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Integrality in the population’s health care programs

A integralidade na atenção à saúde da população

Roseni Pinheiro 1
Alcindo Ferla 2
Aluisio Gomes da Silva Júnior 3

Abstract This article examines integrality as one Resumo Este artigo discute o princípio da inte-
of the doctrinal principles of the Brazilian State gralidade do Sistema Único de Saúde no Brasil, a
Health Policy – the Unified Health System (SUS) partir das práticas. Integralidade é o eixo organi-
– whose aim is to offer health care as a right and zativo de práticas de gestão das ações, que tem na
as a service. Integrality is the foundation around garantia do acesso aos níveis de atenção mais com-
which managerial activity practices are organized plexos seu principal desafio. Desenvolvemos um
and whose main challenge is guaranteeing access referencial analítico ancorado em três dimensões:
to the health care system’s most complex assistance organização dos serviços, conhecimentos e práti-
levels. We developed an analytical reference cas de trabalhadores de saúde e políticas governa-
grounded on three dimensions: service organiza- mentais com participação da população na sua for-
tion, knowledge, the practices of health workers mulação. As práticas de gestão são campo de cons-
and government policy formulation with input trução da integralidade, constituindo arena polí-
from the population. Managerial practices are tica na qual participam gestores públicos de dife-
fertile ground for integrality and are the political rentes esferas de governo, prestadores privados, tra-
arena in which public managers of different gov- balhadores de saúde e sociedade civil organizada.
ernment levels, private service providers, health Integralidade na atenção à saúde da população é
care workers and organized civil society partici- fruto da interação democrática dos sujeitos impli-
pate. Integrality in health care can only occur cados na construção de respostas governamentais
through the democratic interaction of subjects in- capazes de contemplar as diferenças expressas nas
volved in the creation of government responses demandas em saúde.
Instituto de Medicina which are capable of contemplating the differenc- Palavras-chave Integralidade, Gestão de servi-
Social, Universidade do es expressed in the health care needs. ços de saúde, SUS, Brasil
Estado do Rio de Janeiro.
Rua São Francisco Xavier
Key words Integral care, Health services man-
524 / 7º andar / bl. E, agement, SUS, Brazil
Maracanã. 20550-900 Rio
de Janeiro RJ.
Universidade Comunitária
de Caxias do Sul.
Instituto de Saúde da
Comunidade da
Universidade Federal
Pinheiro, R. et al.

