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Principles and characteristics of Permanent Education in Health: rescue and resistance in favor of a potent SUS and in defense of life
Princípios e características da Educação Permanente em Saúde: resgate e resistência em favor de um SUS potente e em defesa da vida

Marcia Naomi Santos Higashijima (psicologanaomi@gmail.com)
Helvo Slomp Junior
Alcindo Antonio Ferla
Laura Camargo Macruz Feuerwerker
Emerson Elias Merhy
Ricardo Burg Ceccim
Jader Vasconcelos
Alessandro Diogo De Carli
Mara Lisiane de Moraes Santos

Abstract: Permanent Education in Health (PEH) transcends the National Policy for Permanent Education in Health, forged with its own principles and characteristics to meet the qualification needs of the workers in the Unified Health System. However, over the years, attacks and contradictions to PEH have been observed through the implementation of unsystematic or fragmented hierarchized actions, focused on information (rather than action), and centered on the techno-bureaucratic induction of practices, without recognition. In this sense, the present study aimed to explore, systematize, and problematize the characteristics and principles of PEH through literature analysis and dialogical encounters with some of its conceptual creators. It is understood that PEH is an investment in life, with formative actions that problematize work processes and articulate teaching and intervention in reality, bringing implications for users and their singularities; this being a movement of resistance to the deconstruction of PEH. The result was an essay on the systematization of the characteristics of PEH, presenting reflections on ways of producing management, attention, participation, and training as living work in health.
Keywords: Brazilian Health System. Health Permanent Education. Working in Healthcare.

Resumo: A Educação Permanente em Saúde (EPS) transcende a Política Nacional de Educação Permanente em Saúde, forjada com princípios e características próprias para atender a necessidade de qualificação dos trabalhadores do Sistema Único de Saúde. Contudo, ao longo dos anos observou-se ataques e contrariedades à EPS com a implementação de ações assistemáticas ou fragmentadas, hierarquizadas, focadas na informação (não na ação) e centradas na indução tecnoburocrática das práticas, a recognição. Neste sentido, o presente estudo teve por objetivo explorar, sistematizar e problematizar as características e princípios da EPS, a partir da análise da literatura e, encontros dialógicos com alguns de seus forjadores conceituais. Compreende-se que a EPS é uma aposta na vida, com ações formativas que problematizam os processos de trabalho e articulam ensino e intervenção na realidade, trazendo implicação com os usuários e suas singularidades; sendo este um movimento de resistência à desconstrução da EPS. O resultado foi um ensaio de sistematização das características da EPS, apresentando reflexões para os modos de se produzir gestão, atenção, participação e formação como trabalho vivo na saúde.
Palavras-chave: Sistema Único de Saúde. Educação Permanente em Saúde. Trabalho em Saúde.

Introduction
The challenges for the implementation of the Brazilian Unified Health System (SUS, Sistema Único de Saúde) raised the need for a national policy to qualify health workers, focusing on user-centeredness, and the legal principles of the SUS, and that used daily work as a training space. In 20041, the National Policy for Permanent Education in Health (PNEPS, Política Nacional de Educação Permanente em Saúde) was created and included the defense of life, power relations in care, the democratization of relationships and the recognition of different knowledges. Permanent Education in Health (PEH), a Brazilian formulation based on SUS guidelines, is a tool to produce new ways of thinking and acting in the face of the expanded concept of health and everyday challenges of teamwork, bringing new ways to discuss health and work processes, professional training, sector management and popular participation.
Studies2-6 have portrayed different concepts and actions of PEH, the indiscriminate use of the term and the managers’ and workers’ lack of knowledge about the subject, in addition to the absence of users or social control in PEH actions. In these publications, the predominance of the hegemonic model of education is observed, that is, the recognition named as PEH, which implies substantial losses for training in and through work, if not the total suppression of the purposes proposed in its presentation as a strategic policy. The studies do not problematize the results, they make the disputes and conflicts invisible in the political context of the PNEPS, and its creation within a conception of “deep” implementation of the SUS, as well as of the PEH itself, so that it can expand as a methodological development.
In this sense, in the effort to explore and understand PEH movements in scientific productions, by the time this article was being written, no texts were identified in the literature that systematize, in a single material, the principles and characteristics of PEH, not as a checklist, but problematizing them. Thus, the need and importance of exploring such characteristics and principles became evident, systematizing them and giving visibility to these PEH premises, aiming at strengthening this important tool, as well as encouraging its use in everyday services and in teaching, to enhance living work, always bearing in mind the centrality of workers and users in the entire health care process.
Given this gap in the literature, the aim of this study was to explore, systematize and problematize the characteristics and principles of PEH. More than an academic product, it is a movement of resistance to the deconstruction of PEH and the naturalization of the use of the term PEH in hierarchical training practices, devoid of invention, without the protagonism of workers and without sufficient involvement with users and their singularities and complexities of life, that is, their separation from the deep identification with SUS. By bringing together and debating principles and characteristics of PEH, the text intends to contribute to the recovery of its formulation and to resistance against the deconstruction of its meaning and its power as a tool for the qualification of living work in action in the health context.

