Atenção básica como eixo estruturante do SUS: quando nossos consensos já não bastam!

Abstract

We wish to thank Ligia Giovanella and Maria Guadalupe Medina for their careful and consistent comments on our article. We see a strong convergence of ideas in the points raised, and if the three texts were "hybridized" they would result in a more powerful article than the original, providing a nearly consensual view of the dilemmas facing basic health care today. Perhaps our main challenge is to "dismantle our consensuses" and raise new problems for discussion. Our research group at Federal University of São Paulo (Unifesp) has endeavored to understand the obstacles for basic health care to approach the ideal projected for it in recent decades. Our point of departure is a series of underlying questions: how does the health workforce translate or "transcreate" the basic health care policy expressed in official documents? 1,2. How do users re-signify basic health care and other services and make use of them? 3,4. Is it possible, considering the actual work conditions and the "real workers" that provide daily care while facing a growing demand, to operate a health care model that aspires to combine treating disease, conducting prevention and health education, "qualified listening", and valorization of subjectivity, all mixed together? The discussants appropriately emphasize the strides and impacts resulting from the expansion of basic health care. This is the starting point for our consensus. However, we reiterate the article's basic question: beyond the shortage of physicians and chronic underfinancing, what other factors impede the consolidation of a powerful basic health care network with case-resolution capacity? Our working hypothesis is that without new subjects, and thus if new perspectives are not incorporated into this debate, we will make little progress. We insist on the need for "new political air", exploring new angles, needs, and desires when reflecting on the necessary steps forward for basic health care. We may need to incorporate "users/utilizers" (an intentional pleonasm) and their potentialities in managing the life and work of health units and in the formal circuits in which they move. And we should keep in mind the transformative/creative (but also conservative) force of health professionals in their daily work. We will only be able to escape the circularity (and repetition) of discussions on basic health care with the real incorporation of new subjects. How can we do this? We agree with Medina when she refers to: "the degree to which the disconnect between formulation and implementation results from the national policy's incapacity to grasp the actual limitations or 'conditions of possibility' of the real world (the municipalities in this case)". For us, the "conditions of possibility of the real world" refer to both the restrictions and the potentialities, creativity, and permanent production of modes of care that result from the encounters

Participação social no contexto da Atenção Primária à Saúde

“…Dessa maneira, constata-se ser possível incorporar os "usuários-usadores" e seu potencial na gestão da vida e do trabalho das unidades de saúde, como proposto por Cecílio e Reis. 12 Os autores alertam para a necessidade de incorporação real de novos sujeitos, visando escapar da circularidade e da repetição nas discussões sobre APS.…”