Unified social assistance system and the occupational therapist insertion

Abstract

Introduction

Occupational therapy is the profession with more historical visibility related to the health field. Within the scope of the public policy of social assistance, its insertion started to be officially foreseen from 2011, however its action has been developed in the beginning of occupational therapists’ action in Brazil.

Objective

To present the profile of occupational therapists inserted in the services and/or programs of the Unified Social Assistance System (SUAS) in Minas Gerais (MG) state, Brazil.

Method

Documentary research was carried out, using the SUAS Census as a source of information. Quantitative data from municipalities with occupational therapists per year, by equipment, services, and role between the years 2012 to 2019 were mapped. The data were treated using simple statistics, and the results were organized into analytical categories, which were part of the discussion of the results.

Results

Data from occupational therapists were found in SUAS equipment for Basic Social Protection, Special Social Protection, and at the management level. A relevant number of occupational therapists in services for people with disabilities stood out.

Conclusion

The constitution of social occupational therapy, the recognition of the profession's specialization in social contexts, and the provision of this professional in the SUAS has expanded the debate and the possibilities of action with a focus on social protection. Other studies are suggested about the professionals’ profile, as well as the practices developed by them, aiming to understand their actions, application of theoretical-practical knowledge and contribution of the specificity of occupational therapy in this context.

Keywords:
Social Welfare; Public Policy; Professional Practice; Occupational Therapy

Resumo

Introdução

A terapia ocupacional é uma profissão com mais visibilidade histórica na área da saúde. No âmbito da política pública da assistência social, sua inserção passou a ser oficialmente prevista a partir de 2011, embora atue neste setor desde o início de suas ações no Brasil.

Objetivo

Neste estudo, objetivou-se traçar o perfil dos terapeutas ocupacionais inseridos nos serviços e/ou programas do Sistema Único de Assistência Social (SUAS) no estado de Minas Gerais (MG).

Método

Realizou-se pesquisa documental, tendo como fonte de informações o Censo SUAS. Foram mapeados os dados quantitativos de municípios com terapeutas ocupacionais por ano, por equipamentos, serviços e função entre os anos de 2012 e 2019. Os dados foram tratados por meio de estatística simples e os resultados foram organizados em categorias analíticas, as quais integraram a discussão dos resultados.

Resultados

Foram encontrados dados dos terapeutas ocupacionais em equipamentos do SUAS da Proteção Social Básica e da Proteção Social Especial e no nível da gestão. Destacou-se quantitativo relevante de terapeutas ocupacionais em serviços para pessoas com deficiência.

Conclusão

A constituição da terapia ocupacional social, o reconhecimento da especialização da profissão em contextos sociais e a previsão deste profissional no SUAS tem ampliado o debate e as possibilidades de atuação com foco na proteção social. Sugere-se outros estudos acerca do perfil desses profissionais, bem como das práticas desenvolvidas por eles visando compreender suas atuações, aplicação dos conhecimentos teórico-práticos e contribuição da especificidade da terapia ocupacional neste contexto.

Palavras-chave:
Assistência Social; Política Pública; Prática Profissional; Terapia Ocupacional

Introduction

Historically, occupational therapists have developed their professional work with populations with issues related to health-disease processes, mainly people with disabilities (PWD), people with mental illness and/or with other health conditions (Soares, 1991). Throughout the 1970s, the social theme gained emphasis in occupational therapy in Brazil, when the debate on the risks of medicalization of social problems intensified, and on the need to analyze the reach of the political-social dimension of the professional performance of this category, mainly based on criticisms about the technical role of social adaptation and maintenance of the excluding and stigmatizing institutional reality carried out in total institutions (Barros et al., 2002). Also in this decade, the category recognized the social dimension as the center of professional intervention for marginalized populations in processes of disruption of social support networks resulting from social inequalities (Barros et al., 2002; Galheigo, 2016). Thus, in the mid-1980s, occupational therapy in the social field began to emerge in professional discourses (Galheigo, 2016). Thus, the debate on understanding the “social” as a dimension present in all occupational therapy and as a specificity of this profession intensified and matured, which would need its own methodologies and practices, in view of the demands that emerged from the social issue (Barros et al., 2002). In this context, in the late 1990s and early 2000s, through a partnership with professors from three universities in the state of São Paulo - Universidade de São Paulo, Universidade Federal de São Carlos and Pontifícia Universidade Católica de Campinas -, it created an inter-institutional project, called METUIA, around which they began to develop extension actions and publish academic productions referenced to what they came to call Social Occupational Therapy (Galheigo, 2016).

Still, in this process of institution of the social field, the Federal Council of Physiotherapy and Occupational Therapy recognized, through Resolution No. 383 of 2010, the specialty "occupational therapy in social contexts", describing the areas of work of the occupational therapist in social contexts, among them, social assistance (Brasil, 2010).

In 2011, through Resolution No. 17/2011, the National Council for Social Assistance (CNAS) ratified that higher-level professional categories would form part of the reference teams of the Unified Social Assistance System (SUAS), in order to meet the specificities of social assistance services (Brasil, 2011). The possibility of insertion of the occupational therapist in the SUAS materialized in the midst of challenges - political, social, technical-scientific and practical - which intertwine with the context of the history of constitution of the profession itself (Almeida et al., 2012; Soares, 1991).

Although there are these regulations for the inclusion of occupational therapists in the SUAS services, the scope of this insertion in the context of the aforementioned policy is questioned, since there are still many challenges for the professional consolidation of this category. Thus, it is reaffirmed that dimensioning the number of professional occupational therapists and what positions they have occupied in the context of social assistance is necessary to understand the insertion in this policy, as well as to enhance and, perhaps, guide future strategies that can expand spaces for this action. Such studies are essential, especially in the state of Minas Gerais (MG), which stands out due to the lack of studies of this nature. Therefore, within the scope of this research, based on a descriptive exploratory approach, the objective was to outline the profile of occupational therapists inserted in the SUAS in MG.

