Gustavo Tenório Cunha

Apoio Matricial e Atenção Primária em Saúde

Este artigo apresenta a proposta de apoio matricial e equipe de referencia como recurso para a organizacao do trabalho em saude na Atencao Primaria, objetivando limitar a fragmentacao da atencao, consolidar a responsabilizacao clinica, valorizar o cuidado interdisciplinar e contribuir para a regulacao das redes assistenciais. Esses arranjos objetivam construir, no âmbito gerencial, uma cultura organizacional democratica, e no plano epistemologico um manejo do conhecimento que valorize a singularidade dos casos e possibilite um equilibrio dinâmico entre os saberes dos varios profissionais de uma equipe ou de uma rede assistencial. Discutem-se a experiencia dos Nucleos de Apoio a Saude da Familia e a experiencia pioneira de Campinas-SP, Brasil, em Apoio Matricial.

Medical paradigms and Primary Health Care: surveillance of the population and/or production of life?

Over the past few decades there has been an important debate in Brazil about health care alternatives to the dominance of Hospital Medicine. Discussion around theoretical propositions such as ‘Health Surveillance’, ‘Health Promotion’, ‘Programmatic Actions’, the ‘Project of Life Defense’, ‘Amplified Clinics’ the ‘Micropolitics of Care’, ‘Peripatetic Clinics’, ‘Harm Reduction’ and others1-3 have informed this debate, but perhaps one of the key question can be distilled into the nature and future role of the General Practitioner. The history and place of Hospital Medicine is well-established in the Brazilian Public Health System (SUS) but how does primary health care with its different experts, discourses, technologies and practices integrate with the hospital system to create a universal and comprehensive ‘Web of Health Care’? Are there lessons to be learned from other countries about how to manage this problem of integration? Some Anglo-Saxon countries with universal health care systems, such as the UK, have addressed this problem through providing and supporting a strong primary care sector. However, simply transferring these organizational arrangements to Brazil is unlikely to succeed as there is a very different history and cultural tradition. Yet a number of authors4-7, influenced by post-structuralist thought, have argued that these new forms of health care integration that can be seen in other countries are underpinned by important shifts in the very nature of medical knowledge and clinical practice. Understanding these changes may show the possibilities and limits of health care reform in Brazil. The starting point for many of these analyses is Foucault’s Birth of the Clinic8 in which he described the origins of the system of modern medicine that for more than two centuries is by the sort of clinical activity that occurs in hospitals. In the late 18th century Hospital Medicine emerged as a consequence of the key idea that disease could be localised to an intra-corporal pathological lesion. Previously, disease had roamed through the body and between the body and its environment; these was no specific point at which the disease ‘stopped’, where it could be captured or treated. The idea of a localized pathological lesion, however, meant that it became possible to carry out a clinical examination of the patient’s body to identify the lesion (as well as a post-mortem to confirm that diagnosis). And what better place to conduct this examination than the ‘neutral’ space of the hospital, unencumbered by all the distractions of the patient’s ‘natural’ home. This framework for understanding the nature of disease/illness has dominated health care provision for over two centuries but that does not mean it will continue for centuries to come. As Foucault8 (p. 3) noted: “this order of the solid, visible body is only one way in all likelihood neither the first, nor the most fundamental in which one spatialises disease. There have been, and will be, other distributions of illness”.

Paradigmas médicos e Atenção Primária à Saúde: vigilância da população e/ou produção de vida?

