ABSTRACT

This work aimed to describe and to analyze the most recent initiatives carried out, within the scope of federal management, for the implementation of the National Permanent Health Education Policy (PNEPS). It takes as reference the Kingdon public policy cycle, describing how the topic was included in the government agenda in 2003, and analyzes the content of the documents that materialize the proposals of the Policy. Subsequently, it focuses on the description and analysis of the movement triggered in 2017-2018, with the accomplishment of a series of regional events, which resulted in the identification of the weaknesses faced in the implementation process of the PNEPS, subsidizing a set of proposals that referenced the initiatives triggered, aiming at the effective implementation of the PNEPS in the scope of the Unified Health System (SUS).

KEYWORDS
Public policy; Education continuing; Unified Health System; Human resources

Introduction

The international debate currently held on issues related to health work and education encompasses reflection on policies, regulations and interventions related to education, training and professional practices, highlighting the need to articulate the training with the skills required by the work, the use of new teaching methodologies and the incorporation of information, education and communication technologies in health ¹1 World Health Organization. WHO Health Work Force 2030: towards a global strategy on human resources for health world Health Organization; 2015..

This topic appears among the commitments assumed by the countries to agenda 2030 ¹1 World Health Organization. WHO Health Work Force 2030: towards a global strategy on human resources for health world Health Organization; 2015. as part of strategies to strengthen universal health systems, a renewed commitment, in 2017, at the Pan American Sanitary Conference ²2 Relatório da 29 Conferencia Sanitaria Panamericana. 69 Sessão do Comitê Regional da OMS para as Américas; 25-29 set. 2017; Washington, (DC): Organização Pan-Americana de Saúde. (OMS/OPAS); 2017., when the situation of human resources in health on the continent was discussed, pointing to recurrent challenges, such as: inadequacy of professional profiles, precarious working conditions, low productivity and limited quality of performance of health professionals, among others.

In the case of Brazil, it is important to recognize that the process of construction of the Unified Health System (SUS) ³3 Teixeira CFS, Souza LEP, Paim JS. Sistema Único de Saúde (SUS): a difícil construção de um sistema universal na sociedade brasileira. In: Paim JS, Almeida Filho N. Saúde Coletiva: teoria e prática. Rio de Janeiro: MedBook; 2014., over the last 30 years, has contemplated the implementation of policies and programs that resulted in the decentralization of management, expansion of coverage of the actions and reorganization of health services ⁴4 Viacava F, Oliveira RAD, Carvalho C, et al. SUS: oferta, acesso e utilização de serviços de saúde nos últimos 30 anos. Ciênc. Saúde Colet. 2018; 23(6):1751-1762., having as one of the consequences the reconfiguration of the labor market in the sector and the considerable increase of the labor force directly or indirectly linked to the production of health services and actions at many levels of complexity ⁵5 Machado MH, Ximenes Neto FRG. Gestão da Educação e do Trabalho em Saúde no SUS: trinta anos de avanços e desafios. Ciênc. Saúde Colet. 2018; 23(6):1971-1979..

This process has placed the need to promote changes/transformations in the staff training, either in undergraduate and postgraduate courses, and in the scope of services, through actions of permanent education, which accentuated the concern with the relations between the institutions that make up the personnel training system and the health system ⁵5 Machado MH, Ximenes Neto FRG. Gestão da Educação e do Trabalho em Saúde no SUS: trinta anos de avanços e desafios. Ciênc. Saúde Colet. 2018; 23(6):1971-1979.^,66 Noronha JC, Noronha GS, Pereira TR, et al. Notas sobre o futuro do SUS: breve exame de caminhos e descaminhos trilhados em um horizonte de incertezas e desalentos. Ciênc. Saúde Colet. 2018; 23(6):2015-2060., a topic that challenges scholars, managers and health professionals.

In this sense, the creation, in 2003, of the Secretary of Labor Management and Health Education (SGTES), of the Ministry of Health (MS) allowed the handling of ideas, knowledge, programs and financial resources, expanding the possibilities for developing government policies in this area, as well as stimulating the dialogue between different actors of partner institutions and entities representative of the management of the SUS, such as the National Council of State Health Secretaries (Conass), the National Council of Municipal Health Secretaries (Conasems) and the National Health Council (CNS).

