From Health to Education: from colonialised performances to confrontations

ABSTRACT

This study analysed a set of discourses from the Unified Health System (SUS) that intersects education and health in the context of work. The central focus of this debate lies in the permanent education proposed by the political-legal framework of the SUS, aiming at putting pressure on practices for a given transformation. Based on Maria Lugones’ arguments about work as a racialised element, attributed to gender and colonial imposition, the discourse of part of this framework was critically analysed. The use of the term transformative pedagogical act was questioned and reflections were made on considerations put forward by female workers who made it clear that such transformative intentions constitute disputes over the exclusion of bodies and knowledge.

Keywords
Education; Coloniality; Women Workers; Health

RESUMO

Este estudo analisa um conjunto discursivo do Sistema Único de Saúde (SUS) que intersecciona educação e saúde pelo contexto do trabalho. A centralidade do debate está na educação permanente proposta pelo arcabouço político-legal do SUS e que tem por objetivo tensionar práticas para uma dada transformação. Com base em argumentos de Maria Lugones sobre trabalho como elemento racializado, atribuído de gênero e constituído como imposição colonial, foi feita a análise crítica do discurso de parte deste arcabouço, tendo por questionamento o uso do termo ato pedagógico transformativo e por reflexão ponderações apresentadas por trabalhadoras que explicitam que tais intenções transformativas são disputas para exclusões de corpos e saberes.

Palavras-chave
Educação; Colonialidade; Mulheres Trabalhadoras; Saúde

Introduction

In 2023, the Brazilian Institute of Geography and Statistics published the 2022 Census, indicating that the Brazilian population is approximately 208 million people. Estimates suggest that more than 150 million people exclusively use the public healthcare services of the Unified Health System (SUS) (Brasil, 2022). SUS was legislated and built in the 1988 Constitution to accommodate and monitor millions of people in the Brazilian states. In the National Register of Health Establishments of the Ministry of Health (MS), more than 330,000 services are available (Brasil, 2022), with the participation of almost 3 million female workers, which account for 80% of women working in healthcare in Brazil (Machado et al., 2022).

The SUS was part of an affirmation of Brazil’s re-democratisation process, based on the reorientation of healthcare as a universal right. According to Onocko-Campos and Furtado (2006), the healthcare system demanded services with ethical-political proposals enabling ruptures with the former model of care. Such model had as its epistemic foundations illness as a mistake on the part of sick people and a device for social segregation, authorising isolation and moralising therapeutic treatments for them. For this rupture, conceptual frameworks such as social participation, fight for reparations and reorganisation of society were mobilised. At the time of re-democratisation, a dense network of forces that wanted the SUS to be a pact to confront the epistemic violence present in health practices was strengthened.

In order to build and expand the SUS, public policies were instituted to reorient health practices towards its principles and guidelines, such as comprehensive care and equity. One of the axes proposed during the reconstruction of healthcare was the training of people at everyday work, focusing on the large number of female health workers in healthcare after the 1988 Constitution. Thus, from 1988 to 2019, the Brazilian State provided for Education as a relevant element for transformative actions favouring SUS’ guidelines and principles (Brasil, 2004a).

As a result, health education assumed several dimensions, one of which was training as a pedagogical act at work, aiming at modifying the work process with actions aimed at female workers. Specifically, it started from a set of technical-legal productions with this focus, centred on the National Policy for Permanent Education in Health (PNEPS), the first version of which was published in 2004. Permanent Education in Health (EPS) was presented in Ministerial Decree 198/2004, as a SUS strategy aimed at ‘[…] training and developing workers for the sector’, based on everyday healthcare (Brasil, 2004b, p. 1). At this point, Health began to have in Education an entity capable of moving the structures of the SUS, including funding for pedagogical projects.

We emphasise in this policy the transformation/transformative textual element, situating from it the approximation between Education and Health in the interpretation of pedagogical practices and their effects of social transformations. The ordinance proposes ‘[…] training processes for healthcare workers […] with the goal of transforming professional practices and organising work itself’ (Brasil, 2004a, p. 8). This educational draw on healthcare practice soon came to be called permanent education and from this that we analysed the political-discursive agendas that emulate female workers, their knowledge and practices based on the transformation/transformative intention. We highlight the grammatical force of this pedagogical intention that, by using this adjective, built a relation between education and power, characterising the training and development of workers as holders of the power to transform. Such power interests us as subjects of confrontations in the SUS to affirm existences and female workers.