The Insertion of Occupational Therapy in SUAS: History, Construction and Potentialities

Social protection systems, materialized by social policies under the responsibility of the State and developed with the purpose of protecting and guaranteeing social rights, seek to ensure criteria of equity and distributive justice, as well as the reduction of social inequalities (Veroneze, 2017; Wolf & Oliveira, 2017).

In the case of Brazil, social security involves three public policies that aim to guarantee the right to well-being, protection and social justice, namely: social security, health and social assistance policies (Veroneze, 2017), highlighting the last one as analysis scenario of the present study. By exploring the historical path of the Brazilian social assistance public policy, it is possible to identify that, prior to the Carta Magna of 1988, the offer of social assistance in the country had a welfare, charitable, hygienist and clientelist profile that still today marks the conflicting scenario between the benefit and the right (Mota, 2017).

With the end of the military regime, political re-democratization brought possibilities for the consolidation of the Brazilian social protection system from the 1988 Constitution, making the State's responsibilities official and legally affirming social security, outlining a new path for social assistance in Brazil. It is in this context that social assistance first appeared as a public policy, composing the tripod of social security, and being recognized as a citizen's right and responsibility of the State (Boschetti, 2009). Consequently, in 1993, the Organic Law of Social Assistance (LOAS) n. 8.742, whose purpose is to regulate this policy and establish norms and criteria for structuring social assistance, which, as a right, requires determination of objective laws, norms, principles and guidelines (Brasil, 2009b).

The IV National Social Assistance Conference, held in 2003, as well as the approval of the National Social Assistance Policy (PNAS) in 2004, and the Basic Operational Norm in 2005, were of paramount importance, as they demonstrated the intention to put into practice the creation of SUAS, reinforcing the commitment of such bodies to implement LOAS guidelines by the Ministry of Social Development and Fight against Hunger (MDS) through the National Social Assistance Secretariat (SNAS) and CNAS (Brasil, 2005).

SUAS bases its principles on the universalization and equality of social rights, on respect for the dignity and autonomy of the individual, family, and community, as well as on the dissemination of programs, services, benefits and assistance projects; in the right to family and community coexistence, in addition to equal rights (Brasil, 1993). It is organized based on a protection system with two distinct levels of complexity: Basic Social Protection (PSB) and Special Social Protection (PSE), offered in different equipment, organized into services, programs, projects and benefits of SUAS with an emphasis on territorial reference, when considering the demands and needs of the population and having the family as the main focus of attention (Brasil, 1993).

With the aim of preventing risk situations by strengthening family and community ties, the PSB is aimed at the population that is in a situation of social vulnerability and/or weakened affective bonds, but whose rights have not been violated. The PSE, on the other hand, contributes to the reconstruction of family and community bonds, the strengthening of potentialities and acquisitions, and the protection of families and individuals to face situations of personal and social risk, due to the violation of rights. PSE is further divided into medium and high complexities. The first is aimed at individuals who have their rights violated, but preserve family ties; the second is aimed at individuals who have violated rights and broken ties, ensuring full protection for this population (Brasil, 2005).

According to the National Typification of Social Assistance Services, created in 2009, services linked to PSB can be operated in Social Assistance Reference Centers (CRAS), Child, Adolescent, Youth and Elderly Centers referred to CRAS and/or at home. The medium-complexity PSE services are operationalized in the Specialized Social Assistance Reference Centers (CREAS), in units referred to CREAS, and in the Day Center and Specialized Reference Center for Homeless Population (Centro Pop), while the services of high complexity PSE are offered in Reception Units (Oliveira, 2020).

Although the scientific production about occupational therapy in SUAS is still scarce, there has been a growth of publications on this theme, addressing theoretical-practical relationships through research results, theoretical essays, reports of practices, experiences and experiences in SUAS (Almeida & Soares, 2016; Almeida et al., 2012; Araújo et al., 2011; Bezerra et al., 2015; Borba et al., 2017; Chaves et al., 2015; Costa, 2016; Minatel & Andrade, 2020; Morais & Malfitano, 2016; Oliveira et al., 2019; Oliveira, 2020; Oliveira & Malfitano, 2021; Pinho et al., 2019; Pinho, 2020; Prado, 2020; Surjus, 2017; Viana, 2013).

In some of these studies, the insertion, role, and possibilities of interventions of the professional occupational therapist in the SUAS were investigated. In the study by Araújo et al. (2011), occupational therapists who worked in institutions linked to SUAS in the city of Belém (PA), unanimously considered that the profession has specific characteristics that are consistent with the principles and guidelines of SUAS and that can meet the demands of the population served, therefore, the inclusion of the profession/professional in the SUAS team is legitimate (Araújo et al., 2011). Oliveira et al. (2019) demonstrated that there was an increase in the number of occupational therapists in SUAS, with a greater number of them in the southeast region, as well as indicating the need for continued investment in graduate training, and the development of technical-professional capacity. Still, among the studies on professional performance in a study on the national scene, Oliveira (2020) demonstrated that more than half of them work in the southeast region and in Day Centers (Oliveira, 2020; Oliveira & Malfitano, 2021).