The performance of the SGTES has included, among other relevant initiatives, the formulation of the National Permanent Health Education Policy (PNEPS), launched in 2003, and institutionalized with the publication of Ordinance GM/MS nº 198, dated February 13, 2004 ⁷7 Brasil. Portaria GM/MS nº 198 de 13 de fevereiro de 2004. Institui a Política Nacional de Educação Permanente em Saúde como estratégia do Sistema Único de Saúde para a formação e o desenvolvimento de trabalhadores para o setor e dá outras providências. Diário Oficial da União. 14 Fev 2004., which established guidelines for its implementation, fostering regional policy conduction and interinstitutional and intersectoral participation. Subsequently, Ordinance GM/MS nº 1.996/07 ⁸8 Brasil. Portaria GM/MS nº 1.996 de 20 de agosto de 2007. Dispõe sobre as diretrizes para a implementação da Política Nacional de Educação Permanente em Saúde. Diário Oficial da União. 20 Ago 2007. was published, which proposed new guidelines for PNEPS, which comprise, currently, the normative base of the SUS, consolidated in 2017 ⁹9 Brasil. Portaria de Consolidação nº 3 GM/MS de 28 de setembro de 2017. Consolidação das normas sobre as redes do Sistema Único de Saúde. Diário Oficial da União. 29 Set 2017..

The concept of Permanent Education adopted in this normative framework considers that this implies the establishment of

It is intended, thus, for multiprofessional audiences, that is, the health team inserted in the many organizational levels of the service network, with the aim of transforming technical and social health practices, with a view to guaranteeing access, improving quality, the humanization of health care for the population and the improvement of the management capacity of the SUS.

From the pedagogical point of view, the Permanent Health Education (PHE) takes as a starting point for educational actions,

It must be considered, therefore,

The formulation and implementation of the PNEPS stimulated the scientific production on this topic, and was the object of analysis in some studies that point to important evidences of the difficulties of articulation between managers, workers, social control instances and Institutions of Higher Education (IES), incipient participation of municipal managers and difficulties in the use of financial resources, which have repercussions on the reduced implementation of the Teaching-Service Integration Commission (Cies), foreseen in the PNEPS, in the vagueness of parameters for project construction and in the absence of evaluation of the actions implemented in changes in the practices of training, management and health care ¹⁰10 Ferraz F, Backes VMS, Mercado-Martines FJ, et al. Gestão de recursos financeiros da educação permanente em saúde: desafio das comissões de integração ensino serviço. Ciênc. Saúde Colet. 2013; 18(6):1683-1693.

11 Ferraz L, Vendruscolo C, Marmett S. Educação Permanente na Enfermagem: uma revisão integrativa. Baiana de Enferm. 2014; 28(2):196-207.

12 Nicoletto SCS, Bueno VLRC, Nunes EFPA, et al. Desafios na implantação, desenvolvimento e sustentabilidade da Política de Educação Permanente em Saúde no Paraná, Brasil. Saúde Soc. 2013; 22(4):1094-1105.

13 Macedo NB, Albuquerque PC, Medeiros KR. O desafio da implementação da educação permanente na gestão da educação na saúde. Trab. Educ. Saúde. 2014; 12(2):379-401.^-1414 França T, Pierantoni C, Belisário AS, et al. A capilaridade da Política Nacional de Educação Permanente em Saúde no Brasil. Atas-Investig. Qualit. Saúde. 2016; 2:66-75..

Currently, considering the problems that affect the effective consolidation of SUS - such as underfunding ¹⁵15 Paim JS. Financiamento da Saúde: questão política para além do setor. Cremeb-Vida & Ética. 2014; 5(18):17., recomposition of public-private relations ¹⁶16 Vieira FS. Nota Técnica. Crise econômica, austeridade fiscal e saúde: que lições podem ser aprendidas? Ipea: Brasília, DF; 2016.^,1717 Scheffer M. O capital estrangeiro e a privatização do sistema de saúde brasileiro. Cad. Saúde Pública. 2015; 31(4):663-666., changes in the management of complex units and reorientation of priority policies and strategies -, there is a need for adjustments in various areas of work management and health education. With regard to PNEPS specifically, it was identified the need for a reflection on the strategies to be adopted to ensure its effective implementation, considering regional, state and local specificities.