To this end, this study aimed at focusing on education as a transformative proposal for work in the SUS and colonialised agendas for the permanence of places of exclusion imposed on women workers. Based on Maria Lugones’ (2008) argument on work as a racialised and gendered element, we analysed the discursive universe of Education in the context of health work. We conducted a critical analysis of the discourse emphasising the PNEPS set of documents, as this is the main technical-legal guideline for training proposals in the field of health work. The authors of this article are SUS female workers, advised by professors, which generated reflections positioned by female workers suffering the immediate action of interventions in health work.

Research background

We aimed at highlighting education as a disputed element in the SUS, based on health work as a transformative pedagogical act, as well as the possible implications that this transforming intention can have on the erasure and recognition of female health workers. Specifically, we seek to question the modern/colonial political discourse and its effects of subalternisation, and therefore the effects of meaning imposed on Amefrican women health workers (Gonzalez, 1988) that certain pedagogical proposals produce. We believe that making this issue visible involves SUS female workers, especially Black women. This justify our choice of the category of amefricanity, proposed by Lélia Gonzalez (1988), to situate the collective that constructs work in everyday healthcare.

Gonzalez (1988) questions the narratives that build the recognition of what Brazilian society is, reflecting on its historical-cultural formation and how racism and sexism play a part in these relations. She criticises the import of Eurocentric discursive elements, proposing a reinterpretation of Améfrica Ladina¹ based on the Brazilian amefricanity, suggesting that such approach brings us closer to crucial issues for the recognition of our ethical-political projects and the construction of possibilities for reexistence and confrontation.

In this study, there is an ethical-political project built in the territory of the authors of this research that has fostered ideas and perceptions of confronting erasures historically imposed in health. Such ideas and perceptions were built up during meetings of a collective of female workers who campaign for permanent education in the SUS, in a peripheral region in the centre-south of the state of Minas Gerais. The authors of this article were three of the workers in this group, which started in 2018 and continued as part of an outreach program of a local Federal University in partnership with nine city halls in the area.

The motive that brought us closer to crucial issues of criticism of the erasures experienced in our territory was built within the extension project. This motive and issues produced reflections on epistemic shifts that culminated in this investigation on national and international agendas that dispute work in the SUS. We chose to stress the transformative pedagogical act discursive element presented in various documents analysed for their claim to the knowledge and bodies of female healthcare workers. For this reason, we chose Maria Lugones’ (2008) arguments on the colonial gender system as an interpretative guideline.

The author exposes the intertwinement between coloniality and gender, denouncing that the indifference and violence produced by this system has led to domination, especially against Amefrican women. Lugones (2008) points out that this domination has been historically enforced through exclusions based on race, class, sexuality and gender, elements that in turn have organised human relations on social and discursive bases and are therefore part of the SUS and the daily lives of female healthcare workers.

Maria Lugones (2008, p. 94) emphasised women’s refusal of the impositions that coloniality and gender produce and these refusals are part of our struggles. We, the authors of this scientific article, understand that work and education are part of this confrontation in the SUS and that the textual label transformation/transformative has been configured over the years as a stage for disputes over the veiling or recognition of women's intellectuality. Thus, we investigated the political discourses on work as a transformative pedagogical act and their meanings for conditions of subalternisation. We started from Lugones’ (2008, p. 97) observation that work is ‘[…] simultaneously racialised and gendered’, founded on a Western perspective, with a close relationship between capital and knowledge. The state of the art of publications investigating conceptions of work and education in the SUS revealed a dispute between projects for society and its knowledge and practices (Brasil, 2003; Batista; Gonçalves, 2011; Melo; Oliveira, 2017). We followed such tension.

We used the arguments of Viviane Resende (2019) to analyse Education in dispute. The author presents the power of discourse in the construction of reality as a path for social and textual analysis of acting in the world, revealing ideologies and counter-ideologies through the relation between language and society. The SUS is constituted of people and social and governmental movements that strengthen the power of discourse in the dispute over ethical-political projects, with their own publications positioning health in terms of acting in the world. To situate this investigation, we present as a locus of enunciation and criticism the position of three female workers, the first three authors of this text. We are part of a collective that follows the PNEPS and work to strengthen the SUS in the centre-south periphery of the state of Minas Gerais.

Regarding the subject of this study, the SUS has been proposing actions and languages for the ‘[…] training and development’ of female workers (Brasil, 1990, p. 3) since its institutionalisation. Its publications are official, widely disseminated, open access, and co-authored by society through health councils and governmental spheres. Based on these publications, we analysed societal forces that dispute discourses and practices in the movement for health. We tried to make discursive practices on health work observable as a transformative pedagogical act, both as reproducers of the subalternisations inherent in the modern/colonial system of gender, and as refusers of these impositions through the paving of re-existence paths.