Regarding graduate training, Oliveira et al. (2019) and Viana (2013) indicate the urgency of inserting themes that contemplate occupational therapy in SUAS, both in undergraduate courses and in the technical-scientific organization to work in this field. In fact, the inclusion of occupational therapists in the SUAS seems to be driving the inclusion of this theme in graduate training, with some publications of experience reports on extension projects and/or mandatory curricular internship being found. Chaves et al. (2015) reported an experience of occupational therapy academics working with adolescents assisted in a Service for Coexistence and Strengthening of Links (SCFV) of a CRAS, in the municipality of Belém do Pará. Another study, developed by Borba et al. (2017), reports an experience of the practice of a professional internship in occupational therapy at the Universidade Federal de São Paulo (Unifesp), from 2011 to 2014, at a CRAS unit in the city of Santos/SP, covering the Welcoming Section and Provisional Shelter for Adults, Elderly People and Families living on the streets and Living Togetherness Service for Young People.

Pinho et al. (2019) published a study on the actions developed by Pop Centers and the perspectives of coordinators around the dimension of work and productive inclusion for the homeless population. Prado (2020) conducted a survey on the work of occupational therapists in Living Centers and Passage Houses, demonstrating relevant work in expanding, creating and strengthening social support networks of users of these services. Surjus (2017) conducted a reflective essay on the issue of social inclusion in the work of intellectual PCD and occupational therapy practices within the scope of public policy on social assistance in Brazil.

According to Almeida et al. (2012) and Almeida & Soares (2016), who presented elements of the historical process of insertion of occupational therapists in SUAS, professionals act based on a social context, together with individuals, groups and communities in processes of disruption of social support networks, disruption of the bases of coexistence and social belonging and violation of rights. Interventions can be aimed at preventing and transforming the reality in which they find themselves, seeking to rescue and implement the right of these individuals to participate in meaningful activities that provide feasible opportunities to “live with dignity, carry out social exchanges, prosper, develop potentials and projects of life in various spheres of life, and find satisfaction, in line with their cultures and beliefs” (World Federation of Occupational Therapists, 2006, as cited in Almeida & Soares, 2016, p. 170). Occupational therapy conducts unique processes and actions, with the protagonist participating in the activities that they propose as mediators of real transformation. In this way, the attitude and its construction process - knowledge and meanings - provide empowerment and enhance production capacity (Castro et al., 2009, as cited in Almeida & Soares, 2016).

Certainly, there are other practices of occupational therapy in SUAS that have not yet been published or reported in scientific events. However, based on the previously exposed studies, it appears that occupational therapy contributes to the practice of social assistance, in different equipment and services, and it identifies convergences between the work of occupational therapy and the propositions of the PNAS and the services and actions developed by SUAS, making the inclusion of this professional in the context of social assistance justifiable. Furthermore, it is important to highlight that the definition process that validated the insertion of the occupational therapist in the SUAS services was characterized by the participation of occupational therapists who worked mainly in the field of social assistance and social occupational therapy, in Forums and Regional Meetings and State Workers, as well as at the National Meeting of SUAS Workers, in Brasília. Important themes about the quality of services and the production of a better perspective of the possibilities and attributions of occupational therapy were discussed, together with the other professionals, based on the ethical and political commitment of the profession, as well as on the challenges of implementing the PNAS (Almeida et al., 2012).

Social assistance in Brazil lives amidst challenges associated with sociopolitical issues of structural and conjunctural contradictions that, associated with terms such as assistance, social inclusion and combating poverty, maintain social inequalities, according to Almeida & Soares (2016, p. 169). One of the responsibilities of occupational therapists involved in building a fairer and more diverse society, according to the authors, is “to integrate processes that aim to elaborate, invent, evaluate and improve new ways of intervening on old problems in dialogic processes with the population that experience".

In this perspective, taking as a reference the work developed in the social assistance policy, its methods and objectives, there is congruence with the perspective of occupational therapy, with emphasis on practice in social contexts, which, in a central way, deals precisely with the issues that lead people to the SUAS services. According to Almeida & Soares (2016, p. 169):

Situations of vulnerability and violation of rights result in the impediment or difficulty (systematic or temporary) of people or social groups to autonomously carry out activities that are significant for themselves and their social environment. [...]. However, many times, these experiences of suffering, and the paralysis that is immanent to them, are silenced in the face of pre-defined and standardized responses from programs, services, and professionals.

In this way, the insertion and performance of occupational therapy in social assistance broadens the discussion and recognition of the profession, beyond the context of health. In addition, it reaffirms the space for practice and theoretical production in the social context, based on the consequences established by the situations and living conditions of the public that is the target of the services offered by SUAS and by the differentiation in the way of acting, thinking and intervening with this population.

Given the incorporation of the occupational therapist in social assistance/protection services, before and after the institution of SUAS, as well as the study carried out at the national level (Oliveira, 2020), and, considering the interest in regional studies - especially in MG, where the Universidade Federal de Minas Gerais (UFMG) is located -, it is important to seek to map the occupational therapists inserted in SUAS, in the state of MG. The geographical focus of MG is also based on the lack of a published study with this theme and statewide scope.

It is hoped that the results of this study will contribute to the perception and visibility of the inclusion of occupational therapists in SUAS and, perhaps, to expand the insertion of professionals in this context.

Method

This study is a documentary, exploratory, descriptive research. Documentary research is characterized as a comprehensive and intense verification of documents that have not undergone any analysis process or can be re-examined, in search of new information or interpretations, with the aim of extracting information to understand a certain phenomenon (Sá-Silva et al., 2009).