Introduction within health services, always permeated by

emancipating values6. Values based on the assur-
Integrality is one of the doctrinal principles of ance of autonomy, on the exercise of solidarity,
the Brazilian State health politics – the Unified and on the recognition of free choice of the kind
Health System (SUS) –, whose aim is to join ac- of healthcare one desires. Perhaps this acknowl-
tions that realize health as a right and as a service. edgement may help us regard ourselves as collec-
To prioritize integrality in health politics tive beings “resulting from our intersubjective-
means understanding its functioning based on ness”, who live in public spaces still lacking an al-
two reciprocal movements developed by people loted and socialized political action – the health
involved in health organizational processes: over- services7.
coming obstacles and implementing innovations In healthcare organization experiences, it can
in health services, in the relations among the sev- be noticed that the SUS can also be effectively
eral SUS managerial levels, and among these and built in users’ and workers’ everyday life8, by of-
society1. fering different equity and integrality patterns,
Both movements can be considered the main made up by management, healthcare and social
constituent links in integral care offered to the control practices. Health, as citizenship right to
population, which summarizes questions consid- and as life defense, requires us a comprehensive
ered relevant for its conceptual and practical ap- analyses, so that it can be identified as a category
propriation in Collective Health. And these issues which holds movable and progressive standards,
are forthrightly, and often contradictorily, relat- and the health system, its organization and the
ed to economic and social policies adopted in practices within it must be able to follow it, and
Brazil during the last decades. These policies ex- even to always make new possibilities possible, in
clude many people, concentrate wealth and erode a renewed movement of integrality and equity1.
social life2, exponentially increasing demand for Then it becomes necessary to apply all possi-
public health actions and services. ble combinations of technical, political and ad-
If, on one hand, the organization of our soci- ministrative forces in each different place – ac-
ety, based on capitalism, has favored a lot of cording to the users’ needs9; as indicated by tech-
progress in production relations, mainly concern- nical studies and planning, and also in conformi-
ing the increasing sophistication and technolog- ty to the workers’ practice8 – to dynamic arrange-
ical improvement in different fields, including ments that, in every progress, are able to pressure
health, the same does not apply to social relations. and to organize conditions for a new successful
These reveal people’s diffuse and growing suffer- step.
ing, who is routinely subjected to serious inequal- In this sense, in order to understand integral-
ity patterns, expressed by tough individualism, by ity in people’s healthcare, we propose the analyt-
stimulus to wild competitiveness and by people’s ical reference developed by Ferla et al. 1, and we
negative discrimination with disrespect to gen- correlate it with different studies on integrality
der, race, ethnicity and age questions. healthcare practices. In their analysis, the authors
Out of this process’s way there is the Federal adopt three dimensions: one related to services
Constitution, which creates and establishes SUS organization; one concerned with knowledge and
directives, provides basic elements for Brazilian practice of health workers; and the third one con-
actions and healthcare logical reorder, in order cerns State politics formulated along with peo-
to warrant the necessary actions towards better ple’s participation. Each dimension can be syn-
living conditions of all citizens. thesized as follows:
Despite the health sector’s historical shortage
of financial resources and the institutional nor- Services organization dimension:
mative culture to carry out federal policies, it is integrality prioritized in the
possible to identify the emergence of innovative (re)organization of services
and successful experiences, in several Brazilian
states and municipalities3,4, 5. This dimension concerns the need for assur-
In such experiences, one can identify some ing access to all different levels of technological
integrality attributes, as far as they reveal the field sophistication required in each situation, so that
of practices as especial places where several assistance can be successful.
healthcare institutional innovations take place. Within the context of the consolidation of
Innovations which are daily built by continuous SUS, it has been observed that integral health-
democratic interactions of those involved in and care practices are associated with at least two

Ciência & Saúde Coletiva, 12(2):343-349, 2007

more principles that orientate the system: uni- highlighted as this notion exceeds the condition
versality and equity. of a mere directive, to reveal itself a real “ban-
In fact, for Cecilio 9 these three principles form ner” which forms a major “image-objective”. It
“a triple, entwined concept, almost a sign”, and can be translated as a societal project permeated
fiercely express the struggle for citizenship, jus- by justice and solidarity ideals.
tice and democracy, consolidated in the ideal of However, the universalist legal and institu-
the Brazilian Sanitary Reform. The magnified tional outline of that time already reflected a
view of the idea of integrality defended by the counter-hegemonic position in the scope of the
author would comprise all integrality, equity and international debate about health policies imple-
universality proposals, thus configurating “the mented by developing nations. Situation then was
pure essence of public health politics”10. marked by structural adjustments and progress
So as to reflect on integrality and equity, Ce- of neoliberal politics, pointing out a smaller and
cilio9 considers health necessities as “analyzers”. smaller State participation either in economic
According to Cecilio, listening to needs increase politics or in the provision of social actions and
intervention’s capacity and possibilities, on the services – here including health politics.
part of health workers, concerning the problems It must be clear that integrality is one of the
of those people who demand health services. main divergences between Brazilian health poli-
The author bases his ideas on Stotz11, for whom tics and the formulations of international agen-
such necessities, although socially and historical- cies, such as the World Bank. The situation is ex-
ly determined and built, can only be apprehended pressed on the fact that there is an agreement with
within their individual dimension, which express- several other directives defended by us, such as
es a dialectic relation between individual and so- political-administrative decentralization and so-
ciety. So, in the articulation of micro and macro- cial control – although integrality remains a non-
politics, integrality, to be fulfilled, does not depend consensual issue. This fact would be enough to
only on the services’ single space 9 – even if these justify the importance of an extensive reflection
satisfactorily play their social role – but also on on the senses of integrality13. So the struggle for
the articulation between services, and sectorial the qualitative change in health politics towards
and intersectorial actions. This happens because, the construction of a health system with univer-
depending on the moment the user is living, the sal access, equity and good-quality services now
health technology he needs can be either in a pri- resembles resistance to public policies adopted in
mary healthcare unit or in a more sophisticated the last decade10.
service12. Or it can even depend on the coopera- On the other hand, for Cecilio9, the concrete
tion among other State sectors9. way to articulate actions considered integral de-
Therefore, the population’s access to all levels fines the ethical level of programming and assess-
of technological sophistication would be condi- ing health assistance, dimensions that are found
tion and starting point for the construction of in health planning’s and management’s hard nu-
SUS’s integrality principle. At the same time, ac- cleus. Then comes another challenge: how could
cess only would not guarantee integrality, since this concrete way be realized? First of all, we un-
this principle depends on other factors to become derstand that the concrete way to articulate re-
real. Among these factors, there is the creation of quires the collective construction of innovative
links between users and staff, improvement of the technologies and tools within daily healthcare
population’s living conditions, and the establish- practices and management. Such practices will
ment of the user’s autonomy in his attempt to concern negotiation of different pacts and agree-
have his needs met and to have his health neces- ments among sectorial policies instances and civil
sities fulfilled. society. In other words, a dynamic innovation
It is important to notice that, as we place the process in public management.
Sanitary Reform movement within the context The idea of innovation in public health man-
of the struggle for democratization – carried out agement arises from the comprehension of its or-
in the political scene since 1970 –, one observes ganization in two main directions: type and con-
principles and directives of the 1988 Brazilian tent of politics (new policies) and management
Constitution: the institutionalization, according of these policies (new management forms, new
to Mattos13, of the “criticism which has nurtured decision processes, and new forms of services pro-
the dream of a radical transformation of the pre- vision). From this viewpoint, innovation would
vailing health concept in healthcare system ac- include new agents in the formulation, manage-
tions and practices”. Once again, integrality is ment and provision of public health services14.
Pinheiro, R. et al.