To this end, we relied on Barbosa Filho’s (2016) argument on studies of political discourses mobilised by the State. In our analysis, we started from the discursive universe laid out in public policies instituted by the Brazilian state to find cosmopolitics in motion through work in the SUS by pedagogical act. We noticed the persistence of the term transformation in the discourses and gave it analytical relevance. For this reflection, we relied on the questioning presented by Barbosa Filho (2016) on the discursive practice of State neutrality in the face of social interests. This argument allows for debates on the ethical-political projects that constitute the discursive universe of the SUS, bringing textual productions authored by the MS to the centre of the investigation. The intention is to highlight management as a participant in disputes in Brazil over both social organisation and the division of labour.

In order to deepen the critique, we analysed the succession movements to the PNEPS and chose as the main analysis framework the last ministerial ordinance produced by the MS on this subject, the Portaria Gabinete Ministerial/Ministério da Saúde No. 3,194 of 2017, published approximately 13 years after PNEPS publication. Ordinance GM/MS No. 3,194/2017 states right at the start that it aims to ‘[…] transform health practices towards meeting the fundamental principles of the SUS, based on local reality and the collective analysis of work processes’ (Brasil, 2017, p.1, emphasis added), using the relation between education and transformative power to affirm its intention. Alongside this ordinance, we also found publications related to national public management and social control. Both authors, management and control, contribute to policies that guide work as a transformative pedagogical act in the SUS and to the configurations that this transformation receives depending on the document.

For this investigation, we studied technical and bibliographic documents available on the official platforms of the Brazilian Ministry of Health and the National Health Council (CNS). We chose as inclusion criteria documents dealing specifically with the subject, published from 2003 to 2018. We chose this interval because in 2003 the document Educational Politics and Development for the Unified Health System was published, with the main ideas that guided the 2004 PNEPS. In 2018 the ministerial production National Policy of Permanent Education in Health: what has been produced for its strengthening? was published, analysing what had been done on Permanent Education in Health, emphasising the importance of the last ordinance published on the subject: GM/MS No. 3,194/2017. By exclusion criteria, we chose publications that dealt with topics other than permanent education. The documentary choices in chronological order of publication and with a brief definition are presented below:

1. Educational Politics and Development for the Unified Health System (SUS): Ways for the Permanent Education in Health, 2003, indicates the main ideas for the PNEPS/SUS.

2. Educational Politics and Development for the Unified Health System (SUS): Ways for the Permanent Education in Health: Poles of Permanent Education in Health, 2004, on education poles.

3. Ordinance GM/MS No. 198/2004 institutes the PNEPS for the training and development of workers.

4. Ordinance GM/MS No. 1996/2007 establishes guidelines for the implementation of the PNEPS.

5. Ordinance GM/MS nº3.194/2017 provides for the program to strengthen EPS practices in the SUS.

6. National Policy of Permanent Education in Health: what has been produced for its strengthening? published in 2018, deals with debates on updating the PNEPS.

Through the critical study of discourse, we sought the emergence of plots that would expose permanent education as something revealing the modern/colonial system of gender (Resende, 2019) from the situated critique of female workers when they act through a transformative pedagogical act. We understand that the power of the SUS discourse in relation to the training and development of female workers is constituted by cosmopolitics that question the conditions imposed on the existence of female health workers, placing us in ethical-political projects to confront epistemic violence.

The theoretical-methodological design of this study aimed to materialise the discourse on education at work in the context of health, by identifying methods of producing capital and colonialities. To this end, critical discourse analysis began by presenting the context (conjuncture), identifying the main textual corpus and the extended corpus, and then constructing reflections on the discourses of certain social practices (Marcuschi, 2005). The main corpus of the analysis was Ordinance GM/MS No. 3,194/2017 and the other aforementioned publications were used as the extended corpus. We began the investigation by presenting the ordinance and its context, followed by discourse analysis to understand the text, the contexts and, from a decolonial perspective, the colonial legacies and their relational effects (Resende, 2019).

First Approach to Ordinance GM/MH No. 3194

Ordinance GM/MS No. 3,194/2017 is authored by the MS and aims to strengthen Permanent Education in Health (EPS) practices, which were established as official terminology by Ordinances GM/MS No. 198/2004 and GM/MS No. 1,996/2007. Ordinance GM/MS No. 3,194/2017 has the typical textual genre of a ministerial ordinance, which is public, political in nature, and contains expository components that introduce the topic along with prescriptive elements detailing the norms and operationalisation of the proposal within the document. It consists of 16 articles divided into four chapters: general provisions; financial incentives for implementation; monitoring and evaluation commission; and final provisions.

