by 81.6% and 74.9% of project and group coordinators (table 2).

These findings indicate that the edition of the PET-Health under analysis has advanced in relation to the implications in health services and in the community and reinforce the importance of the interinstitutional partnership and the participation of the population in the deliberation and decision-making spaces that involve SUS, on the basis of participatory management 13. They also suggest that programs such as PET-Health can catalyze the insertion of debate and activities based on interprofessional education in the SUS, subsidizing the disruption of the hegemonic model of health training 14.

Specifically asked if the GraduaSUS edition is innovative compared to the predecessor editions, 77.3% of the set of coordinators responded positively. It was verified, also, a high percentage of those who did not know how to respond to this questioning, mentioning that such respondents may not have participated in previous editions (table 3).

Table 3 Perception of the coordinators about the innovation of the Education through Work for Health Program edition GraduaSUS in relation to the previous editions, according to the coordinators. Brazil, 2018 

Evaluation Project Coordinators Group Coordinators
n=103 % n=342 %
Yes 81 78.6 263 76.9
No 2 1.9 20 5.8
I don't know how to answer 20 19.4 59 17.3

Source: Own elaboration based on the research data, 2018.

In the evaluation of the coordinators, there are two main aspects of PET-Health/GraduaSUS that have a positive impact on the production of changes in the service and in teaching: project coordination by the health service and reports of experiences in the Community of Practices (CdP), two major differentials of this edition in relation to the previous ones. The first places the health service as a co-responsible for the process of changes in the field of training and as an active actor in the determination and development of the activities carried out within the scope of PET-Health 3. The second aspect presents itself as an opportunity to share experiences and collective construction of knowledge about SUS. Because it is a virtual network, the CdP breaks down the geographical barriers and the difficulties of encounters between the actors that operate the SUS in the different territories, providing dynamism in collaborative learning.

Regarding the main negative aspects, the numerical composition of the groups was the most indicated by the project coordinators (27.2%) and group (24.3%). It calls attention to that, for most respondents, none of the options presented in the questionnaire had a negative impact on the production of changes, as shown in table 4.

Table 4 Aspects of the Education through Work for Health Program edition GraduaSUS that impacted on the production of changes in teaching and health service, according to the coordinators. Brazil, 2018 

Aspects of the program edition Project Coordinators Group Coordinators
n=103 % n=342 %
Positively impacted
Project coordination by the health service 74 71.8 180 52.6
Reports of experiences in the Community of Practices 60 58.3 181 52.9
Compliance with the guidelines of the Coapes 46 44.7 148 43.3
Mandatory medical course requirement 39 37.9 92 26.9
Numerical composition of groups 37 35.9 90 26.3
Neither of the previous options caused impact 3 2.9 24 7.0
I don't know how to answer 3 2.9 17 5.0
Negatively impacted
Project coordination by the health service 10 9.7 74 21.6
Reports of experiences in the Community of Practices 5 4.9 13 3.8
Compliance with the guidelines of the Coapes 3 2.9 10 2.9
Mandatory medical course requirement 15 14.6 53 15.5
Numerical composition of groups 28 27.2 83 24.3
Neither of the previous options caused impact 53 51.5 146 42.7
I don't know how to answer 8 7.8 30 8.8

Source: Own elaboration based on the research data, 2018.

For the coordinators, in general, the main factors that hampered the integration of teaching-service-community within the framework of the PET-Health/GraduaSUS were the resistance of the professionals of the health services not participating in the program and the communication. A significant proportion of the group coordinators (33.3%) also indicated that the reluctance of the managers to release professionals to teaching activities (preceptory) was difficult (table 5).

