More Doctors Program and work development: a continuing education effect

The article being discussed analyzes the educational component of the More Doctors Program (PMM), mobilizing opinions for dialog. Among these opinions, it is undeniable that PMM constituted a political and epistemic milestone in the professional health education debate, as some authors point out, under the public policy action. To begin with, I highlight an aspect that is barely visible in the debate regarding the relationship among education, the Brazilian National Health System’s (SUS) health education policies and PMM: the grand effect of permanent health education on the participating professionals and teams.

Mobilizing such a large number of professionals (doctors registered in Brazil or in exchange programs, particularly Cubans) is, by itself, a strong strategy. Although it has a reduced visibility to qualify healthcare, the exchange program questions the development of health work based on education and aligned with SUS policies, thus being related to the regulation and organization of education and work.

The relationship between professional mobility and education/development of/at work is not only an empirical finding, but also PMM’s clear purpose, as stated in the first article of Federal Law nº 12871/2013¹: PMM was instituted “in order to ‘educate’ medical human resources for the Brazilian National Health System (SUS)”¹ (Art. 1º). PMM’s objectives include: reduction in the lack of doctors in priority areas; strengthening of primary care, permanent health education and teaching-service integration; professional improvement in public policy practice; encouragement to conduct research applied to SUS; and “exchange of knowledge and experience among Brazilian health professionals and doctors who graduated from foreign institutions”¹ (Art. 1º, Item VI).

I emphasize the relationship between professional education and strengthening experiences in the diversity of services and scope of SUS coverage as a device for change in education and development of/at work, which is in sync with policies jointly implemented by the Brazilian Ministries of Health and of Education. According to the legislation, I highlight the acknowledgement in the exchange of experiences between Brazilian professionals and those graduated in other countries as a learning and education device. For some time, I have been saying that PMM became a “Science Without Borders” with backward flow. Support to mobility of professionals for scientific and cultural learning is provided with the arrival of foreigners to share experiences in the learning process and thus develop work in primary care. The “Science Without Borders” (CsF) Program was created in 2011² and implemented by the Ministries of Science, Technology and Innovation, and of Education, with an ambitious goal to grant 20,000 scholarships/year in 18 priority areas and topics, such as health³. CsF gained visibility due to the internationalization aspect of science and education. However, it is connected to the idea of scientific, technological and industrial development and innovation by qualifying professionals through different (cognitive, socio-interactive and occupational) experience in international mobility.

The relationship between professional education and work development is associated in health to health residency programs and the National Policy for Education and Development of SUS⁴. The epistemic basis of this policy takes into consideration the occupational world submitted to conditionalities and determinations that are more complex than the explanatory capacity of the disciplinary sciences. It attributes to work a pedagogical capacity to mobilize learning in different scopes related to professional practice within health systems and services^5,6. “The educational principle of work,” in this case, is related to the estrangement that mobilizes knowledge that impels crossing disciplinary boundaries, overcomes specialized fragmentations, aggregates different dimensions to care practice and associates “significant learning” initiatives (effect of contact with diversity) that are able to constructively activate transformations in the produced knowledge and in occupational practice⁶. This is not a theoretical review nor is it about legal instruments, but rather about identifying that some PMM ideas belong to the epistemic field of health education and its recent legislation, which aims at prompting changes in health education and work. However, paradoxically, they are barely visible in the public debate and analyses.

Considering that, according to the article, more than 18,000 seats in different services were occupied by doctors, particularly in territories with extreme health vulnerability, who made contact with the other professionals in the teams (130.000 workers, in a conservative projection), this scenario enables to presume a process of exchange, interprofessional collaboration, technical and cultural exchange of intangible dimensions. Additionally, if we consider that professionals mobilized by PMM were updated on SUS policies right before joining the teams and that most of them, particularly Cubans, had a prior educational and professional experience profile that was diverse in terms of primary care practice and international collaborations⁷, we will structure a hypothetical framework of the effects noticed in the disseminated evaluative research and a topic for future research specifically pointing to the development of work with permanent health education initiatives, as suggested by SUS policy, as a real, but not yet sized, effect of PMM.

However, the disclosed images about the relationship between education and work in PMM are mainly related to the clash of ideas regarding the production and organization ways of the Caribbean country, characterized with prejudice about the work of Cuban professionals. In a context in which the truth seems to be an effect of repeated affirmations, rather than their empirical evidence, this is a debt of the evaluative research to PMM, more than an explanatory framework and research question. This debt stands out in the permanent education and health work development processes, including their micropolitical aspects.

In any case, it also reflects the need to advance on a general debate related to health education. Back to the article being discussed, I now associate hypotheses and findings to two theoretical issues. The first one is brought up by Maria Cecília Donnangelo and Ricardo Bruno Mendes-Gonçalves, among others, and is related to the prevailing liberal logic in medical professions and to tensions produced by transformations in the occupational world. I think it is not possible to analyze medical entities’ practice in PMM only by understanding them as agents in the process of implementation of a policy. We have to be able to identify the changes in the occupational world and in how professions are organized, as well as the changes in education over the last two decades, particularly the profile diversification of higher education newcomers to understand part of the reactions of entities and institutions.

The second issue, as already evidenced in the article, is the need to think of regulation ways that resist to the weakness of democratic institutions, as recent history has shown in Brazil and other countries, with the expansion of the State’s role in regulating professional education to SUS and the discontinuities in PMM with the government change in 2016. Teaching and research institutions that comprise the social structure and reflect its values and understandings of the world do not seem sufficiently strong to resist ideas and to the universality of thought, as in its initial project.

Lastly, the article makes us reflect upon professional health education, democracy and the institutions that comprise the State and the society. This is an undeniable merit in a time when everything that is solid seems to vanish into thin air, using the known image of Marshall Berman to speak not of production in capitalism but of human rights, citizenship, freedom, education and health in modern times.

References

• ¹
  Brasil. Presidência da República. Lei Federal nº 12.871, de 22 de Outubro de 2013. Institui o Programa Mais Médicos, altera as Leis no 8.745, de 9 de Dezembro de 1993, e nº 6.932, de 7 de Julho de 1981, e dá outras providências. Diário Oficial da União. 23 Out 2013.
• ²
  Brasil. Presidência da República. Decreto Federal nº 7.642, de 13 de Dezembro de 2011. Institui o Programa Ciência sem Fronteiras. Diário Oficial da União. 14 Dez 2011.
• ³
  Brasil. Ministério da Saúde. Ministério da Justiça. Portaria Interministerial nº 1, de 9 de Janeiro de 2013. Institui as áreas e temas prioritários de atuação do Programa Ciência sem Fronteiras. Diário Oficial da União. 11 Jan 2013.
• ⁴
  Brasil. Ministério da Saúde. Política de educação e desenvolvimento para o SUS: caminhos para a educação permanente em saúde: polos de educação permanente em saúde. Brasília: Ministério da Saúde; 2004.
• ⁵
  Ceccim RB, Feuerwerker LCM. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis. 2004; 14(1):41-65.
• ⁶
  Ceccim RB, Ferla AA. Educação e saúde: ensino e cidadania como travessia de fronteiras. Trab Educ Saude. 2008; 6(3):443-56.
• ⁷
  Gomes LB, Merhy EE, Ferla AA. Subjetivação dos médicos cubanos: diferenciais do internacionalismo de cuba no Programa Mais Médicos. Trab Educ Saude. 2018; 16(3):899-918.

Publication Dates

• Publication in this collection
  16 May 2019
• Date of issue
  2019

History

• Received
  12 Dec 2018
• Accepted
  12 Dec 2018