The specific objectives of the ministerial ordinance are detailed in the Article 3. We immediately highlight the first item of this article, which begins with the expression training and development. This expression has been identified in various documents authored by the MS, establishing a connection between this ordinance and others through its thematic declaration. In this first item, the scope of the ordinance is detailed: ‘[…] to promote the training and development of workers in SUS, based on the daily issues related to healthcare and the organisation of work in health’, under the title Programa para o Fortalecimento das Práticas de Educação Permanente em Saúde no SUS - PRO EPS-SUS [Program for Strengthening EPS Practices in SUS] (Brasil, 2017, p. 1).

We then observe the remaining four items that establish the relation between PRO EPS and the National Policy of Permanent Education in Health (PNEPS).

II - Contribute to the identification of Permanent Education in Health needs for SUS workers and professionals, in order to develop strategies aimed at improving healthcare and health management, with Primary Care as the coordinator of the process, and to strengthen the participation of social control in the sector, thereby creating a positive impact on individual and collective health.

III - Strengthen Permanent Education in Health practices in states, the Federal District, and municipalities, in alignment with the needs for the qualification of healthcare workers and professionals.

IV - Promote intra- and inter-institutional collaboration, in order to create commitments among the different management networks, health and education services, and social control, with the development of educational activities and comprehensive healthcare, enabling the creative addressing of problems and greater effectiveness in health and education actions.

V - Encourage the planning, execution, and evaluation of training processes, shared among educational institutions, health residency programs, and health services, using the Contratos Organizativos de Ação Pública Ensino Saúde […] as a guiding tool to promote the integration of training actions with the Permanent Education processes in the health network

(Brasil, 2017, p. 2, emphasis added).

Let us focus on item three, which uses two terms to identify the target audience of the action: workers and professionals. This description textually marks differences among the people working in SUS, which raises questions for us, as it points to understandings of functions and gender distinctions. These distinctions are part of the training actions for those involved (Scott, 2017). This linguistic resource translates differentiations that organise hierarchies, configured as insurmountable by the coloniality of knowledge. Walter Mignolo (2003) proposed this term to highlight the hierarchies and erasures of knowledge and practices imposed by the modern/colonial system on racialised bodies, deemed inferior by Eurocentrism.

It was in October 2017, during the 10th ordinary meeting of the Tripartite Inter-Management Commission (CIT), that the Department of Labour Management and Health Education (SGTES) presented the proposal called PRO EPS SUS.

Context and Discursive Practices on Work in Health as a Transformative Pedagogical Act

The SUS is a battleground for disputes over healthcare work in Brazil, with Permanent Education in Health emerging as a strategy driven by questionings to what we refer to in this study as the modern/colonial capitalist discursive universe. In the document Educational Politics and Development for the Unified Health System (SUS): Ways for the Permanent Education in Health: Poles of Permanent Education in Health (Brasil, 2004a), the Department of Health Education Management (DEGES/SGTES/MS) indicates that the purpose of the Permanent Education is to be a transformative axis for SUS, beyond “punctual changes in hegemonic models of health education and care” (Brasil, 2004a, p. 8).

In the previous year, the SGTES and DEGES had published their objectives, which involved developing proposals to materialise SUS principles with the management of healthcare work and education (Brasil, 2003). To achieve this, both were responsible for the ‘[…] qualification of workers and the organisation of health work’ (Brasil, 2003, p. 2). In 2003, meetings on the subject were held, culminating in the publication of one of the documents that form the expanded corpus of this study, the Educational Politics and Development for the Unified Health System (SUS): Ways for the Permanent Education in Health.

This document contextualises the relation between work and education, mobilising the term permanent education and proposing that this project be a political-epistemic one, critical of the process of health work training and development. In the third paragraph, DEGES highlights its proposal for the theme, based on ‘[…] training itineraries together with their insertion in services and the social management of public health policies’ (Brasil, 2003, p. 3). DEGES makes explicit in the publication the need for reform in the Brazilian State, following the proposals envisioned by the Sanitary Reform. The Brazilian Sanitary Reform movement and its foundations criticised, through different epistemic matrices, actions interested in control and segregation, treating it as a foundational movement of SUS (Baptista; Borges; Rezende, 2019).

In 2003, DEGES pointed out the relevance of the relation between the components in motion for permanent education, based on a political commitment to changes in management practices. In the document Educational Politics and Development for the Unified Health System (SUS): Ways for the Permanent Education in Health, there is a passage presenting, through metaphors, the proposed relation among the components that implemented the PNEPS: ‘[…] commitment to change, suppressing the image of the pyramid and levels of management’ and ‘[…] bringing to the scene the capacity to value the potential for mobilisation and destabilisation of traditional structures’ (Brasil, 2003, p. 12).