Table 5 Factors which have hampered the teaching-service-community integration within the scope of the Education for Work in Health Program edition GraduaSUS, according to the coordinators. Brazil, 2018 

Difficulties in teaching-service integration Project Coordinators Group Coordinators
n=103 % n=342 %
Resistance of healthcare professionals not participating in PET-Health/GraduaSUS 41 39.8 149 43.6
Resistance of managers in freeing professionals for teaching activities 27 26.2 114 33.3
Communication 38 36.9 104 30.4
Low pedagogical training of the preceptor(s) to receive students 29 28.2 90 26.3
Interpersonal relationship 25 24.3 73 21.3
Inappropriate profile of student(s) 7 6.8 9 2.6
Inadequate profile of academic tutor(s) 8 7.8 16 4.7
Resistance from users 1 1.0 10 2.9
Rigidity in work proposals 4 3.9 17 5.0
No difficulty was found 19 18.4 76 22.2
I don't know how to answer 3 2.9 6 1.8

Source: Own elaboration based on the research data, 2018.

On the resistance of health professionals to the exercise of preceptory, studies indicate that it may be associated with curricular incompatibility with the logic of the service and with the devaluation of this role by managers, educational institutions and professionals themselves. This devaluation is due to the lack of regulation of the role of the preceptor, lack of knowledge about the preceptory and not subsidization of the teaching activities performed 15-17.

The preceptory in the context of the PET-Health can be understood as a pedagogical activity carried out by a health professional, which incorporates the task of mediating the learning process of the student in contact with the world of work. In this understanding, it instigates the problematization of reality, critical reflection and the search for collective solutions that confront everyday situations of the teaching-service 14. It is assumed, therefore, that for the effective performance of this role, the qualification processes of these actors are pressing.

In the light of the above, the GraduaSUS edition included in its list of prerogatives the requirement that the projects contemplate actions of teacher development and preceptor, reaffirming that they are indispensable for the changes intended to be reached 4.

As for the payment model, the coordinators were unanimous in affirming that the direct transfer of scholarships to the members values the subjects involved in the process of teaching-service-community integration; and, for the majority (76.4%), this form of transfer facilitates, speeds up and strengthens the financing of health education actions according to the needs of the SUS.

Regarding the free entry field, 257 (57.8%) coordinators commented on the edition of PET-Health/GraduaSUS, which were grouped in the four categories presented following.

The positive repercussions of PET-Health/GraduaSUS

The records of the respondents refer mainly to the positive repercussions of PET-Health/GraduaSUS, which was considered as an important device to promote the integration of teaching-service-community and induction of curricular changes aligned to the DCN, according to other studies on previous editions of the program 18-20.

It gave opportunity to the linked courses of moments of discussion about formation, an expansion of the teaching-service-community integration and the certainty in the construction of a more articulated formation in the and for the SUS.

Contribution in a significant way to implement the curricular changes that were already being constructed and rehearsed in previous versions.

Our university was able to establish, in 2018, an interprofessional discipline for all courses in the health area as provided for PET-Health.

Still on this perspective, the program has, significantly, configured itself as a strategy to expand the practice scenarios, especially for courses that are still little inserted in the PHC, due to the reduced number of Family Health Support Centers and little recognition of the importance of these professions at this level of care 3, such as phonoaudiology, biomedicine and veterinary medicine, providing, in some cases, the first contact of students of these courses with the FHS.

Extremely important for the group of Veterinary Medicine, because it put the student in contact with an extremely important and at the same time little valued within the course.

In physiotherapy, the academics do not have this direct contact with SUS. And, with PET-Health, it was noticeable the easiness that the scholarship holders acquired and the understanding of how they work in the SUS network.

It should be emphasized, as well, that the PET-Health/GraduaSUS was punctuated as a strategy to mobilize university management, culminating in changes in internal norms and implementation of health services linked to IES. These contributions are aligned with what is stated in Resolution nº 569/2017, which ratifies the social responsibility of IES with the territory in which it is inserted and its community and the commitment to support the development of health services and care networks and the training of health professionals, transforming local reality 21.

PET-Health/GraduaSUS has transformed the reality of our university and among the legacies I can highlight: 1) It promoted a training course for pharmacists of the SUS; 2) Promoted the creation of a clinical pharmacy service.

Mobilization of university management and the accomplishment of changes of the internal norms that strengthened the preceptory and the multiprofessional actions.