In this context, solidarity can be incorporat- With these senses, it is possible to quantify
ed as an institutional device, a new practice, once integrality within this dimension, as a political
it represents a democratic value that acquires the device that criticizes knowledge and power insti-
sense of social action, and potentializes the re- tuted by everyday practices which enable people
sponsibility of the agents involved in health pol- in public spaces to produce new social and insti-
itics formulation and implementation, where in- tutional health arrangements. Such arrangements
tegrality would be priority. And, as priority, inte- are often marked by conflicts and contradictions,
grality leads us to the solidarity of knowing health in an arena of political contest which defends
workers’ practices, and evokes the analysis of an- health as everyone’s citizenship right, and not just
other dimension, as follows. a right of some. So integrality is conceived as a
plural, ethical and democratic term. The dialogue
Dimension of health workers’ is one of its constituent elements, because its prac-
knowledge and practices tice results from the conflict among several so-
cial voices that, when efficient, can produce po-
In this dimension, we have conceived the abil- lyphony effects – in other words, when these voic-
ity to create the welcoming reception and to in- es can be heard17. However, the dialogical func-
tegrate health services. Integrality is here under- tion does not always produce polyphony effects
stood as a process of social construction, which (according to Bakhtin 18), but monophony ones,
has in the idea of institutional innovation a great when dialogue is covered up and only one voice
potential for its achievement, since it would al- is heard. That is, when integrality does not mean
low the creation of new institutionalities patterns. efficient practices, there is only one voice, one
These can be regarded as experiments that can side, one without the other, only one can decide
provide more horizontal relations among their on the health he desires.
participants – managers, health professionals and As social construction and practice, integral-
users – concerning the production of new knowl- ity gathers substance and expression in the field
edge based on the practice of healthcare agents. of health, as far as this perspective tries to over-
Healthcare is here understood not as a health come the traditional way of making politics us-
attention level or as a simplified procedure, but ing models which require ideal conditions and
rather as an integral action with meanings and then can never be fulfilled19. Rather, it is a kind of
senses which consider health the right of being – policy-making that subordinates practice to tech-
being in the sense given by Heidegger: being-there nocracy with its disciplines external to the health
(cf. Abbagnano 15). We could think the right to area, and that finally splits up work processes,
being as respect to differences, its relations with sometimes producing negative asymmetry,
ethnicity, gender or race, or even consider people caused by knowledge and power relations in ev-
with disabilities or pathologies, and their specif- eryday services. But such everyday practices, when
ic needs. Or on the organizational and political taken as source of creativity and criticism, can
levels: for instance, to ensure access to other ther- potentialize emancipating actions of scientific
apeutical practices or ensure that the user will knowledge – which is imprisoned by the method
actively participate in deciding the best medical that legitimates and authorizes it – and of soci-
technology he will use. In relation to health facil- ety as well, so that the latter can discuss which
ities, we have already identified the characteris- knowledge must be granted and by which sourc-
tics of a welcoming place. es. As a matter of fact, some historians called at-
It means treating, respecting, welcoming, car- tention to the role played by practices in modern
ing for the human being during his suffering, human knowledge production, which has been
which, to a large extent, results from his social ever considered as a place for checking ideas, nev-
fragility 2. This statement is frequently found in er for coming up with ideas20.
other researches carried out by our group (cf. The study of practices in our research does
www.lappis.org.br), where integral action is also not aim at making an archeology of integrality,
conceived as people’s “among-relations” – “entre- but rather to set out a genealogy in the Foucault-
relações”, according to Ceccim 16. That is, integral ian sense – that is, genealogy as coupling of schol-
action as effect and repercussion of positive in- arly knowledge and local memories, which allows
teraction among users, professionals and institu- the formation of a knowledge of historical strug-
tions, represented by attitudes, such as respectful gles, and the use of this knowledge in present tac-
treatment, with quality, welcoming reception and tics21. And this outline is almost a map of differ-
link production. ent criticism to the knowledge instituted in the