In 2004, the MS issued Ordinance GM/MS No. 198, officially coining the term Permanent Education in Health (EPS). The legal provision that inaugurated the proposal referred to EPS as a pedagogical act aimed at ‘[…] establishing organic relationships among teaching and actions and services, and between teaching and healthcare’ (Brasil, 2004b, p. 3). For this, the MS resumed the Brazilian Sanitary Reform as a discursive element. Also in 2004, the management of permanent education was configured as a Network of State and National EPS Centres, which in 2007 was reorganised as Permanent Commissions for Teaching-Service Integration (CIES) through Ordinance No. 1,996/2007.

Notably, 2004 is a remarkable year, as it is the date of the publication of EPS as a public policy (Brasil, 2004b). From then on, a set of documents was produced by the MS, and from 2017 to 2019, the last group of ordinances on the theme was published. At the time, the MS issued the ordinance on strengthening EPS and a set of ordinances on its financing. Gonçalves et al. (2019) analysed this political movement, observing that its intention was to resume and strengthen the implementation of national policy.

The EPS political agenda circulated through spheres of the Brazilian health system. In 2017, for example, the National Council of Medicine promoted regional meetings focused on the training and permanent education of councillors, involving 3,875 participants, ‘[…] most of them being Black women’ (CNS, 2018, p. 2). This agenda was also featured as a topic for international institutions such as the Pan American Health Organization (PAHO) and the World Health Organization (WHO). In 2017, PAHO launched the Sustainable Health Agenda for the Americas 2018-2030: A Call to Action for Health and Well-Being in the Region. Among the objectives and goals is the ‘[…] strengthen the management and development of human resources for health with skills that facilitate a comprehensive approach to health’ (OPAS, 2017, p. 31).

For its part, the WHO (2010, p.10) had created the Global Health Workforce Network, aimed at ‘[…] maximizing the potential of all health professionals through a virtual network, stimulating interprofessional collaboration and encouraging countries to contribute to a global health agenda’. This agenda was described as complex, requiring workers to undergo effective training to acquire ‘[…] the skills needed to become part of the collaborative practice-ready health workforce’ (OMS, 2010, p. 10). To this end, the WHO launched in 2010 the guidelines described in the document Framework for Action on Interprofessional Education and Collaborative Practice.

The publication defines interprofessional and collaborative education as a pedagogical practice with the strategic horizon of addressing what the entity identified as the global health workforce (HW) crisis (OMS, 2010), which would justify transformative proposals. According to the WHO (2010, p. 9), the world was experiencing a shortage of health professionals, and ‘[…] Governments around the world are looking for innovative, system-transforming solutions that will ensure the appropriate supply, mix and distribution of the health workforce’ (OMS, 2010, p. 10).

However, we question what underlies the WHO’s discourse of crisis and to what transformation this discourse points. According to Sousa Santos (2003), the WHO constructed a discursive universe for health based on the naturalisation of relations between expertise, capital, and workforce, elevating health as a matter of interest in foreign policy. Throughout the 21st century, especially after the Cold War, health entered global security agendas as a geopolitical strategy to address disruptions in the flow and accumulation of capital (Sousa Santos, 2003). In its 2010 publication, WHO justified the proposal by arguing that in crisis situations, ‘[…] In situations of humanitarian crisis and conflict, a well-planned emergency response is essential’ and that professionals must know how to ‘[…]overcome water, food, and medical supply gaps […] mobilize whatever resources and expertise are available within the health system and the broader community’, concluding that ‘[…] collaboration among health professionals is the only way to manage the crisis’ (OMS, 2010, p. 15).

We highlight possible interpretations of these discursive practices of the WHO. This international health institution created a set of assumptions on health that translate it as a persistent and inherent crisis of the present, and that a solution lies in collaboration among health professionals. However, the metonymic construction of order between health and crisis and its implication for pedagogical proposals became an object of analysis in this study, as it made explicit a structuring element of the coloniality of knowledge, which is the relationship between capital and expertise. In the WHO’s discourse, health (the whole) is translated as a crisis (part), with the crisis being unquestionable, as is the intention to transform the practices of health workers. However, the flexibilization of the workforce was part of this intention as a response to the announced crisis, which, by participating in this reason by metonymy, also became unquestionable.