Methodological Pathway
The analysis and problematization of the principles and characteristics of PEH were part of the research entitled “Experimentations of Permanent Education in Health – cartography based on the paths taken by managers and health workers in a Brazilian capital”, approved by the Ethics Committee on Research with Human Beings under CAAE approval number 15449419.6.0000.0021.
The study, carried out from 2019 to 2020, analyzed the ways in which some experiences designated as PEH would be aligned with its original principles, and whether they served to value life and people in the work of teams at basic units under the scope of the Family Health Strategy. In this section, information was sought about the principles that characterized PEH actions in various productions such as books, videos and scientific articles, or in the manifestation of opinions published in different sources.
A search was carried out in the literature, in the electronic databases PubMed®, Scientific Electronic Library Online (SciELO), Google Scholar and Virtual Health Library, using the descriptors “permanent health education” AND “public health”; “continuing education” AND “public health” and “permanent education” AND “literature review”, in Portuguese and English, without restrictions on the publication period. The Ministry of Health website was also used for consultation.
The materials with the principles and characteristics of PEH in Brazil that emerged from the searches were predominantly from the journals Interface, Comunicação, Saúde e Educação, Ciência & Saúde Coletiva and Saúde em Redes, in addition to the material related to the EPS em Movimento project8-11. These materials disclosed the names of three authors who were transversally present in most of the texts: Emerson Elias Merhy, Laura Camargo Macruz Feuerwerker and Ricardo Burg Ceccim. These authors were interviewed to promote a reunion with the original ideas that supported the formulation of the Brazilian PEH, sixteen years after the publication of the PNEPS, which would allow visualizing movements, pathways and crossings over time.
Thus, the texts presented in Table 1 were selected to be triggers in the interviews because they address PEH characteristics and explore them together with those who collaborated in its construction.
The interviews with the three authors took place using remote communication technology (Google Meet®), between July and August 2020, and were recorded in audio and video. The observation and listening to the audiovisuals did not seek recurrences or representations. This was not a content analysis, but a shared, rhizomatic production, which was validated by successive revisits by the researchers and interviewees and, thus, the group of authors of this article was constituted.