In this perspective, MS, through the Department of Health Education Management (Deges), linked to SGTES, in partnership with Conass, Conasems, CNS, Technical Schools of the SUS (Retsus), Public Health Schools (ESP), IES, Pan American Health Organization (Paho) and other secretariats of the MS, has started the discussion process on PNEPS with the objective of collectively discussing strategies to update Ordinance GM/MS nº 1.996/07.

Thus, it was agreed the accomplishment of Regional Workshops, involving states and municipalities, to evaluate the implementation process of this Policy, whose organization was built collectively involving Deges/SGTES with the technical cooperation of the teams of the Institute of Collective Health of the Federal University of Bahia (ISC/UFBA), the Institute of Social Medicine of the State University of Rio de Janerio (IMS/Uerj), Medical School of the Federal University of Minas Gerais (UFMG), Oswaldo Cruz Foundation (Fiocruz), and the participation of the Conass and Conasems.

Six Workshops were carried out, bringing together managers and technicians from the Northeast, North, Central-West, Southeast and South regions, forming a movement to resume the debate around PNEPS, constituting the starting point for the elaboration of proposals that generated initiatives within the MS, as well as in the states. Considering the richness and strategic importance of this process, the objectives of this article are to describe and analyze the activities carried out, as well as to systematize the proposals elaborated collectively, with a view to contributing to the debate about the effective implementation of PNEPS within the SUS.

Theoretical-methodological procedures

The delimitation of the object of study took as reference the theory of the cycle of public policy, developed by Kingdon ¹⁸18 Kingdon, J. Agendas, alternatives and public choices. Boston: Little Brow; 1994., which comprises four distinct moments: a) the determination of the agenda; b) the formulation of the policy (identification of problems, selection of proposals and alternatives, negotiation and, formalization in law); c) the implementation of the policy that includes the preparation of plans, programs and projects within the public bureaucracy and its execution; and d) evaluation of the policy, which includes the identification and evaluation of the process, results and impact achieved with the implementation of the plans, programs and projects, basis for elaboration of proposals for improvement and/or changes in objectives and actions proposed in the framework of policy ¹⁷17 Scheffer M. O capital estrangeiro e a privatização do sistema de saúde brasileiro. Cad. Saúde Pública. 2015; 31(4):663-666..

In the specific case of PNEPS, it was considered that the entry on the agenda and the formulation of the Policy have materialized the publication of the aforementioned directives, so that as a study object the actions carried out by the MS in 2017-2018, under the coordination of the Deges/SGTES, to resume and intensify the support to the states and municipalities for the development of the implementation of the PNEPS. It is worth noting that implementation is the crucial moment of the policy cycle, insofar as it consists in materializing the proposals in managerial and operational actions that focus on the problems identified, actions carried out by the policy operators, whether managers and technicians responsible for the planning and programming of the actions, or the professionals and workers who act directly in the execution of the actions ¹⁹19 Pinto ICM, Vieira-da-Silva LM, Baptista TVF. Ciclo de uma política pública de saúde: problematização, construção da agenda, institucionalização, formulação, implementação e avaliação. In: Paim JS, Almeida Filho N. Saúde Coletiva: teoria e prática. Rio de Janeiro: MedBook; 2014..

The information related to the process initiated in 2017-2018 were extracted from institutional documents, reports, ordinances and other publications of the MS which record the activities carried out to mobilize the institutional actors responsible for the implementation of the PNEPS in the states, in order to systematize the results of the a collective analysis of the PNEPS implementation process, the proposals, suggestions and recommendations emanating from the Workshops held in 2017 (chart 1) and the actions undertaken in 2018 to follow up and concretize the implementation and evaluation process of the PNEPS throughout the Country.

Analysis of the formulation and implementation process of PNEPS

As previously mentioned, the creation of PNEPS has as its normative framework the publication of Ordinance GM/MS nº 198, dated February 13, 2004, and its implementation guidelines published in Ordinance GM/MS nº 1.996/07. These documents contain the objectives and guidelines of this policy, also establishing the functions and responsibilities of each SUS management body in relation to the development of PHE actions of health professionals and workers.