The Crisis was presented as a strategy to update the agenda of labour precarization and sustain its international division. Ordinance No. 3,194/2017, invoked the principles of SUS to justify the need to ‘[…] stimulate, monitor, and strengthen the professional qualification of workers in the field for the transformation of healthcare practices’ (Brasil, 2017, p. 1). However, it resorted to the WHO’s epistemic exegesis to point out the paths for transformation, promoting an interdiscursivity with documents that interpreted the world by order of reason that implied notions of the system-world, the existence of a centre-periphery dynamic, and the recognition of knowledge production centres based on the international division of labour. An example of this can be found in item II of Article 4 of the Ordinance:

II – Incorporation of strategies that enable Permanent Education in Health actions in the reality of health services, such as information and communication technologies and training modalities that utilise the principles of Interprofessional Education and Practices in Health.

Discursive and Social Practices of Permanent Education in SUS

To question the discourses surrounding SUS in relation to the updates of agendas that organise social relations through subalternisation, inherent to the modern/colonial system of gender, we begin with a brief analysis of the Brazilian context that gave rise to the discursive set in focus. At the time of the ordinance publication in 2017, Brazil was experiencing its first-year post-impeachment of President Dilma Rousseff from the Workers’ Party (who was exonerated in the same year). Simultaneously, there was the implementation of Constitutional Amendment No. 95, which established a ceiling for public spending and reduced the role of the state in guaranteeing social welfare through fiscal austerity.

In Brazil, the material determinants and worldviews that structure social inequalities exploit crises to maintain the capitalist social order, supporting patriarchy and slavery. Barbosa Filho (2016) argues that there is a principle of inequality between authorised and unauthorised discourses, which is projected onto political discourse, stemming from power relations instituted by a social order and translating into and for the maintenance of the international and sexual division of labour. Crisis has become a historical social linguistic resource that serves to maintain radical dissimilarities, authorising violence and indifference between peoples and territories.

The modern/colonial system of gender, based on Eurocentric interpretations, creates barriers and places of exclusion for the maintenance of the international sexual division of labour (Lugones, 2014). This division composes and is composed of the racism and sexism imposed on Amefrican women (Kilomba, 2019). The discursive and social practices related to the overthrow of President Dilma Rousseff and Constitutional Amendment No. 95, which limited public spending, affecting social spending, are contexts for this racist patriarchal agenda. According to Barreto (2018), the discursive element crisis was present in the discursive practices of the legislature and the media to achieve the meaning effect of its undeniability, which soon after justified the coup and austerity measures. The undeniable discourse serves as a condition for the continued exclusion of Amefrican women.

As Silvia Federici (2018) has pointed out, for this system, women represent the idea of permanent danger and lurking enemies, typified in various ways. The discursive typification promoted by this system turns into effects of meaning for a social organisation that exploits people as a disposable workforce, as Lugones (2008) has argued. This is a workforce carrying secular impediments determined by colonial differences and wounds, both of which are configured by this system that conditions fictional boundaries on life to impose positions and privileges of colonial whiteness, as Grada Kilomba (2019) and Lélia Gonzalez (1988) have pointed out. To this end, colonial whiteness has recreated agendas to update these wounds (Kilomba, 2019).

From the perspective of the workers writing this article, the new funding model for primary care, the Previne Brasil proposal, authored by the MS, federal administration 2019/2022, is an example of this recreation aimed at subalternisation. The description of the Previne Brasil proposal on the Ministry of Health’s website had the objective of inducing ‘[…] managers and professionals to take responsibility for the people they assist’ (Brasil, 2022). According to Áquilas Mendes, Mariana Melo, and Leonardo Carnut (2022), this proposal institutionally induced the SUS to commercialise health, holding workers directly responsible for part of the transfers not received by city halls.

There was a close relationship between offers of pedagogical practices to workers in order to adapt the workforce to achieving goals/procedures, a condition for the transfer of resources by the tripartite management. As a result, the de-funding of the SUS has shifted from an action of political-budgetary veto and economic and fiscal austerity to the blaming of individual workers, reproducing gender and racial violence typical of modern/colonial and capital inheritance. The de-funding of the SUS updated the colonial wounds and their practices of invisibilization and impediment, imposing the process of dehumanisation of the modern/colonial system of gender on women workers, their bodies and their knowledge.

In 2007, the Brazilian Ministry of Health published Ministerial Order GM/MS No. 1,996 on the PNEPS guidelines, detailing its implementation procedures:

Sole Paragraph: The National Policy on Permanent Education in Health must consider regional specificities, the overcoming of regional inequalities, the need for training and development for work in health, and the already established capacity for institutional provision of formal education actions in health.

Article 2. The regional implementation of the National Policy on Permanent Education in Health will be conducted through the Regional Management Committees, with the participation of the Permanent Commissions for Teaching-Service Integration (CIES)

(Brasil, 2007, p. 1).