Results and discussion

What the guide texts tell us
The principles of PEH involve teamwork, service, practice, the field of action, the fact that it can take place in any space and the recognition that everyone “knows” something or something. Thus, the presented characteristics address the understanding of PEH as conception and practice, completely moving away from the idea of education as the reproduction of knowledges. Therefore, the condition of this writing is also to dialogue with these characteristics, seeking a production that makes sense for managers, workers and users. Therefore, what will come is not a state of the art, but the effort to make the principles and characteristics of PEH-SUS visible and sayable.
We understand that, being PEH, the action involves the SUS response to health needs, and the strengthening of embracement and care networks. Among the characteristics, the way of conducting it (or the “method”) involves the actors themselves in the daily work. PEH is a concept-tool for thought, which generates production in action, mobilization, meetings, recognizing that training is also porous to our existence12. PEH is the close relationship between education and work in health in its everyday practices. As an educational orientation, it is based on problematizing teaching and meaningful learning; a strategy of and for SUS in the training of workers and development of work13.
In PEH, the world of work is considered as a “pedagogical environment”, not being characterized only as a formal production space, as opposed to training spaces. The SUS network must be a permanent school, involving training processes10 based on the problematization of reality9,11, survey of prior knowledge7,8 and problems that mobilize different actors, in addition to identifying the needs of workers in their different contexts, in ascending order8.
PEH is not carried out by prescribing refresher courses and programs. It is essential that education processes make sense for workers and users, not just for the management, recognizing that everyone knows, does and governs7,8,10,11, resulting in the collective production of care, stimulating innovative and more democratic practices8. It must be a protected space to give voice, produce sayings, discuss work processes, for collective processing and shared knowledge11, as well as to produce mobilization, questioning, provocation, displacement, deterritorialization10, with the articulation of collectives that give new meaning to the experienced and shared daily life8. It becomes an organized work of reflection and production of alternatives8, transforming the work process into the object of participatory and active reflection by the workers8, porous to reality7,10,11, turning the invisible into the visible10.
It was understood that there is a primary condition for changing practices: discomfort7,8,11. Based on the discomforts experienced in daily work, triggered by the detection and contact with the way of doing things that proves to be insufficient to deal with the challenges, it is possible to develop alternatives and face the challenge of producing transformations, of allowing oneself to be surprised and recognize oneself 11. It is the discomfort that provokes individual and collective protagonism10, opens space for sharing care among workers and between workers and users, new possibilities of relationships, of forwarding9; with the user (and the collective in which they are inserted) and their needs being the focus of the organization of health work, considering them to be the bearer of knowledges and desires9, providing gains in autonomy and life8,11.
The meetings, emerging in these situations of exchange, collaboration, coexistence, provocation, discomfort and possibility of practices, cause new meanings to be incorporated into formulations about work, possibly consisting in the main “method” of this Brazilian formulation of PEH.
Thus, in contact with the protagonist authors in the analyzed bibliography, these characteristics were revisited and updated with the expansion of initial understanding. The bibliographic findings were reviewed through dialogue with these selected authors, who were also able to review the product and share the dissemination of their results. The intention is not to design a standard structure to recognize and implement PEH, but to problematize its power in qualifying the work processes and production of everyday management collectives. It is expected that offering the PEH characteristics in a systematized and problematized way will contribute to the development of training processes in and through work, its core and meaning.

What the guide authors tell us
The characteristics of PEH identified in the publications and problematized with their authors are presented below.

World of work as a pedagogical means
Merhy uses the word “immanence” to say that learning takes place everywhere we live (living and working places are pedagogical environments when we problematize our experience in interaction with others) and uses as a reference the indigenous leader and philosopher Ailton Krenak, who says that life is a school (verbal information). This characteristic speaks of the process of producing knowledge in ways and spaces of living, that is, of our experience in the field, of what calls us to produce knowledge (knowledges and practices). For example, the Nursing Technician sharing the embracement with the Community Health Agent realizes that a warmer embracement of the user, without any hassles, makes them feel safer and more comfortable to talk about what they came to demand from the service, while the Agent learns that the clinical conditions for defining a suspected case of Covid-19 were updated by the Technical Note published on the previous day.
Meaningful learning and production of meanings
Meaningful learning was expanded, reaching a new concept: the production of meanings. Teaching and learning is a mutual affect, which is why it is necessary to affect and let oneself be affected, to learn from the body, from the experience of interactions, in everyday life, in experience. Feuerwerker reports the need to talk about differences in expectations, as the worker tends to place the disease at the center of the user\'s life; in turn, the user wants help so that the problem bothers them as little as possible (verbal information). From (sensitive) listening, understanding the user\'s ways of living, the values and expectations with which they are operating, it becomes more possible to trace paths together, and thus, produce common meanings and the sharing of the therapeutic project. For example, the doctor advises the user with diabetes to make changes to their diet so as not to decompensate their health status, including the indication of times at which to eat. However, the user, a beneficiary of an income cash transfer program, a daily wage worker, is not even able to choose the time or composition of their diet.

