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Introduction
The management functions in the areas of education and health are exercised between subjects with different levels of knowledge and power. Participation and co responsibility of the different subjects and representative segments of management, care, education and social control applies to the recent inter-ministerial articulation strategies in Brazil, aiming refocusing education on health, such as the National Program of Vocational Reorientation Training in health (Pro-Health), released in 2005 by the Ministry of Health (MH), in partnership with the Ministry of Education (ME).1) MH bet these partnerships, coupled with the comprehensive approach to the health-disease, with emphasis in Primary Care, convinced that high investment in adaptation of physical, technology structure and medicine network, separated of the real preparation and involvement of professionals with the proposal of the Unified Health System (SUS) is not efficient strategy to consolidate the Health Policy. Pro-Health has the integration teaching-service as essence, approaching movements of the university with the services and the foundation in economic reality of population.1 Bet on an effective process of integration - praxis-2 through the effective participation of representatives of the involved segments, with a view to the construction and implementation of proposals for the training and professional development in health.
To be viable monitoring the implementation of the Pro-Health as a process that can produce results attuned to the reality of each Higher Education Institution (HEI), are recommended self-assessment strategies. In this sense, is proposed the dialogue between the various subjects that are part of the program: HEI, Department of Health and Community.1 In 2005, in the State of Santa Catarina, the Community University of Chapecó Region (Unochapecó), had approved the project in the MH relating to Pro-Health, in partnership with the Health Department of the city. In 2008 and 2012, were approved two other proposals, including the Regional Health Management. In the integrated proposal of Unochapecó and other structures, formal instances (management committees) were created for the implementation of the project and the conduct of its stages of self-assessment called: General Coordinator Commission (GCC) and Local Management Committee (LMC) of the Pro-Health.
Studies on the Pro-health evidence challenges for the proposal is to establish itself as a reorientation of education program from regional reality and practice of health services, requiring the interest and co-responsibility of all involved (HEI, professionals, managers and users of the service) aiming to form resolute professionals. Thus, to establish a link between these important subjects, it would minimize-obstacles that arise in its work.3,4 The study aimed to analyze the representation and participation of the segments that structure the four-way approach of SUS ( management, care, education and social control)5 in the management committees of integrating teaching and service in health.
Methods
Qualitative study with exploratory and analytical approach, type of case study6, with the instances GCC and LMC as scenario. The participants were some members of the four-way approach of the formation of SUS.5 After obtaining the consent of the institution for the study, was done a direct observation of six meetings of the committees, registered in field diaries. This pre developed observation instrument, contained Descriptive Observation Notes (DON), regarding the relevant aspects of organization, planning and dynamics of meetings; and Reflective Observations Notes (RON). At the end of the observation time occurred the realization of focal interviews6 with 11 subjects chosen intentionally, five members of the GCC, three LMC and three who were part of both structures. All participants were interviewed individually in a private place and time according to their preference, by collecting the signing of the Informed Consent. The interviews were recorded and transcribed, and later, forwarded to participant’s validation. Data saturation criterion was used, when there was the characterization of a particular pattern in the speech, expressing the sufficiency of information for the study.
As inclusion criteria, participants of the interviews should have participated in one of inter sectorial committees in one of the four segments in the period 2006 to 2012, for at least six months. Subjects who were retired or removed (sick leave, etc.) during the period of interview were excluded from this group. The study had the participation of 25 subjects in total (among them 11 interviewed and the others participants of the committees). Data were collected between the months of October, 2012 and February, 2013 and analyzed from thematic analysis,7 supported by the theoretical framework of the educator and social scientist Paulo Freire.
This work is part of a larger study entitled: Integration Teaching-Service: movements of the management committees in the process of professional reorientation in health training, which was approved by the Ethics Committee in Research with Human Beings of the Federal University of Santa Catarina (UFSC), under number 242.966/2012, following the criteria of the National Health Council Resolution 466/12.8 Participants were identified by nicknames which represents characters of classic literary stories and corresponding to the represented segment (Management - M, Care - C, Social Control - SC and Education - E).
Results
Representation through dialogue: possibility of negotiating
Negotiation is understood as a participation tool, to foster the ability to decide, transcending the mechanistic practice toward a critical position. The participation arouses in the subject the possibility of do the story through social responsibility. In this perspective, dialogue is associated with the idea of citizen participation, negotiating, deciding, executing and finally transforming the reality.2 The four segments represented in the management committees of the Pro-Health agree that the dialogue established during the meetings make possible reflect on the reorientation of training process, although there are difficulties related to communication between subjects [...] be able to sit with people and talk is a more effective interaction, full of meaning, it is not so far away. People have the opportunity to express themselves, not only by words, but also with no verbal communication [...] (Capitu - M).