In this research, we used secondary data, publicly accessible, available on the Censo SUAS virtual platform, published as official data by the Ministry of Citizenship (MC). The Censo SUAS is a social assistance monitoring and surveillance mechanism of the social assistance policy that collects data through an electronic form filled out by state and municipal social assistance secretariats and councils (Brasil, 2007). The data obtained are available divided into different databases and separated by categories. The category analyzed in this research concerns the Human Resources (HR) components of various SUAS equipment and services between the years 2012 and 2019. years, and considering the legal provision of occupational therapy professionals in social assistance from 2011 onwards (Brasil, 2011).

Data were accessed via the Censo SUAS website in the topic corresponding to “Download processed data” (Brasil, 2008). In this place, the information is distributed by year and equipment/service. All files were downloaded from 2012 to 2019, of the equipment/services that were the focus of analysis in the study, namely CRAS, CREAS, POP Center, Day Center, Reception Units, Living Center, Welcoming Family, Municipal Management and Management State. The files used were those referring to the HR of each service/equipment. The documents were in Excel® spreadsheet format, using the tools of this program to locate the descriptive “occupational therapist” and filter the results, selecting “MG” in the UF column (Federal Unit) and “occupational therapist” in the Profession column, from the program itself, to get to the relevant information. The collected data were reorganized in new Excel® spreadsheets, condensing only the information referring to occupational therapists in the state of MG, and treated using simple statistics, with the results being organized into analytical categories, which were part of the discussion of the results, namely: number of occupational therapists by function, year, service/equipment and municipalities.

The analysis for this research included information on all services found with occupational therapists in SUAS, which totaled nine analysis scenarios. It is worth mentioning that in this research, an occupational therapist was considered to be a subject with a higher education in occupational therapy, according to the Censo SUAS, which presents information in the profession category, and not in function. A quantitative descriptive analysis was carried out and a comparison was made with conflicting and similar literature related to the theme of this research.

It is important to highlight that, despite the apparent work and investment in the construction and maintenance of the Censo SUAS, the completion of the questionnaires that support the database is done by different equipment and municipalities. Therefore, there may be imprecision and divergences in the form of filling, as well as in the information filled in (Oliveira, 2020). It is a public data source and a government responsibility.

For the analysis of the data presented here, we used a dialectical method of interpretation, in which, through a continuous process, we identified dimensions, categories, trends, patterns and relationships, revealing their meaning. We understand that data analysis is a process that accompanies the entire investigation. Therefore, we identified relationships and constructed interpretations as the data were collected, considering the field of historical and totalizing specificity that produces the information. It is an interpretation that proposes to reveal the intrinsic, conflicting, and antagonistic content of reality (Prodanov & Freitas, 2013).

Results and Discussion

In the sample selected for this research, data from occupational therapists in SUAS equipment and at the management level were found: two equipment from PSB (CRAS and Centro de Convivência), four others from PSE (CREAS, Centro POP, Centro Dia, Reception Units, and a Foster Family service); and two management levels (Municipal and State). It is important to highlight that, in the years 2012, 2013 and 2014, information was available only on CRAS, CREAS, Pop Center, Reception Units, Municipal and State Management. As of 2015, information about Day Center and Community Center was added to the Censo SUAS. Data on Host Families are available from 2017 onwards. It should be noted that some data were not found, and others, even predicted, were not possible to analyze, since they were described by numerical code, as in the case of the Coexistence Center referring to 2019. Thus, the data extracted and analyzed on the insertion of occupational therapists computed in the HR list of each SUAS service or equipment, from 2012 to 2019, in the state of MG, arranged in four categories of analysis: quantitative of occupational therapists distributed by function; year; equipment/service/management and quantity of municipalities in MG with occupational therapists in SUAS.

Distribution of occupational therapists by function in SUAS in MG

For the analysis of the function/position that the occupational therapy professional performs in the SUAS services and equipment, we ratify that the variable “occupational therapists” refers to the professional's training and not to the function performed by them. Between the years 2012 and 2019, the functions, according to those with training in occupational therapy, found described in the Censo SUAS can be seen in Table 1.

Table 1
Number of occupational therapists by function in SUAS in MG per year (2012 - 2019).

Function	Year								Total
	2012	2013	2014	2015	2016	2017	2018	2019
General services (cleaning/upkeep)	1	0	0	0	0	0	1	0	2
Administrative support	1	1	1	2	1	1	4	2	13
Caregiver’s Assistant	0	0	0	0	0	0	1	0	1
Recorder	0	0	0	0	0	1	0	1	2
Caregiver	2	1	0	2	0	0	2	0	7
Resident caregiver	0	0	0	1	0	0	0	0	1
Social educator	0	2	3	10	7	6	6	7	41
Advisor/Social educator	0	0	0	1	1	0	1	2	5
Middle level technician	0	0	0	1	1	1	1	1	5
Coordinator	2	3	3	6	7	9	8	6	44
Director Coordinator	0	0	1	0	0	0	0	0	1
Technical Team	24	23	31	0	0	0	0	0	78
Higher level technician	12	15	17	80	99	99	181	165	668
Intern	0	0	0	0	0	0	1	1	2
Others	5	1	7	12	21	22	36	31	135

• Source: Elaborated by the authors (Brasil, 2008).

The “Total” column shows the greater or lesser recurrence of the functions occupied by the professional occupational therapist over the period analyzed, and it was not possible to account for the total number of occupational therapists from 2012 to 2019. In this research, an increase in the number of occupational therapists in social assistance in MG, from 2012 to 2019, was revealed, and, also, found in a study on the insertion of this professional in the national scenario in the period from 2011 to 2016 (Oliveira et al., 2019). In line with this same study and with the research by Oliveira (2020) for the period from 2011 to 2017, the results in Table 1 demonstrate that the most frequent functions of occupational therapists within the SUAS in MG was that of “Higher-Level Technician ” (952), which, added to the functions “Technical Team” (78), “Coordination” (45) and “Coordinator/Director” (1), demonstrates the expressive insertion of this professional as part of the technical team. The results on the insertion of the occupational therapist in the coordination function corroborate the CNAS resolution, which provides for the insertion of this professional in this function (Brasil, 2011). However, there is a significant number of professionals who have training in occupational therapy, but are not occupying the function foreseen in the resolution. Among them, the function “Others” (184) and Social Educator (38) stand out. If, on the one hand, this result points to a possible way of inserting the occupational therapist in the SUAS, as indicated by Oliveira (2020), on the other hand, it draws attention to possible situations of precarious work opportunities, in functions that the role will probably not be that of an occupational therapist.