Problematization of reality and of the daily work
A frequent term in PEH is problematization, understood by Ceccim as interrogating your knowledges (verbal information). Feuerwerker adds: problematizing is asking questions about what we are doing, feeling and collecting (verbal information).
Problematizing is asking questions to oneself and to others, it is giving visibility to the knowledge that is implicit, appropriated individually, it is a way of making the “penny drop”, it is not an expected fit, it is rather the disconnection to produce other correlations. An example of this is to ask yourself about the construction of the unit and sector agenda. Why is there a themed agenda, with the day of the elderly, pregnant women, hypertensive and diabetic people? Does this thematic agenda meet the needs of my territory or am I just reproducing a model without reflection? It is important to carry out a survey of scheduled and spontaneous demand to plan the agenda during the week.

Consider prior knowledges
This is a characteristic that assumes that everyone “knows” about something and anything in their own way, according to Merhy (verbal information). There is no greater or lesser knowledge, everyone knows something and this recognition is important, from their diversity, their explanatory universes, their intellectual appropriations. It is not possible to problematize without considering that everyone has their own experiences and conceptions, as the questions must come from these experiments in life, from the daily life that produces knowledge.
In the experience of care, it is necessary to consider the knowledge of others. We need this to be transposed to health teams, as they are multiple, broad, from all age groups and from the most diverse cultural backgrounds or origins. For example, considering that the loofah (vegetable) is a plant, a food used to make soup, and regionally appreciated for being delicious and inexpensive.

Ascending process
Merhy points out that being ascending means considering the needs identified by workers and users (verbal information), and not simply placing a management demand from top to bottom, “down the throat” imposition (willingly or unwillingly). The “ascending process” is characteristic of the difference between education emanating “from the office”, such as training and qualifications, and education that “reaches the office”, according to a problematizing reading of needs, listening and monitoring processes, networks of conversation and interlocution.
One example is related to the concept of embracement, an idea launched as a challenge to the integration of teams and dialogue with users in general, and which became a place for risk classification and screening, from a team debate to a model to be replicated.

Shared management
It is the understanding that everyone governs, managers, workers and users, including that it is expected so that problems can be solved, according to Feuerwerker; it is sharing commitments, arrangements, pacts (verbal information). It is the collective production of care through sharing, which encourages the exchange of experiences and opens up possibilities for innovative and more democratic practices. It means being able to define together, as a team and with the participation of the user, what can be done to improve the quality of care and the lines of care.

Participatory and active reflection by workers
The wager expressed here is that the work process belongs to workers, and it is necessary for them to take ownership of it, which is why they must have active and reflective participation in this organization; work capable of caring does not result from simply following a protocol or a guideline. Soft technologies value living work, soft-hard technologies (verbal information) are not enough, as Merhy reaffirms. It is not just about creating a service charter, it is about analyzing “whether” and “how” this charter meets the needs, dialogues with the values and desires of the population in each territory; and it is not just about proposing a thematic agenda if it can\'t dialogue with people\'s health conditions. What can go very well in one place can go very wrong in another, because the economic, social, cultural, political dynamics and people are different.

Protected space
The space, moment, time, condition reserved for giving voice to what is not said, but felt, where/when work processes are shared, discussed and re-discussed and agreements are processed, must be a protected space, whether by having been reserved and respected, whether through freedom of expression, opinion or place of speech, in addition to being part of the very logic of organizing the team\'s work environment. “Protected space” as a characteristic of PEH is a guarantee of freedom in welcoming collectives. It can be about reserving time and place (protected) or it can point out that time and place are protected spaces (a modus operandi) and a condition for building trust to say what one feels and thinks, without reprisals.
The collective processing of practices instead of prescriptions and delegations, meetings as conversation circles and not purely informative ones, demand protected spaces, as can be the various informal times and places, such as tea in the refectory where you talk about a service, the WhatsApp® group where people discuss how to carry out home visits in times of pandemic and the fear of contamination, or even the doubts answered by a colleague about the month\'s report and so on.