In this ordinance, the CIES were described in Article 2, paragraph 2, as ‘[…] permanent intersectoral and interinstitutional bodies that participate in the formulation, implementation, and development of the National Policy on Permanent Education in Health, as provided in Article 14 of Law No. 8,080, of 1990, and the Basic Operational Norm for Human Resources (NOB/RH) – SUS’ (Brasil, 2007, p. 2). In Ordinance GM/MS No. 3,194/2017, the CIES is detailed in the text, with emphasis on Articles 3 and 5:

Article 3. The Regional Management Committees, as per Ordinance No. 399/GM of February 22, 2006, are the permanent negotiation and co-management bodies, formed by the municipal health managers of the set of municipalities in a given health region and by representatives of the state manager(s). The Regional Management Committee must establish a regional planning process for Permanent Health Education that defines priorities, responsibilities of each entity, and support for the local planning process […]

Article V. The Permanent Commissions for Teaching-Service Integration (CIES) must be composed of municipal, state, and Federal District health managers, and, according to the specificities of each region, by: state and municipal education managers and/or their representatives, SUS workers and/or their representative entities, educational institutions offering health courses through their distinct segments, and social movements linked to the management of public health policies and social control in SUS

(Brasil, 2007, p. 2).

According to Luiz Anildo Silva, Marinês Leite, and Camila Pinno (2014, p. 421), the CIES enable the collective construction of local and regional planning for permanent education. However, the authors highlight some challenges to this collective construction, such as the need to ‘[…] break with the dichotomy of conception versus execution promoted by managers’ (emphasis added), in which management conceives, and workers execute. In the ordinance that addresses the CIES, No. 1996/2007, the components participating in the CIES are described, including social control, management segments, education representatives, and workers, but participation is already characterised as an act exclusively obligatory to management.

At this point, we draw attention to the discursive resource that modern/colonial reason employs. Through metonymies of order, there is a concealment of elements that constitute the whole, which becomes represented by a single element supposedly with the power to represent the entire whole. Metonymy reveals hierarchies among the parts that constitute the whole, in this case, the knowledge of management versus the other subordinated elements, as pointed out by Saulo Rodrigues (2007). Thus, the idea that the CIES is a horizontal space conceals performances of the reproduction of modern/colonial gendered reason, creating hierarchies between management, workers, and social control—a situation that we must pay attention to and question. The composition of the CIES in the health region of the authors of this research reflects this situation, with rare participation and many absences of representation of assistance workers.

As Luiz Gustavo Souza (2022, p. 6) denounced, the normalisation of silencing is a legacy of our colonial formation, which naturalises the erasure of knowledge and practices, assuming for one part the function of speaking for the whole. The author identifies this as an epistemic violence inherent to the modern/colonial system, which updates agendas of racialisation and gender attributes through characterisations of radical dissimilarities (Souza, 2022). Additionally, as pointed out by Barbosa Filho (2016), public policies structure their discourse based on the prerogative that management desires the common good, mobilising images of a State external to social interests and conflicts.

However, political mechanisms of exclusion of workers under the guise of possible inclusion, without its actualisation, underlie this discourse (Souza, 2022). Ultimately, there is the explicitness of the arrogance of a reason that sees itself as unconditionally free, distant from ideologies and interests, and therefore self-sufficient (Rodrigues, 2007, p. 71). At this point, we highlight the discursive position of the MS, which organised itself to create conditions for knowledge and practices based on supposedly depersonalised work processes, but without the workers.

The State, in its representation of management as a social force that sees itself as a regulator and financier, determined in some documents who would have the authority to problematise work in SUS, organising protagonism and erasures. Management assumes the zero point (Grosfoguel, 2008) for knowledge construction in SUS, highlighting hierarchies among different knowledge. According to Viviane Resende (2019), coloniality differences serve to demarcate the possibility of observation exclusively from an epistemic place, deemed neutral, the zero point, or the eye of God, as described by Grosfoguel (2008), which in the modern/colonial system of gender belongs to the Western White man. Neutral and absolute knowledge reinforces the geopolitics of knowledge, labour, and sexual division (Grosfoguel, 2008; Lugones, 2014).

This geopolitics was resumed by Ordinance GM/MS No. 3194/2017, through its interdiscursivity with WHO documents on education and interprofessional practices in health, whose argumentative basis, as previously presented, was the supposed crisis in the health workforce. The Ministry of Health makes explicit in Article 4, item 2, the following guideline for strengthening Permanent Health Education: ‘[…] incorporation of strategies […] such as information and communication technologies and training modalities that utilise the assumptions of Interprofessional Education and Practices in Health’ (Brasil, 2017, p. 2). However, as Silvia Federici (2018) observed, crisis is an argument that participates in the Global North’s corollary to make incontestable a given social organisation that imposes the idea of work in which women care and do not appear, transferring their labour to patriarchy (Federici, 2018).