Over the past few decades there has been an important debate in Brazil about health care alternatives to the dominance of Hospital Medicine. Discussion around theoretical propositions such as ‘Health Surveillance’, ‘Health Promotion’, ‘Programmatic Actions’, the ‘Project of Life Defense’, ‘Amplified Clinics’ the ‘Micropolitics of Care’, ‘Peripatetic Clinics’, ‘Harm Reduction’ and others1-3 have informed this debate, but perhaps one of the key question can be distilled into the nature and future role of the General Practitioner. The history and place of Hospital Medicine is well-established in the Brazilian Public Health System (SUS) but how does primary health care with its different experts, discourses, technologies and practices integrate with the hospital system to create a universal and comprehensive ‘Web of Health Care’? Are there lessons to be learned from other countries about how to manage this problem of integration? Some Anglo-Saxon countries with universal health care systems, such as the UK, have addressed this problem through providing and supporting a strong primary care sector. However, simply transferring these organizational arrangements to Brazil is unlikely to succeed as there is a very different history and cultural tradition. Yet a number of authors4-7, influenced by post-structuralist thought, have argued that these new forms of health care integration that can be seen in other countries are underpinned by important shifts in the very nature of medical knowledge and clinical practice. Understanding these changes may show the possibilities and limits of health care reform in Brazil. The starting point for many of these analyses is Foucault’s Birth of the Clinic8 in which he described the origins of the system of modern medicine that for more than two centuries is by the sort of clinical activity that occurs in hospitals. In the late 18th century Hospital Medicine emerged as a consequence of the key idea that disease could be localised to an intra-corporal pathological lesion. Previously, disease had roamed through the body and between the body and its environment; these was no specific point at which the disease ‘stopped’, where it could be captured or treated. The idea of a localized pathological lesion, however, meant that it became possible to carry out a clinical examination of the patient’s body to identify the lesion (as well as a post-mortem to confirm that diagnosis). And what better place to conduct this examination than the ‘neutral’ space of the hospital, unencumbered by all the distractions of the patient’s ‘natural’ home. This framework for understanding the nature of disease/illness has dominated health care provision for over two centuries but that does not mean it will continue for centuries to come. As Foucault8 (p. 3) noted: “this order of the solid, visible body is only one way in all likelihood neither the first, nor the most fundamental in which one spatialises disease. There have been, and will be, other distributions of illness”.

A gestão por meio da avaliação individualizante e competitiva como elemento comum nas políticas públicas e gerenciais contemporâneas: uma contribuição crítica a partir de Michel Foucault

ABSTRACT: This article contains some reflections about the challenges posed to public poli-cies’ management vis-a-vis the hegemony of the managerial logic raised by the neoliberal economic rationality. It examines, in particular, aspects of the strategic role that evaluation is taking on in public policies’ management. The framing in the work processes generated by the contemporary capitalist logic requires new strategies to control production, work and life. From the discussion on ‘the neoliberal art of governing’ proposed by Foucault (2008, 2009), we expect to broaden the debate about this issue through concrete examples in the field of health and in other fields, such as education and scientific production. KEYWORDS: Neoliberalism; government; public policy; evaluation. 1 Universidade Estadual de Campinas (UNICAMP) – Campinas (SP), Brasil. tadeudepaula@gmail.com 2 Doutor em Saude Coletiva pela Universidade Estadual de Campinas (UNICAMP) – Campinas (SP), Brasil. Professor da Universidade Estadual de Campinas (UNICAMP) – Campinas (SP), Brasil.gustavotc9000@gmail.com

The management by means of the individualizing and competitive assessment as a joint element in contemporary public and management policies: a critical contribution from the work of Michel Foucault

ABSTRACT: This article contains some reflections about the challenges posed to public poli-cies’ management vis-a-vis the hegemony of the managerial logic raised by the neoliberal economic rationality. It examines, in particular, aspects of the strategic role that evaluation is taking on in public policies’ management. The framing in the work processes generated by the contemporary capitalist logic requires new strategies to control production, work and life. From the discussion on ‘the neoliberal art of governing’ proposed by Foucault (2008, 2009), we expect to broaden the debate about this issue through concrete examples in the field of health and in other fields, such as education and scientific production. KEYWORDS: Neoliberalism; government; public policy; evaluation. 1 Universidade Estadual de Campinas (UNICAMP) – Campinas (SP), Brasil. tadeudepaula@gmail.com 2 Doutor em Saude Coletiva pela Universidade Estadual de Campinas (UNICAMP) – Campinas (SP), Brasil. Professor da Universidade Estadual de Campinas (UNICAMP) – Campinas (SP), Brasil.gustavotc9000@gmail.com