The meetings foster exhibition of impressions and difficulties through different point of view, through dialogue, which is expressed in verbal and nonverbal communication and an interaction, charged of meanings. These aspects are observed during the meetings, according to observation notes: Regarding the dialogue movement, established during the meetings of committees, they occur in an orderly manner and raise new ideas, periods of study and reflection on the interministerial structuring actions and the training reorientation movement, beyond the perceptions of each segment represented on the process (RON - researcher). The participation of students allows the exchange of information and knowledge between the different professions, which favors the reorientation of training: It's been cool attend meetings, sometimes they [members] say: I did not know that nursing had that look, for example, for me nursing was another thing [...] (Aurélia - E).
The representative of the education sector assumes, during the meetings, that the subjects representing other segments seem to have difficulties in interpretation, related to different professional languages that are used. This also occurs in the interactions of everyday life, in a methodology - which it is intended - interdisciplinary within the HEI. That's because people are impregnated by concepts that are specific of their profession, which also blocks communication and dialogue: People do not understand what you're talking about, because they come loaded with a set of concepts and ideas that are of the profession [ ...] need a glossary to be able to deepen better in this dialogue, sometimes you think you are communicating, but you are not (Aurélia - E). There is an approach of the power relations triggered there, highlighting the status of the university as a place of 'knowing' and the service as a space of 'doing', in the interaction between the entities. The representative of attention reinforces that power is related to the understanding of the process, which gives voice to the subject [...] know: between knowledge and practice, the power of knowledge and the power of practice? I think they are relations of power [...] looks like I have time to talk, but nobody heard me! I have the impression that I do not collaborate, even though I speak [...] because it is already defined [...] this dialogue has to come to the bases. It can reach the understanding of each sector, each institution [...] (Emma - C).
When analyzing the speeches of social control segment it is clear that the exercise of representation occurs in a limited way, as there are a number of 'misunderstandings' related to language and diversity of projects presented and discussed. The difficulty lies primarily in the transfer of the discussions that take place in instances to those represented, in this case, members of the Municipal Health Council (MHC). It is further considered that the representation must be more participative, which means expose better the facts together to pairs: [...] till that language that is used to pass it to them, it is very technical, it is not one thing more objective [...] they may have difficulty understanding. When a project is proposed, sometimes I question things. But I could be much more participative [...] questioning more, act more [...] (Alice - SC). Participants appear to represent (in the sense of acting on behalf of) the segments management, care, education and social control, to have a voice, giving rise to the expression of diversity, aiming the debate and decision making.
Legitimacy of representation: establishing "fruitful relations"
In the segment management, the representative says that feels like 'spokesman' of the represented subject. In their experience with the committees, in some moments, had to return to their peers, before issuing an opinion, because the positions taken in this type of structure does not belong to one person, and yes, to the segment represented: [.. .] you will speak by the segment where professionals are inserted, users, who come in search of services, which have political pressures, at last, 'N' situations that interfere. When you speak, your speech has to represent and bring it to the table. [...] Many times we were mouthpieces, if we had the information we were empowered to be able to discuss, argue (Capitu - M). Represent, for the management, means defending the interests of the collective, which is not always understood by the participants of the committees. However, she says that it is necessary to defend ideas and argue when there is no agreement with something: When you represent an institution, you are representing some interests of the collective and this is not always well understood. [...] If you put an idea, you need to defend it, need to justify. If you do not agree with an idea, also you need to argue why not [...] (Capitu - M).
Representing also assumes have freedom to expose what has been entrusted to him: I think if you are representing someone, it is because people trusted you, then it also gives freedom (Alice - SC). On the other hand, it points to the need and also the difficulty to create a consultation to peers represented. Thus, often, it is difficult to express a collective position and this ends up being personal or even, some situations make impossible to express an opinion: [...] the Municipal Council of Health has no space and also has not a forum. For example: will have the meeting of the Management Committee, comes the call, the secretary forwards, but we still did not sit, as Council, to discuss the issue (Mr. Darcy - SC). This same subject mentions that he cannot guide the discussion with the represented segment, and misses a more active representation. He notes that exerts a representation focused on the issues that are part of their everyday work, i.e., geared to job demands and the relationship that maintain with Pro-Health, instead of defending the real interests of the users: [... ] could not abide this discussion in the Council, in short, a number of things of Council dynamics. [...] Perhaps, if within the MHC had a space to do this discussion about the project [Pro-Health], would facilitate (Mr. Darcy - SC).