Deterritorialization and porosity to others and their issues
One effect of problematization is the production of mobilization, questioning, provocation, disaccommodation, denaturalization, radical loosening of certainties, openness to creation. PEH opens space for creations and inventions. It breaks down barriers, makes people leave the place, provides a look from other perspectives.
Porosity is the sieve, one can flow through it, leak out or stop at its screen, staying inside. Merhy states that in the field of soft, relational care technologies, we must understand that flowing, being porous to reality, is recognizing that we are all affected by different concepts and disputes (verbal information), and that to produce care it is necessary to talk about it, be in people\'s lives, stop trying to govern the lives of others based on our prescriptions.
In a more philosophical language, it is being able to run in the midst of life, being open to new possibilities of caring for others, which are not through our own perspective, our experiences and values, but through dialogue with the experience of others, of whom we are willing to care, and/or who we work with. It is also about recognizing the constitutive differences of each worker, the lives of each one and how all experienced realities impact the way in which we establish relationships between peers and with users.

Sayability and contact with discomfort
Sayability is speaking, seeing, feeling, putting on stage, giving visibility through speech to what is invisible/hidden. Feuerwerker says that it is exposing what is implied, it is interrogating/denying what is naturalized or routine, even without it being written or made explicit (verbal information). It would be worth asking ourselves if we have already reflected on our work, talked about it, questioned it, without becoming trapped in the complaint, because that is where the discomfort comes from, which is that pebble in the shoe that hurts us when we step on it, i.e., that pokes us when we put weight/force/energy on top of it and then we think: “I need to get this stone out of my shoe”.
This is the problem of PEH, the one that leads you to action, that moves you to something. Because it is not enough to remain in thought and reflection, you have to have energy, practice, care, transformation. How often do we organize an entire work process to favor individual comforts, but with less commitment to the user? How many times can we celebrate that the services we provide are original to our team, our territory, our users?

Organized work of reflection and production of alternatives
Feuerwerker says: “to recognize that the health unit is a tower of Babel” because it is inhabited by all multiplicities, and because everyone starts from certain knowledges and wagers that have not been talked about and shared (verbal information). An ongoing educational process recognizes that there are several disputes, which is why it insists that dialogical spaces can coexist with the troubled routine so that the disorganized can be organized and reorganized as many times as necessary, producing alternatives beyond those already available. It is using space to produce outputs and, as much as it may seem disordered, for example a circle with 30 people and several people talking at the same time, the end result can be the joint construction of some work process, and the process itself is a method that addresses this disorder. PEH favors the institution of organized production collectives, and protected time and place favor the emergence of new statements, participatory planning in action, new and sayabilities.

User and collective involvement
If the user is the focus of the health work, one must recognize their knowledges, connection networks and autonomy. We, workers, are there to support them in producing health and not to condition them to our will, as if they had no desires, values, beliefs, their own routine, etc. Therefore, PEH involves sharing care among workers and between workers and users, producing new possibilities for relationships, forwarding, developing protagonism and autonomy in individual and collective life.
This characteristic, therefore, seems to be central to PEH: the user, as the main interested party, cannot be left out of PEH processes; on the contrary, they are the protagonist and main beneficiary of these processes. For Merhy, assuming the user as a guide, as a co-creator produces new meanings, new concepts and practices of care, training and management; promotes user confidence in services, and improves the quality of professional and institutional care (verbal information).
Who are we or how arrogant are we to want to define the path of the users we serve? How can you tell someone else what to do about your life, without establishing with them the knowledge processes, life processes, without knowing their routine, their culture, their environment? It takes bonding, dialogue, recognition of the power of life that is within each person.

Final considerations
The systematization and problematization of the characteristics and principles of PEH show that it emerges as a wager to encourage health work to go beyond the concept of prescribing conducts and the vertical development of protocols. It emerges as a wager to put health work in favor of the production of potential for living, escaping the logic of subordination and subjection. It is necessary to have views, conducts, ways of caring that meet social health needs and favor a health system in embracement and care networks.
Moreover, PEH is a space for dialogue among workers, between workers and managers, between workers, managers and teachers, between all of these and the users of health actions and services. It is a wager that in everyday work, life-producing projects are built in a shared way, including the understanding of care. With this exercise it is possible to recognize a way of training and qualifying in health that goes beyond the classroom, that does not establish a boundary between teaching and service, and that places everyday life as a living, creative, inventive and formative process.
Thus, this article wishes to operate as a device for thoughts and practices that enrich living. It is not expected to be a concept-representation of PEH, but to be useful for workers, managers and users, whose intention is to transform practices, or for teachers and educational institutions whose intention is to transform education and a subjective production of care.
Table 1

References
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