As previously mentioned, before and after the institution of SUAS, the occupational therapist was present in different socio-assistance services in Brazil, pointing to the insertion of this professional in social protection services. Although an increase in the number of professionals in the SUAS in MG was identified, none of the scientific publications mentioned in the introduction refer to the context of MG, which corroborates the need for further regional studies.

According to the SUAS Human Resources Operational Norm (Brasil, 2006), higher education is required only for coordination functions and as a member of the technical team; for the other functions, listed in Table 1, secondary or fundamental education is required. In the period from 2012 to 2019, it is noteworthy that professional occupational therapists performed functions for which higher education is required, as well as other functions for which a lower level of education is required.

Despite fewer occupational therapists performing functions that require a level of education lower than higher education, we cannot fail to highlight the probable difficulties in hiring this professional compatible with their training, among them, the difference in funding for small, medium and large municipalities (Minas Gerais, 2020). In addition, it must be considered that the professional occupational therapist is not a mandatory presence in the SUAS teams (Brasil, 2011).

Distribution of occupational therapists per year in SUAS in MG

In 2019, a total of 219 occupational therapists registered in the SUAS in MG were found, and in 2012, the initial year of the research, there were 54 professionals working in social assistance services. Over the years, the numbers have been increasing, except in the years 2013, 2017, 2018 and 2019, in which there was a decrease compared to the previous year. The number of professionals per year can be seen in the graph below (Figure 1).

Figure 1
Number of individuals/year with training in occupational therapy enrolled in SUAS in MG, from 2012 to 2019.

When analyzing the quantitative data of occupational therapists per year included in the SUAS, a relevant growth can be seen from 2015 onwards, compared to previous years. Probably, such growth is justified from this year onwards, when information regarding two new facilities - Centro Dia and Centro de Convivência - began to be made available in the Censo SUAS.

Distribution of occupational therapists by equipment, service, and management at SUAS in MG

Among the socio-assistance service units analyzed are: CRAS, Living Center, CREAS, POP Centers, Day Center and Reception Units. The Welcoming Family service was also analyzed in the service category, in addition to Municipal and State Management. The results of this analysis are shown in Table 2.

Table 2
Total occupational therapists per social assistance equipment in MG per year, from 2012 to 2019.

Number of vacancies occupied by occupational therapists in Social Assistance Equipment/Service/Management per Year
Year	CRAS	CREAS	Centro POP	Centro DIA	Municipal Management	State Management	Foster family	Reception unit	Community center	Total professionals per year
2012	20	3	-	-	-	-	-	31	-	54
2013	17	2	-	-	-	-	-	26	-	45
2014	19	3	2	-	-	-	-	39	-	63
2015	25	3	3	122	-	-	-	49	21	223
2016	23	2	-	153	-	-	-	55	36	269
2017	17	3	2	130	-	-	1	52	47	252
2018	21	3	1	153	3	1	1	52	44	279
2019	16	10	1	145	2	1	1	43	-	219
Total	158	29	9	703	5	2	3	347	148	1404

• Source: Elaborated by the authors with databases from Brasil (2008).

Among the equipment, it is noticed that the Day Center (703) is the equipment that covers most of the occupational therapy professionals inserted in the SUAS in MG, as well as in Brazil, according to the study by Oliveira (2020). Followed by Reception Units (347), CRAS (158), Coexistence Centers (148), CREAS (29), Pop Centers (9), Municipal Management (5), Foster Family (3) and State Management (2).

In order to visualize where occupational therapists are inserted and which public they are dealing with, a numerical survey of professionals was carried out by service offered in each equipment, per year.

Considering that several services are offered in the CRAS and CREAS reference equipment, only the service described as the main activity of occupational therapy professionals in the SUAS Census worksheets was considered. In the POP Centers, occupational therapists were observed in two distinct main activities - Management Activities (administrative) and Specialized Service for Homeless People. Regarding the Reception Units, information was found related to the type of unit and the population served, and not referring to the service. About the Day Centers, Foster Family and Coexistence Centers, no data regarding the services were made available in the documents from the SUAS Census.

It should be noted that, in the CRAS, two services had a greater number of occupational therapists, considering the period from 2012 to 2019. Among them, the Integral Family Protection and Care Service (PAIF) had 41 professionals. This service aims to strengthen the protective function of the family, prevent the breaking of its bonds, promote its access and enjoyment of rights, and contribute to the improvement of its quality of life. In addition, the SCFV had 59 professionals in the period between 2012 and 2019. The SCFV aims to strengthen family and community relationships; promote integration and exchange of experiences among participants. It has a preventive character, based on the defense and affirmation of rights and on the development of user capacities (Brasil, 2009a). In the Basic Social Protection Service (PSB) at home for PCD and Elderly Women¹, as well as in the Happy Child Program (Brasil, 2021), 1 professional was identified in each of the services. Management Activities, Registration and/or Registration Update (CadÚnico) and others appeared as the main activities of occupational therapists in the CRAS, with 7, 4 and 8 professionals respectively.