For some members of education, the representation of this segment occurs through other dialogues, established among peers, during the discussions of the teaching plans and Course Pedagogic Project (CPP) or through the exchange of information between the represented groups: This communication occurs in the discussion of Plans education, the CPP. There is the group that is only educational, also important, we were watching this need to structure this group in the university" (Guiomar - E). These seem to be the major challenges to exercise representation: take ownership of the process and share with peers and find in them a real interest. The representative of education believes that to ensure spaces for discussion with their peers is difficult because it involves investment in time and in schedule: [...] we have tried to ensure some meetings for these discussions or in meetings that are not specific to this: bring reports and try to involve other teachers, but it is very complicated, difficult. I think that requires an investment, in the way of time, availability (Aurélia - E).
Another question concerns the way as how representatives of each segment are designated. This appears in the speech of the representative of attention segment, considering that does not exercise representation in fact and that feels uncomfortable to colleagues by their choice of be a member of the LMC: [...] how do I do this transfer? Besides not do, I think I experienced something like, 'Why do you?' And it has another institutional weight [...] It seemed that I had occupied a space [...] there already enter the internal relations (Emma - A). This data reinforces the possible need for an internal space for dialogue, at the level of each institution or represented segment, in order to clarify the proposal.
Disparity in the representation of segments: the four way approach in disharmony
As for the representation of the four-way approach, it is possible to see that the figure is hampered by the absence of some segments and it has to do with time and capacity of ownership the process, and understanding of the roles of each one: [...] you do not realize the effective participation of all segments [...] is always missing someone (Anna Karenina - M). Participation in the process can be ensured by the representations of the teaching segments - represented by teachers and students - and management - represented by sectoral coordinators - which are always present in the discussions, that is, are the ones who are represented, therefore, participating in the process: [...] we had the issue of participation provided by the representations. So, what we noticed: that Unochapecó was always present and always the Secretariat was present. The other institutions not always, sometimes by difficult, exchange of professional or no understanding of the proposal, at last, we had a little more difficult to bring these people to the meetings (Capitu - M).
Noteworthy is the absence of some elements, such as the Secretary of Health, in meetings of committees, which is represented by other service managers. This is clear, also, when we observe the, in which we took note of the speech of some persons present and when were mentioned the difficulty to 'convince' the manager about the importance of teaching-service integration: The times needed to understanding of the proposal are different. Excessive demands of Pro-Health hinder. It is need new way to convince the manager about the importance of this articulation (DON - representative of management segment). The participation of managers in training reorientation process, both component attention as the component education, figure in the political articulation of subjects, representing leaders of the teachers, the student movement and the health sector. Its involvement and, above all, awareness to the process is critical to the effectiveness of the proposals.
The massive presence of representatives of social control, which are workers and managers, becomes brittle the defense of users and strengthens the defense of the interests of management and workers: [...] social participation is not yet effective; people come because we invite. [...] The counselor who represented was a person who was also of the management, which was also health care professional, [...] by the difficulty of bringing users into the meetings (Capitu - M). Regarding the teaching segment, the incipient student participation in collegiate structures also points to this disparity: The representatives are changing and has those who have become more involved. Today a very important problem is the low participation of social control and students segments [...] (Guiomar - E).
Another issue to be problematized is linked with the power granted to the university in the process and the decresead importance of the others: [...] I see people saying: I could not come, I missed so many [...] as they had to show to the university, or because they are representatives of institutions, so they have to be there [...] (Emma - C). So, occurs that the two most missing segments are: users, as final 'beneficiaries' of improvements of care; and students, the main focus of the teaching-learning process, and on which is need to make changes.
Discussion
Representing assumes participate and, in this sense, Paul Freire2,9 understands participation as exercise of speech, to ingest, as a right of citizenship, in a direct and necessary relation with the educational-progressive practice. He relates the level of participation with the democratization of social structures, possible through dialogical relations between the subject and the reach of the ' unprecedented viable' - something that is not clearly known and lived, but when perceived by those who think idealistically, leaves to be a dream and can become reality.10 In this perspective, intersectoral instance 'puts in the schedule' four segments - management, care, teaching and social control - whose interaction between them is presented from the ideas of the 'four way approach', defined as a proposal to organize education through action in reality to bring changes, mobilize paths, call protagonists and detect the movement of individuals, groups and institutions, as the scenario of knowledge and inventions.5 It is started from the assumption that a collegial space requires horizontality, whose representation and participation constitutes the basis of the process, that want to be democratic.