The analysis of these documents evidences that the inclusion of this topic in the governmental agenda in the health area was a major advance, inserted in the efforts to comply with the provisions of Law nº 8.080/90 ²⁰20 Brasil. Lei nº 8.080 de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União. 20 Set 1990., which explains the responsibility of the SUS to guide the formation of ‘human resources’. The proposals contained in the PNEPS fosters the regional conduction of the policy, the interinstitutional participation through the Cies, in addition to defining budget for projects and actions establishing transparent allocation criteria, coherently, therefore, with the general principles and directives of the SUS in relation to decentralization and participation and social control in the management and execution of health policies.

Furthermore, it should be noted that the discussion process around the formulation of PNEPS involved the decision-making bodies of the SUS, such as the Tripartite Interagency Committee (CIT), the Conass Human Resources Technical Chamber, the Intersectoral Commission of Human Resources and Working Relations (CIRHRT), linked to CNS, as well as Conasems.

The implementation process of the PNEPS, in turn, faced difficulties, pointed out by the previously mentioned studies, and, in the view of the managers and technicians who participated in the Regional Workshops held in 2017, this process was somewhat ‘asleep’, in the majority of states, due to, particularly, the interruption of the transfer of financial resources from the central level (MS) to the State Health Department (SHD), from 2012. Thus, SHD, in their great majority, faced difficulties to follow-up on the planning, scheduling and execution of PHE actions, except in states where there was investment in this area with resources from the state and/or municipal budget ²¹21 Brasil. Ministério da Saúde Relatório Consolidado sobre o processo de implementação da Política Nacional de Educação permanente em Saúde (PNEPS). SGTES/DEGES/Ministério da Saúde: Brasília, DF; 2018..

The resumption of the debate on this process in the Regional Workshops had as objectives: a) to identify the main problems faced in the state and municipal scope for the implementation of PNEPS; b) to identify critical nodes that require institutional support from Deges/SGTES/MS; c) to elaborate proposals for the improvement of PNEPS based on identified needs at state and municipal level ²²22 Brasil. Ministério da Saúde. Termo de referência para as Oficinas Regionais PNEPS. SGTES/DEGES/Ministério da Saúde: Brasília, DF; 2017..

The methodology used in the Workshops enabled the participants, through analysis and debate, to reconstruct a shared image of the reality in which PNEPS operates in their territories. It was also possible to map the institutional relations and a reflection on the practices, complexities, problems, strengths, management processes and pedagogical methods of PHE, according to their own unique needs and possibilities.

It should be underlined that, in addition to their initial purposes, these Workshops were experienced and perceived as an PHE activity, that is, they became a significant learning moment for the participants, constituting an important tool for monitoring and follow-up, since they allowed to examine the development, the instruments used for the management, the problems, the objectives and the results achieved in their implementation in the states, from the perspective of the conceptual and organizational bases of the PNEPS.

With regard to the content of the debate held within the Workshops, it is important to emphasize, firstly, the problematization of the pertinence of the review of the PNEPS regulatory framework, considering that the principles and guidelines of the Policy remain valid, with only the need to carry out a few adjustments in the text, taking into account the current context of Health Policy. Thus, it was considered that the main problem with PNEPS is not the content of the policy, but the difficulties faced in the implementation process, which also contribute to the existence of great heterogeneity and inequality in the situation verified in each federated unit.

The debates, therefore, converge towards the identification of a set of problems and elaboration of proposals and recommendations for the implementation, execution, management, monitoring and evaluation of the PNEPS, which were grouped, according to the different dimensions of the policy, in six categories: a) Concept of PHE; b) Management of financial resources; c) Institutionalization of the policy; d) Decentralization and regionalization of the PNEPS implementation process; e) Monitoring and evaluation of the Policy; f) Relationship/articulation between federative entities in the PNEPS implementation process. Next, a summary of the problems identified, and the proposals elaborated in the Workshops is presented in each of these dimensions.