The negative aspects of PET-Health/GraduaSUS

The coordinators also drew attention to the negative aspects of the GraduaSUS edition, among which, the most cited was the uniprofessional composition of the groups that limited the integration between the different health courses.

It is a setback for students and preceptors to be on the same course, since curricular integration is desired. The model did not cooperate for the changes it has proposed.

The groups’ non-obligation of being interprofessional has severely hampered the proposal of integration of the courses.

According to the notice that governs the edition of GraduaSUS, opting for groups conformed by actors of the same course is based on the idea of expanding the internal discussion about the curriculum, inducing, therefore, effective changes in curriculum frameworks. Nonetheless, the same notice prescribes the obligation of interprofessional activities in the SUS practice scenarios 3,4.

The requirement of medical courses was also considered a negative point, since, according to respondents, the category is resistant to curricular changes and to effective participation in the development of project activities.

I understand the objective that originated the obligatory participation of medicine, however, this obligation did not guarantee effective participation.

A lot of resistance, especially from the teaching staff [of medicine], both to reform the curriculum and to broaden the practice scenario.

Regarding this, a study carried out with medical schools found that the resistance of medical teachers is one of the main difficulties for the implementation of curricular changes 22. Such resistance may be related to the belief of teachers that changes, such as the integration of disciplines and interprofessionalism, could increase their workload 23.

The premise that medical education is more resistant to change than other areas finds support in the historicity itself of the health professions. Medicine is the institutor of the practice of scientific and modern health and from it derive the other fields of the health knowledge, conjuncture that makes the medical hegemony emerge before other health professionals. The doctor still perceives himself/herself superior, and the other categories struggle to be socially recognized 24-26.

This context meets the assumptions of interprofessional education and collaborative practices, which emphasize the disruption of tribalism in professions through learning encounters of different professional categories, so that they can learn with, from and about each other to improve professional collaboration 27.

CdP, a collaborative social network aimed at actors of the SUS, which was adopted as a platform for recording the PET-Health/GraduaSUS experiences on a mandatory basis, was criticized for its instability and poorly responsive interface, although it was considered positive instrument for the sharing of knowledge.

The Community of Practices: difficult to work, time consuming return to publication.

The use of the Sabiá Platform [system through which one accesses the Community of Practices] and the Community of Practices Many errors, many problems. Unfeasibility in use, including in the search for authors of the reports.

According to the respondents, other aspects related to PET-Health that limited the activities and, therefore, the positive results of the executed projects were: the reduced number of scholarships and the running time of the edition that was considered insufficient to reach the agreed goals.

Among the factors not directly associated with the format of the edition, are: the unpreparedness and the turnover of the preceptors; the difficulties of a logistical nature for meetings between groups of interinstitutional projects, formed through a partnership between IES of different municipalities; the social difficulties, in particular, the increase in violence in large cities, which endanger the safety of teachers and students; and those related to municipal management, as evidenced by the following sections:

Change of municipal management, resulting in changes in the preceptories of tutorial groups which, consequently, impacted the group management.

Change of management, which hindered the hiring of professionals for the preceptory, and the resistance of the manager in giving the certificate for authorization of the payment of scholarships and in releasing the preceptors for the activities of the PET.

The coordination of the projects by the health service: controversial point

In the scope of PET-Health/GraduaSUS, the role of project coordinator should be necessarily assumed by a professional linked to the health secretariat, responsible for organizing and distributing the general activities of the project and fostering the integration of groups and the development of the activities proposed.

Due to its unprecedented nature, this aspect was considered by some as a facilitating element and, by others, as a limiting factor in the conduct of projects.

The PET-Health GraduaSUS was an edition that, for the first time, had the protagonism of the service, allowing, in fact, the graduating students to live and respond to the existing real needs of the service.

Transferring the coordination of the project to the manager obstructed the execution of the project, which should be under the coordination of a university manager.