In the first category presented, it is noted that dialogue occurs in communication between subjects, in a meeting, which takes place in practice, in action with reflection, and which is based on commitment to the social transformation.2 This assumes that the subjects are unarmed, open to other possibilities, that the power struggles do not prevail in a place of discussion. The fact of each subject uses the word makes possible the dialogic relationship. It is from a respectful relationship that constitutes the interaction, allowing social subjects to complement their self, not necessarily with the same ideas and positions, but enriching the dialogue through the diversity of thoughts, feelings and trajectories that characterize them.2
Reorienting only have repercussions in the care when all instances are compromised, which has been presented as a difficulty in other studies in this nature.11 The ideology of the 'wheel', to be characterized for committees management, has a political and critical- reflexive nature, i.e., the executors of the actions should be each member institution of the wheel, in a articulation that is not merely a management arrangement, but operates dialogical and pedagogical processes of network planning of atention.5 With this interpretation of the movement that occurs there, is necessary to pay attention to not miss out on the dimension of creativity, freezing relations in the homogeneity positions, without arterial runoff to the free movement of individuals by their different points of view.12 Is in this direction that underlies the discussion on second category that emerged from the data.
Based on the role of effective participation in the exercise of representation, there was homogeneity in the answers: the set of respondents considers the dialogue and participation as tools to effect it and underscores the need to refer to the represented, although this is not always is simple task. There is an understanding, almost consensual, of representation as appropriation of an agenda that will be 'passed on' to the represented segments. These findings, especially in the second category, point to the way to legitimize the representation, found by the social subjects that 'act to' the represented. The study of Abers and Keck12 discusses the dynamics of some committees regarding reciprocal links, supposedly held between representatives members and the represented groups, signaling that the legitimacy depend on a delegation and return between them, in which the representative should be able to reconstruct the reasoning of the represented, defending it effectively. That seems to be a more active and dynamic notion of representation. To mean the act of representing a connotation of trust and freedom, those represented contribute with a process more democratic and creative.12 It is worth remember that the concept of democracy, in this study, is associated with the idea of citizen participation, deciding, and executing, in the end, changing the reality.9
By taking the relationship between representatives and represented, is possible to see that merge two interpretations: one, almost unanimously, in which represent assumes defend interests of the represented group and another in which there must be freedom for the representative present their ideas, because the represented group puts in it confidence. At first, can be considered an act in the place of the missing, having to explain his decision, without considering the individuality of each subject and the relationships that are established in that space; in the second, takes into account the freedom of expression and the size of individual creativity of each subject. This latest, beyond foment the participation and democratization, from the dialogical relations between subjects in search of the 'unprecedented viable', is also perceived as a process of 'innovative interaction' between subjects with different points of view, that face itself and make these dialogical spaces be in constant motion. The movements may involve a creative combustion, producing innovation of ideas, in different ways, i.e., are "fruitful relations",12 originated from elements that are not the result of thinking of one or the other, but rather innovative.
It is observed with emphasis the disparity in the representation of the participants segments of Pro-Health Management instances that should be represented on the four way approach that moves them, as well as the settings within each of these vertices, are assumed that are missing elements to fit the vertices or that there is intervention of elements. These difficult the effective participation of all segments involved in the teaching process. There is a proposal comprehension deficit and this hinders participation, particularly of the segments that are not working in the practical activities of the Pro-Health, although they are also beneficiaries and co-responsible for them, such as social control. The reason may be in the question that the subject that represents that segment not always defends the interests of the user. The ownership of the process involves effective participation9,13 and, in the studied case, are the representatives of the teaching and management segment the most involved with the movement of teaching reorientation, in detriment, mainly, of social control.
It is possible conclude, from this study, that the representation and participation of the four segments in the committees of integration teaching-service are expressed in the dialogue, through the willingness to listen, to interpret other languages, which generates movements in the direction of learning of subjects with a common objective. Thus, the instances become arenas of conflict mediation, consensus, recognition powers, negotiation and representation. The legitimacy of representation happens as far as meaning that the subjects attribute to it: either as defense interests of the represented group, and then the biggest challenge is to take ownership of the process and share with represented; sometimes as freedom of expression of representatives in a democratic process in which there is reciprocal trust between the parties, allowing the most creative process. The representation and participation express themselves in disharmonic way, more strongly in teaching, represented by teachers, and in management, represented by professionals. Also, is incipient the representation of social control, especially with the participation of service users. It is recommended, therefore, to reflect on the meaning and possibilities of participation and representation in committees that integrate teaching and health service. When intersecting, these particular spaces are transmuted into something new, such an image as objective, which may produce new facts. To occurs this transformation of reality, the subjects that are part of the educational institutions and the health workforce need to strengthen relations, dialogue with each other and plan co-management moments of the teaching process.