In view of the brief characterization of the services that make up the PSB, it is clear that the objectives of this level of social protection corroborate what is described as the domain and attributions of the occupational therapist in social assistance at this same level by Almeida et al. (2015), which reinforces the inclusion of this professional in the SUAS trained to work in the CRAS. Among the 19 attributions described by Almeida et al. (2015), actions aimed at preventing the rupture of family and community ties and strengthening them stand out; promotion of social relationships involving doing in families and in the community through meaningful group activities in the context of local realities and for the family and its members; the strengthening of support networks and social, emotional, economic and information exchanges; the promotion of experiences that allow the individual and collective recognition of difficulties, among others. In addition, some of the occupational therapy publications refer to PSB, such as the work by Chaves et al. (2015) and Borba et al. (2017).

In the CREAS, the Service for Protection and Specialized Care for Individual Families (PAEFI) stands out during the research period, with 5 occupational therapists in total; the Service Specialized in Social Approach, with 3 professionals; the Social Protection Service for adolescents in compliance with the socio-educational measure of Assisted Freedom (LA) and Provision of Services to the Community (PSC), with 1 occupational therapist, and the Special Social Protection Service for PCD, Elderly Women and their Families, with 8 professionals, this being the medium complexity service with the largest number of occupational therapists. The Management Activity and Others service has 7 professionals, 3 in the first and 4 in the second.

In the Centros POP, where the Specialized Service for Homeless People is offered, which is part of the Special Social Protection of Medium Complexity, 5 occupational therapists were located and, in the others, Management Activity and Others, 1 professional was found in each service.

In the Reception Units, the Institutional Reception Service is offered, related to the Special Social Protection of High Complexity. The purpose of this service is to receive people in different types of equipment, aimed at families and/or individuals with broken or weakened family ties, in order to guarantee full protection. Reception facilities are separated by target population, including children and adolescents; elderly; adults and families; women in situations of violence; youth and adults with disabilities. The organization of the service must guarantee privacy, respect for customs, traditions and the diversity of: life cycles, family arrangements, race/ethnicity, religion, gender and sexual orientation (Brasil, 2009a). However, the data made available in the Censo SUAS on the type of unit and population were only for the years 2015, 2016 and 2019. Therefore, it is observed that Long-Term Institutions for the Elderly (ILPI's) concentrate the largest number of occupational therapists of this equipment, considering the three years that contain the information, totaling 81 professionals, followed by the Inclusive Residences exclusively for adults with disabilities, which add up to 16 professionals referring to the same period.

The Reception Units are the second social assistance facility with the highest absolute concentration of occupational therapists in MG, totaling, from 2012 to 2019, 347 professionals, which corroborates what Oliveira (2020) presented in his research, in which the Reception Units also were the second equipment in absolute number of occupational therapists, from 2011 to 2017, in Brazil, totaling 1563 professionals (Oliveira, 2020).

Occupational therapy has accumulated experience in monitoring people with difficulties in their daily lives, offering care for people with disabilities, changes in human development, the elderly and others (Soares, 1991). Added to this wide professional experience, as well as the accumulation of knowledge production, the occupational therapist in the context of SUAS has the ability to use activities as a socio-occupational mediation instrument, to create strategies of social, cultural and economic belonging, as well as of everyday life organizations, perspectives and life projects, in order to strengthen the social support networks, the affective, economic, informative bonds with people, families or groups, aiming at social protection, strengthening bonds and guaranteeing coexistence family (Almeida et al., 2015; Brasil, 2009a, 2010). Within the scope of this debate, an approximate reflection can be made in relation to the Inclusive Residence and Long-stay institutions, where occupational therapists are required more for their experience in health than for the possibility of acting in the social context. In fact, the occupational therapist can contribute with the accumulated knowledge in the field of health, however, without forgetting to consider the purposes of the PNAS.

Centro Dia is the equipment that presented, in absolute numbers, the highest insertion of occupational therapists in SUAS, from 2015 to 2019, totaling 703 professionals in MG in this period. This equipment offers the Special Social Protection Service for PCD, the elderly and their families, which aims to promote autonomy, social inclusion and the improvement of the quality of life of the participants (Brasil, 2009a). Oliveira's research (2020) demonstrated a diversity of Day Center-type services linked to SUAS, some of which were structured and named as Day Center, and others were implementing this socio-assistance service, as they were being linked to institutions that already served the elderly and people with disabilities with a focus on rehabilitation, such as the Association of Parents and Friends of the Handicapped (APAEs), Rehabilitation Centers, NGOs from various areas, Pestalozzi Societies, equipment for people with autism, an institution for people with visual impairments, a center for generating income, among others. In this way, still in Oliveira's research (2020), some occupational therapists participating in the research who worked in Day Centers, even though they were linked to social assistance, did not recognize themselves in this area of ​​activity.

In the case of our research, although it was not possible to access the linkage of the Day Centers, the significant number of occupational therapists included in this equipment is possibly related to the fact that occupational therapists are described as part of the service's reference technical team (Oliveira, 2020; Brasil, 2012), as well as it may also be related to the expertise of the profession in the field of health with the target population assisted in this service.