Reflections and Possible Paths for Education in the Context of the SUS

In 2021, the National Council of Municipal Health Secretariats (CONASEMS) debated this topic, publicising the course of the SUS and explaining the different forms that permanent education has taken over the last decades. As an example, the organisation presented training processes aimed at managerial solutions to mould female and male workers to the system's organisational processes, highlighting the permanence of this concept over others. This council highlighted there were different proposals for transformative pedagogical practices guided by the relationship with what emerges from the territory and question the organisational processes that operate to maintain power asymmetries.

Silva et al. (2010, p. 559) reinforce that there are many projects and actions on the subject, with different conceptions that mobilise authorship, knowledge and practices that constitute other cosmopolitics. In order to understand the problem and possible ways of overcoming it, we return to the position of the Department of Health Education Management (DEGES/SGTES/MS, 2003) on EPS as the transforming and structuring axis of the SUS. The transformative perspective goes along the discourse on EPS; however, we would point out that there are interests that present different interpretations of the world that are limited to transformation. In the discursive set studied, the intersection between education and health in the context of work made it possible to stress pedagogical practices supported by justifications of transformation. However, according to Lugones (2008), they considered work as a racialised, attributed to gender element, and constituted as a colonial imposition in their epistemic matrix. By focusing the debate on the use of the term transformative pedagogical act, we provoked reflections that made transformative intentions explicit as disputes over the exclusion of bodies and knowledge.

Modern/colonial discursive practice uses the label transformation to construct a reality that recognises subjects by fictional standards based on dissimilarities, guaranteeing the permanence of the epistemic privilege of white Western men. The argument for transformation, in this case, serves to readjust the system to maintain power asymmetries, In other words, to construct knowledge that condition women’s existence to the reproduction of bodies that will be the disposable workforce of this world-system.

Therefore, according to Lugones (2014), this transformation does not restructure Brazilian society or labour relations, as it participates in the matrix of modern/colonial thinking, whose coloniality of power is organised as discourse and society. Danielle Maciel (2021) stated that the analysis of the discourse on the epistemological and ontological mechanisms that construct the international division of labour makes it possible to critique and deconstruct both imperialism and what the author has called the itinerary of colonial discourse. Maciel (2021) unveils colonial and anti-colonial discursive configurations that tension the division of labour and, in this sense, we question the participation of the label transformation throughout the publications and its questionable polysemy.

According to DEGES, EPS mobilises resources and powers and, in fact, there is something great when thinking about policies that question work towards a counter-hegemonic definition of health, based on principles such as equity, social participation and comprehensiveness. We highlight education and its itinerary in the anti-colonial discourse when it is presented by the SUS as a way of questioning privileges, because the health agenda remains a living act crossed by Brazilian capital, racism and patriarchy, which puts pressure on the maintenance of privileges and which must be interrupted. As Lélia Gonzalez (1998) has already pointed out in her life trajectory and her work on amefricanity, and among many others, privileges in Brazil must be questioned. It is necessary to militate and act in various institutional spaces, occupying and counter-arguing colonial myths and agendas.

We reinforce the warning on the violence that the modern/colonial system of gender produces and distances EPS from knowledge of native peoples and territories, pushing it into a relationship between knowledge and capital that updates social and discursive practices of Eurocentric colonialities of power. From the perspective of the authors, if there is a transformative intention favouring ruptures in social organisation and the state, this will happen through the leadership of positions and interpretations of the world that are specific to female workers, especially Amefrican ones.

Note

• 1
  Améfrica Ladina is an expression proposed by Lélia Gonzalez in 1988 to deepen her concept of amefricanidade (amefricanity) in Brazil. The author introduced the term to highlight potential interpretive inversions regarding Ibero-American constructions presented as singular, serving as an interpretive element of Brazilian culture. Lélia Gonzalez challenges this normalisation, arguing on Brazilian historical-cultural formation and its interconnections with racist discursive and social practices. The author goes further, identifying and analysing African elements that constitute Brazilian daily life.

Availability of research data

The data set supporting the results of this study is published in the article itself.

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• Editor in charge
  Lodenir Karnopp

Publication Dates

• Publication in this collection
  08 Nov 2024
• Date of issue
  2024

History

• Received
  19 July 2023
• Accepted
  21 May 2024