Problems identified in Regional Workshops

Based on the processing of the data extracted from the reports of the Regional Workshops, an analysis matrix was constructed that systematizes the main problems faced in the PNEPS implementation process. In spite of the heterogeneity observed in terms of the degree of development of the management, planning, programming and execution of the PHE actions, it is possible to identify ‘problem-areas’, which are present to a greater or lesser degree, in all states. They are:

Management of the PHE Policy: the complexity of the PNEPS implementation management process was verified, due to several factors; among them, the lack of understanding by most managers of the importance of PHE actions for the qualification of management and improvement of health care in SUS stands out. From this fact, more evident in some states, is the lack of prioritization of PHE actions in the planning and programming process, either within the scope of the State Health Plan or, more precisely, in the fragility of regional planning processes of PHE actions. This is also connected with the degree of development of the process of implantation and operation of the Cies and is reflected in the articulation between the several institutions that compose the quadrilateral of PHE ²³23 Ceccim RB, Feuerwerker LCM. O Quadrilátero da formação para a área da saúde: ensino, gestão, formação e controle social. Physis. 2014; 14(1):41-65.. Some states refer to difficulties in the relation with educational institutions, as well as the incipient incorporation of representatives of health workers and social movements in the process of planning and implementing the PHE Policy and Plans, in addition to pointing out, in some cases, the great turnover of managers, especially at the municipal level. Another aspect discussed during the Workshops was the need to deepen the role that can be represented by the Education-Health Public Action Organizational Contracts (Coapes) in the organization of PHE actions and in the teaching-service articulation, including negotiation and relations between public and private institutions.

Funding: all states pointed to the discontinuity of financial transfers from the MS (since 2011) and problems in the management of resources, especially the difficulty of remunerating teachers linked to schools of the SUS, as well as the use of resources due to restrictions in public legislation in this area. Some states have sought alternatives to guarantee the funding of these actions, such as Santa Catarina, Ceará and others, providing resources from other sources, including the state budget.

Model of permanent training/education implemented: participants of the Workshops referred to the coexistence of a traditional training model, characterized by the reproduction of courses and activities focused on isolated professional categories, with the implementation of an innovative model that takes into account the work in team, interprofessional education, the use of active teaching-learning methodologies and the accomplishment of activities of distance education with the use of Information and Communication Technology (Tics) and the demand for training in active methodologies and innovative actions for the development of the area of PHE.

Infrastructure: some states refer to deficiencies in physical space and logistical support to ensure the functioning of the Cies, as well as the absence of the PHE sector in the SHD organizational chart, as well as the lack of resources (personnel, daily tasks, transportation) to carry out the PHE actions. It was also mentioned the lack of state public health schools in some states.

Concept of permanent education: many representatives of the states referred to the need to resume reflection and debate on the concept of permanent education, since it is considered that there has not been a full appropriation of the conception that underlies PNEPS. It is pointed out, as determining fact, institutional instability, especially managerial turnover, proposing a certain ‘conceptual alignment’ that facilitates the process of management and planning of PHE actions. In this perspective, the need to distinguish between ‘health education’, ‘permanent education’, ‘popular education’, distinguishing, also, ‘professional education’ from permanent education is highlighted.

Monitoring and evaluation of permanent education activities: practically all the participants pointed out difficulties in monitoring and evaluating the actions of permanent education, emphasizing the absence of indicators that exceed the mere quantification of the courses and other activities carried out.

Attributions and responsibilities of each level of government and interfederative articulation: state representatives were unanimous in pointing out that, in addition to the discontinuance of financial transfers, the need for technical support from SGTES to implement the PNEPS.

Proposals developed at Regional Workshops

The identification of the problems subsidized the elaboration of a set of proposals in each of the Workshops, which were systematized in a matrix (chart 2), based on similarity and thematic approximation.

Actions triggered by the Ministry of Health in 2017-2018 for the implementation and strengthening of PNEPS

Based on the results obtained with the Regional Workshops, Deges/SGTES triggered, during the year 2018, a series of activities aimed at meeting the demands of the states, seeking to provide immediate answers to some of the main problems identified.