Ciência & Saúde Coletiva, 12(2):343-349, 2007

health field, mainly the biomedical knowledge. given by Santos22, such as tensions, ruptures, and
Criticism arising from different spaces and in the transition of a modern paradigm, reconfig-
places we visited during fieldwork. Spaces (corri- uring knowledge and power.
dors, medical offices, hospitals, squares, streets, Exactly in these “cross-sections” there is a cer-
backyards) and people (doctors, nurses, commu- tain kind of making and applying government
nity agents, patients, families) which, in their daily policies, which we call shared management. A way
movements, revealed themselves as space-quotid- of making policy based on the political and ethi-
ian, as defined by Milton Santos 22: reciprocal re- cal commitment of fully implementing integrali-
union of fixed and flux, space as a contradictory ty in the population’s healthcare.
set formed by a territorial configuration and by
production relations, social relations; and finally Dimension of governmental policies
what guides today’s reflection, the space formed formulated with populational participation
by a system of objects and by a system of actions.
Along this trajectory, we did not describe con- This dimension is related to the ability of gov-
vergences and divergences among kinds of knowl- ernmental politics to organize the health system,
edge, based on the positiveness of their discours- with prominence to new propositions and devel-
es; we identified the appearance of other types of opment of new decentralized, decisive, solidary
knowledge, founding and critical ones. Kinds of arrangements, aiming at the participation of lo-
knowledge that assume strategic character for the cal health systems.
subjects’ transformation, for concepts of world Such capacity refers to management practic-
acting as political device (and why not?, as power es that democratically grant the agents involved
device). We could name it “people’s knowledge”, in the formulation of State policies the main role
local knowledge, discontinuous and not legiti- of meeting the population’s health demands.
mated, knowledge without common sense 21, These practices, known as health shared manage-
which do not find refuge in the rational order of ment, can be defined as an institutional space to
our capitalist society, as stated by Madel Luz 2. In build up practices involving several health agents,
other words, these are types of knowledge eco- through the establishment of joint and perma-
nomic analyses do not explain, but political, so- nent decision devices, on different levels of the
cial and cultural ones do. system6.
We draw attention to the necessary critical To realize this type of management, agents’
examination of the hegemonic source of knowl- spaces in everyday health services management
edge production, which, founded in modernity, must change. However, the need for changes must
often tends to take us apart from the possibility of correspond to a need for transformations in sec-
making new reflections upon the diversity and toral macropolitics. In this sense, one must think
plurality of health investigation objects and strat- again on the SUS’s ongoing formation. This per-
egies, especially the ones centered on practices. In spective, more than allowing the formation of a
this discussion, a very popular saying is implicit – sectoral micropolitics, can recover the dialectical
“knowledge without practice makes but half an unity existing between “health and democracy”
artist”. In this sense, one must make it clear that it which permeated the implementation of the Bra-
urges overcoming the limits of hegemonic theo- zilian Sanitary Reform.
retical analyses produced and used for planning So we have correlated the integrality concept
governmental action. So we will give rise to the beyond sanitary practices strictly speaking, to-
empirical knowledge assembled in the disunity wards the ideal of individual and collective free-
between one condition or the other23 as source of dom, the subjects’ autonomy itself “living their
new knowledge on and basis of health practices. lives their own way” and, therefore, towards the
This perspective is supported by Ricardo Cec- ideal of a fairer and equal society, which defends
cim, who stated that knowledge production is a reform of the Sanitary Reform, based on inte-
made with the truths of inteligence, and not with grality principles.
the truths of the explanatory rational thought24. Finally, it can be noticed, from the analysis of
From this viewpoint, we agree that practice can- innovative experiences for the development of
not be conceived as a mere space for checking new health technologies, how important decen-
ideas, but for coming up with new theories, more tralization, universality and integral care are, as
powerful ones – in short, a field for reflection, triple principles that largely express the process
able to strengthen management, thus assigning of consolidation of achieving the right to health
innovative cross-sections. Innovation in the sense as a question of citizenship. New agents have been
Pinheiro, R. et al.