In line with the PNAS, the Day Center must provide assistance to young people and adults with disabilities in a situation of dependency and their families, with a view to contributing to improving autonomy and avoiding social isolation. Within the scope of this policy, the objective is also to identify situations of risk and violation of rights, seeking to overcome these conditions, avoid repetition of violations, strengthening the protective role of the family. If, on the one hand, the objectives of the Centro Dia involve the discussion of disability, autonomy, and independence, on the other hand, the role of this social assistance service is made explicit. It is even foreseen in the orientation manual for the Day Centers that the demands of health, education, work, among others, are indicated to be addressed through intersectoral work, which in the case of health presupposes the matrixing of the Day Center to the System Health System, involving the different levels of care present in the territory (Brasil, 2012). However, even if the sectoral responsibilities are delimited, we cannot fail to consider the complexity of the health demands that, added to the weaknesses in the financing of the health care network, can corroborate for the demands of social protection and rehabilitation to be imposed on occupational therapists in the SUAS care scenarios (Malfitano & Lopes, 2003; Matos et al., 2022). Despite this challenging reality, Oliveira (2020), in his research, identified that occupational therapists in Day Centers developed their work with a focus on social protection.

The Community Centers presented themselves as a relevant equipment in the insertion of occupational therapists, allocating in their service 148 professionals from 2012 to 2019, in MG. These are public social assistance units that offer SCFV, targeting children, adolescents, adults and the elderly, and their families. Assistance takes place through cultural, sports and leisure activities, according to the age group and life cycle of the users. It aims to encourage integration and exchange of experiences among subjects, promoting self-knowledge, self-confidence, respect for differences and citizenship, seeking to ensure the strengthening of family and community ties. These are spaces that can be managed by social entities or by public authorities (Brasil, 2009a). In the case of the Community Center, which includes assistance to different age and intergenerational groups, it has often contemplated care for the elderly, children and PCD (Oliveira, 2020).

The Foster Family is the service responsible for selecting, training, registering and monitoring foster families, as well as monitoring the foster child and/or adolescent and their family of origin (Brasil, 2009a).

Finally, with smaller absolute numbers, the Welcoming Family service referring to highly complex Specialized Social Protection, with Municipal and State Management, has 10 professionals. It is important to highlight the insertion of occupational therapists in the management, a function which is responsible for the elaboration and conduction of the dimensions of diagnosis, planning, execution, monitoring, and evaluation of social assistance services, having been foreseen by the CNAS resolution to be performed by this professional (Brasil, 2011). “For SUAS, the concept of management is composed of the association between mastering technical knowledge and the capacity for innovation, aligned with the democratic principles of public management” (Brasil, 2008, as cited in Ferreira, 2011, p. 35). Thus, occupational therapists, who historically worked in public management services, have expanded their field of action by assuming management and service management functions within the scope of public policies (Furlan & Oliveira, 2017).

Distribution of Municipalities with Occupational Therapists

The state of MG, belonging to the southeastern region of Brazil, is the state with the most municipalities in the country, totaling 853, and about 21.392.666 inhabitants in 2020 (Instituto Brasileiro de Geografia e Estatística, 2010). According to Crefito 4, Regional Council of Physiotherapy and Occupational Therapy of MG, in 2021, until the moment of the research, there were 2.035 occupational therapists registered in the state (Conselho Regional de Fisioterapia e Terapia Ocupacional, 2015). Currently, MG has two universities with occupational therapy courses - UFMG and UFTM (Universidade Federal do Triângulo Mineiro) -, which together offer 126 places per year.

According to Figure 2, of the 853 municipalities in MG, in 2012, 39 of them had occupational therapy professionals, listed as part of the HR services or equipment of SUAS. In 2013 and 2014, there were, respectively, 35 and 42 municipalities with occupational therapists and, as of 2015, there was a significant growth, with 128 municipalities in this year, 145 in 2016, 140 in 2017, 158 in 2018 and again 140 in 2019.

Figure 2
Number of municipalities in MG with the presence of occupational therapists included in the SUAS and in the period considered (2012-2019).

Still on the analysis of the municipalities (Figure 3), it was possible to observe in which municipalities in the state of MG the occupational therapy professionals who were in the HR of the SUAS services and equipment are located. The following map shows the distribution of professionals in the municipalities for the year 2019.

Figure 3
Map of MG illustrating the number of occupational therapists distributed by municipality in Minas Gerais, in 2019.

In 2019, 140 municipalities had occupational therapists in the HR of SUAS services and equipment, that is, in 16.41% of the state. From what is shown on the map, it is observed that the state capital, Belo Horizonte, concentrates the largest number of professionals, totaling, in 2019, 18 occupational therapists. Followed by cities such as São Sebastião do Paraíso and Pouso Alegre, both in the south of MG, with 7 professionals, Conselheiro Lafaiete, in the metropolitan region of Belo Horizonte, with 6 occupational therapists, Uberaba, in the Triângulo Mineiro region, with 5, and with 4 professionals in the municipalities of Contagem, Itabirito and Itabira. 23 municipalities had between 2 and 3 occupational therapists, and the remaining 109 that have occupational therapists had only 1 professional included in the SUAS.

Among the results of the distribution of occupational therapists by cities, Belo Horizonte stands out, with a greater predominance of these professionals in the SUAS. It can be inferred from these data that, possibly, Belo Horizonte concentrates most professionals because it is the capital, has the largest number of inhabitants in the state and has more equipment and services (Minas Gerais, 2020).

The fact that most municipalities in the sample have only 1 professional possibly points to a weakness in the inclusion of occupational therapists in the SUAS. This may be related to several factors, such as the probable lack of knowledge of the federative entities and respective managers in relation to the role of the occupational therapist in the social context, funding difficulties and the fact that the professional category is not mandatory to compose the SUAS teams. Regarding the challenges of funding and implementing the SUAS, in MG, for example, in 2018, only Belo Horizonte had constituted all the essential areas of the SUAS agreed in the improvement pact (Minas Gerais, 2020).