Firstly, the aim was to recover the funding flow, through the transfer of resources from the MS to the states and municipalities. This decision was materialized in the publication of Ordinance nº 3.194, dated November 28, 2017 ²⁴24 Brasil. Ministério da Saúde. Portaria nº 3.194, de 28 de novembro de 2017. Dispõe sobre o Programa para o Fortalecimento das Práticas de Educação Permanente em Saúde no Sistema Único de Saúde - PRO EPS-SUS. Diário Oficial da União. 29 Nov 1990., which provides on the Program to Strengthen Practices of Permanent Health Education in the Unified Health System (Pro EPS-SUS) and creates financial incentives for the implementation, execution and management of Pro EPS-SUS, with a view to stimulating, accompanying and strengthening professional qualification of workers in the area for the transformation of health practices towards the fulfillment of the fundamental principles of SUS, based on the local reality and the collective analysis of work processes. With this, approximately R$ 70 million were transferred to the municipalities and states for the planning and execution of educational actions that respond to the health needs, respecting the regional/local reality.

In parallel, it was intended to encourage the implementation of teaching-service-community integration processes, expanding the channel of dialogue with the actors involved with the Coapes. In this sense, as a strategy to leverage the contract process in the Country, investments were made to qualify the process of permanent negotiation in defense of the qualification of care and training.

In order to give visibility to innovative experiences, Deges/SGTES/MS, in partnership with Paho/World Health Organization (WHO), launched the Notice of the Innovations in Health Education Laboratory with emphasis on Permanent Health Education, receiving 251 inscriptions, which went through a commission of evaluators, resulting in a first selection of 45 experiences that were presented at a national workshop. Of these, 30 were selected for on-site visitation, with 15 finalists being awarded, who composed a specific publication of the MS/Opas ²⁵25 Brasil. Ministério da Saúde. Laboratório de Inovação em Educação na Saúde com ênfase em Educação Permanente. Ministério da Saúde/Organização Panamericana da Saúde/Organização Mundial Saúde no Brasil: Brasília, DF; 2018., organized in three thematic axes: Teaching-Service-Community Integration; Interprofessional Education and Practices; and Management of the Permanent Health Education Policy.

To technically subsidize the process of planning and programming the PHE actions in the states, a manual was prepared, entitled ‘Guidelines for planning the actions of Permanent Health Education in SUS’, sent to all SHD and Municipal Health Secretariats (MHS) to subsidize the elaboration of Permanent Education Plans.

A specific publication entitled ‘National Policy on Permanent Health Education was also organized: What has been produced for its strengthening?’ ²⁶26 Brasil. Ministério da Saúde. Política Nacional de Educação Permanente em Saúde: o que se tem produzido para o seu fortalecimento? Ministério da Saúde: Brasília, DF; 2018. structured in four chapters, and which addresses relevant aspects of the current movement around the PNEPS implementation, as teaching-service integration; Coapes; program to strengthen PHE; recognition of PHE experiences; incorporation of new approaches in the PHE processes, such as interprofessional health education and incentive to the upward, participatory and regionalized planning of PHE actions in the states.

Finally, in November 2018, it was held, in Brasília, the National Workshop, bringing together about 120 participants, for validation of the Final Report of the Regional Workshops and presentation of the preliminary proposal for the system for monitoring and evaluating PHE actions, which will be developed next year.

Final considerations

The accomplishment of a national debate on PNEPS made it possible to outline the main aspects of the process of implementation of this policy in the states and municipalities of the Country. In this perspective, it was considered necessary to identify the weaknesses faced in each concrete reality, in order to move forward with the preparation of proposals, both in relation to general aspects of the Policy and the role to be played by each level of government and in relation to the preparation of specific proposals that can serve as reference for the improvement of the implementation process in each state.

In this way, it was sought to rescue the protagonism of those who implement the Permanent Education Policy, especially the State and Municipal Health Secretariats, in a process that had institutional support from the MS to trigger initiatives that allowed the resumption of upward planning, in a collective effort to carry out articulated actions among the three entities of the federation, valorization of the experiences in course in the Country, divulged through the Laboratory of Innovations in Health Education, which evidences the potential of the PNEPS with respect to the contribution to the improvement of the quality of services provided by the SUS.

References

Publication Dates

History