Suggestions for changes

Among the records of the coordinators, suggestions for changes of specific points of the GraduaSUS edition were found, and others aimed mainly at the continuity and strengthening of PET-Health, such as: establish PET-Health as a permanent policy; launch more editions of the program; extend the validity of the editions; increase the number of courses involved; increase the number of students per group; predict the shared coordination of a project between management and IES; and the development of in loco monitoring and evaluation actions. Other suggestions can be found in the extracts below:

PET-Health as an integration policy between teaching-service-community should have automatic renewal, through evaluation criteria, and financial resources to support the implementation of planned actions, such as the Tutorial Education Program of the Ministry of Education.

The notice could be leaner and focus on a proposal of objective and specific intervention, centered on Interprofessional Education, and without the requirement of the medical course, since not all institutions that have health courses have a medical course.

PET-Health, which adopts teaching-service-community integration as a structuring device for health education, has added contributions to the movement of approaching education to the health system and the modification of health training 28.

Final considerations

This study sought to identify the main elements of contribution and fragility of the PET-Health/GraduaSUS, aiming to instrumentalize the federal health manager and subsidize their decision-making regarding the ramifications of the program. For this purpose, it considered the perception and opinion of project coordinators (service) and groups (teaching institutions), making it possible to grasp strategic information about the conduct of projects.

The results of the survey demonstrated the positivity, magnitude and relevance of the program in the professional training of the actors involved, as well as in the fulfillment of its main objectives - to qualify the teaching-service integration and to promote curricular changes in the health courses.

Considered as innovative in relation to previous editions, PET-Health/GraduaSUS has brought health institutions closer to the health services, which were raised to protagonists and active actors in the construction and development of the projects. This point, specifically, was mostly considered as a positive aspect of the edition, but some respondents understood it as a limiting element. This apparent contradiction may be due to the uniqueness of this proposal which has not yet been totally absorbed by the actors involved, since, in previous editions, the coordination of the project was a responsibility assumed by the training institutions.

The contributions and suggestions on PET-Health/GraduaSUS signalize the preparation of future notices with investment in monitoring and evaluation actions, resumption of composition of interprofessional nature groups, coordination of projects shared between service and teaching actors and maintenance of the aspects that guide changes in the logic of the training of professionals and in the dynamics of health work.

Aiming at instrumentalizing the decision-makers and subsidizing their decision-making regarding the ramifications of the program, the findings of this study were presented and discussed with the federal health manager, subsidizing the preparation of the new edition of the program: PET-Health/Interprofessionality.

The transformations expected, precisely because they involve paradigm changes and new ways of acting and thinking about health, do not materialize quickly. PET-Health/GraduaSUS has greatly contributed to this process; and new notices can advance in the construction of integrality of care, in strengthening education and interprofessional and collaborative work and, therefore, in improving health outcomes.

In the perspective of continuity and establishment of the program as a permanent policy, new monitoring and evaluation studies need to be developed so that their data subsidize the improvement and strengthening of this initiative, which, as the results presented here suggest, is configured as a powerful instrument of production of changes.

*Orcid (Open Researcher and Contributor ID).

Financial support: the research this manuscript was derived from was financed via Agreement Letter SCON2017-00547, established between the Pan American Health Organization (Paho) and the Center for Studies and Research in Collective Health (Cepesc)

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Received: November 06, 2018; Accepted: February 02, 2019

Collaborators

Magnago C (0000-0001-8799-3225)* participated in the design, planning, analysis and interpretation of data, elaboration of the draft, critical review of the content and final approval of the manuscript, França T (0000-0002-8209-9811)* participated in the design, planning, analysis and interpretation of data; the elaboration of the draft, critical review of the content and final approval of the manuscript, Belisário SA (0000-0002-2240-6146)* participated in the design, planning, analysis and interpretation of the data; the elaboration of the draft, critical review of the content and final approval of the manuscript, Santos MR (0000-0002-1669-206X)* participated in the analysis and interpretation of the data; the elaboration of the draft; critical review of the content and final approval of the manuscript.

Conflict of interests: non-existent

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