incorporated to the national scene and, with uni- es favorable to integrality, which, in its turn, has
versal access, they allow the appearance of new been defined as actions in defense of people’s lives.
experiences, centered on integral healthcare6. This process has been marked by legal and insti-
Once again, this means betterment of inte- tutional changes never seen before in the history
grality senses, and widening of its legal definition, of Brazilian health politics.
i.e., a social action resulting from the democratic
interaction among agents in their everyday
healthcare practices on different attention levels6. Final remarks
It implies rethinking the most relevant questions
of health work process, management and plan- In this paper, we tried to present a viewpoint on
ning, in search of a view that conceives new health the way we understand integrality in people’s
practices and knowledge. A view that is shared healthcare, based on practices. We understand
out among subjects, either in the adoption or in integrality as an important organizational union
the creation new management technologies for of management practices, whose main challenge
integral care. is to warrant access to the more sophisticated
New management technologies must be built healthcare levels8. This challenge requires social
from a democratic and emancipating viewpoint, and joint action, arising from the democratic in-
whose main tools must be social control and po- teraction among agents in their everyday health-
litical participation. As well as assistance technol- care practices on different attention levels.
ogies take practices to be their potential trans- In this sense, management practices are a fer-
former in the daily life of those who search and tile field to build integrality in a concrete dynam-
the ones who provide health services, manage- ics of the political arena, where public managers
ment technologies must consider, in their prac- from several government levels, private providers,
tices, the potentiality within their own transfor- health workers, and organized civil society act.
mation. In other words, management technolo- As we point out the insufficiency of “ideal
gies must warrant democratic interrelation con- models” historically used in health management
ditions of the several sorts of knowledge implied planning, (due to their excessive abstraction, fo-
in their formation – such as epidemiology, bio- malization, inadequacy and difficult assessment
medical sciences, human and political sciences – of realization in health services), we try to high-
in order to contribute to the elaboration of rich- light their unability to meet the population’s
er and more efficient assistance concepts and health needs, which are marked by a high level of
strategies to face the most serious health prob- subjectivity, unpredictability and complexity. So
lems of the population. these models have become imperceptible to the
At last, we all know that integrality was formed “insensitive eyes” of an instrumental rationality
in a specific context (the creation of SUS) after – such as the economic one.
the sanitary reform and other specific social We understand then that integrality in the
movements – women’s, children’s and old peo- population’s health assistance can only come true
ple’s movements – more than 20 yeas ago. But we through the necessary democratic interaction
also now that, almost 15 years since SUS’s con- among subjects involved in the construction of
solidation, the ground became fertile and pro- governmental answers to the many differences
duced important transformations and experienc- expressed in demands for healthcare.

Ciência & Saúde Coletiva, 12(2):343-349, 2007


R Pinheiro, A Ferla and AG Silvia Junior partici-

pated equally in all steps of the paper elabora-


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