The low number of occupational therapists in the SUAS in MG can also be correlated with the low number of professionals who train and enter the job market, as well as the training process, with reference to the curricular bases and guidelines and the profile of the undergraduate course which differs at each university (Pan & Lopes, 2013). The contents related to occupational therapy in social contexts, or even social occupational therapy, are not always included as mandatory content in graduation, and are still in the process of construction (Pan & Lopes, 2013). As an example of this process, in the undergraduate occupational therapy course at UFMG, about 210 (two hundred and ten) hours, out of a total of 3210 hours, are allocated to learning related content on social contexts (Universidade Federal de Minas Gerais, 2008), and, in the UFTM undergraduate course, out of a total of 3915 hours, about 180 are devoted to theoretical content related to social issues (Universidade Federal do Triângulo Mineiro, 2020). The study by Pan (2014) about the teaching of social occupational therapy in Brazil in occupational therapy graduation in Brazil, which included UFMG and UFTM, already pointed to the lack of specific content.

Conclusion

It was possible, in this study, to profile the occupational therapists inserted in SUAS in MG between 2012 and 2019, as well as to identify the services where they are inserted and what functions they perform in social assistance. There was an increase in relation to the spaces where occupational therapists work in SUAS, which is probably related, but not only, to the formalization, in 2011, of their insertion to compose the technical and management teams of social assistance services and recognition of the specialty of occupational therapy in social contexts. It is worth mentioning that, although in this quantitative increase, most are performing functions compatible with graduate training in occupational therapy, one cannot ignore the number of professionals performing other functions that require medium or fundamental level training. The constitution of social occupational therapy, the recognition of the professional specialization of occupational therapy in social contexts, as well as the recent scientific productions on the profession in SUAS, have expanded the debate and the possibilities of professional performance with a focus on social protection, enhancing actions integrated and intersectoral, and contributing to break with the medicalizing/biomedical logic of social problems (Brasil, 2010; Oliveira et al., 2019; Oliveira, 2020).

It is important to highlight that, although Teixeira (2011) has warned about the uncertainties related to the role of the occupational therapist in the SUAS, which could succumb to conservative forces, and remain in the clinical and individual focus, both in the academic debate and through the report of experiences, it has been verified the powerful contributions of the profession, with a focus on the performance of social issues (Araújo et al., 2011; Bezerra et al., 2015; Borba et al., 2017; Chaves et al., 2015; Minatel & Andrade, 2020; Oliveira, 2020; Pinho et al., 2019; Pinho, 2020; Prado, 2020; Surjus, 2017). Even considering the risks of restricting the work of the occupational therapist to the competences built in the field of health, possibilities for practices that encompass the social dimension have been demonstrated, producing the necessary break with the medicalization and psychologization of suffering, and contributing to actions of protection and guarantee of the social rights of the population assisted by SUAS. With this, it becomes increasingly necessary to highlight the occupational therapist's ability to act in the SUAS context, so that there is an expansion of the inclusion of professionals in a more balanced way for other equipment, such as CRAS, CREAS and POP Center, which concentrate basic social assistance services (Oliveira et al., 2019), as well as investing in their training. Converging with this context, Resolution n. 650/2020 of the National Health Council (CNS) presents, in its proposal for National Curriculum Guidelines for the bachelor's degree course in occupational therapy, guiding principles for the training of occupational therapists that are aligned with the principles of social assistance policy with regard to the expansion of autonomy, participation and social inclusion, contribution to overcoming social inequalities, discrimination and violation of civil, political and social rights (Brasil, 2020).

The present study presents gaps related to other variables that could be analyzed to deepen the understanding of the insertion of occupational therapists in the SUAS, such as employment, size of the municipalities and amount of equipment in the state, analyzes that could not be included in the scope of a monograph of course completion. Even so, the results point to the need for further studies, considering the diversity and complexity of the SUAS, both in relation to the levels of protection, equipment and services offered, as well as the very challenging nature of social problems.

It is also highlighted the limitations related to the collection and extraction of data, considering that the information made available in the SUAS Census are secondary sources of information and vary in relation to filling out the forms, grouping data and disseminating it. As a result, some data expected to be included in the analysis were not available on the Portal, and others were disclosed in an illegible manner.

It is hoped that the results of this research can contribute to the knowledge of the panorama of occupational therapists at SUAS. Therefore, further studies are suggested about the profile of these professionals, as well as the practices developed by them, aiming to understand their actions, application of theoretical-practical knowledge and contribution of the specificity of occupational therapy in this context, in particular of social occupational therapy. Furthermore, we cannot fail to consider the work of the occupational therapist in protection and social assistance services since the 1970s, as well as the configuration of social occupational therapy and the social field in the late 1990s, further corroborating the need to investigate in MG, scenario of this research, where and how occupational therapists worked in social contexts. These investigations can contribute to qualify the training of professionals, as well as the creation and implementation of new spaces for insertion of occupational therapists in MG. To conclude, it is also expected that this study can encourage discussions between future and current professionals about possibilities that can enhance the political, social, and professional performance of occupational therapy in the context of social assistance.

• 1
  Aims to prevent injuries that may cause users to break their family and social ties.
• How to cite: Pêgo, C. G., Silva, F. C., & Souza, R. G. M. (2023). Unified social assistance system and the occupational therapist insertion. Cadernos Brasileiros de Terapia Ocupacional, 31, e3392. https://doi.org/10.1590/2526-8910.ctoAO259733922

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Edited by

Guest Editor

Profa. Dra. Marina Leandrini de Oliveira

Publication Dates

• Publication in this collection
  17 July 2023
• Date of issue
  2023

History

• Received
  08 Aug 2022
• Reviewed
  19 Aug 2022
• Reviewed
  13 Dec 2022
• Accepted
  11 Apr 2023