Community Struggle and The Right to Health: Experiences on The Achievement of The Basic Health Unit in Vista Bela

Introduction: Residential Vista Bela emerged on the outskirts of the city of Londrina with the implementation of one of the largest projects in the Minha Casa Minha Vida Program. At the time of delivery of the properties, the neighborhood was free from any public facilities. The lack of access to the right to the city and other social rights, such as health, is evident as resulting from a bourgeois and capitalist State structure, founded on colonialism.

Objective: Discuss the community struggle for the right to health with the conquest of the Basic Health Unit (UBS) in the Vista Bela territory.

Material and Methods: Qualitative research, carried out through document analysis, field diary and semi-structured interviews with community leaders.

Results: The results point to the importance that social mobilization had in the construction of the UBS in the neighborhood, with this struggle led by women from the community.

Conclusions: The need to strengthen the social control of the Unified Health System (SUS) is evident, since the right to health in Brazil has largely been achieved through the construction of the SUS and its programs in Primary Health Care.

Vista Bela is a peripheral neighborhood in the municipality of Londrina, Paraná, created by the Minha Casa Minha Vida Program (PMCMV) [1]. Inaugurated as the largest development of the program, it had 1,440 apartments of 42 m² and 1,272 semi-detached houses of 35 m² built in 2011 and 2012 [2]. Families were selected based on national and municipal criteria: they should be residents of risky or unhealthy areas or be homeless; have a woman as the head of the family unit or have elderly and/or disabled people in their constitution; and having an income of up to three minimum wages [3]. Regarding the heads of household, 84.8% were female and 50.5% were black [4]. At the time of the delivery of the properties, the neighborhood did not have a school, daycare center, health center, public transportation, leisure spaces, local commerce, etc. [5]. The Basic Health Unit (UBS) was delivered in 2015. Also known as the "health post", it is the gateway to Primary Health Care (PHC). It provides care to the most diverse conditions, regardless of age, in addition to coordinating care [6]. It is characterized by actions of promotion, prevention, diagnosis and treatment, rehabilitation and harm reduction, which can be both individual and collective. The connection with the territory, the bond and the stimulus to popular participation are highlighted [7]. In this context of meeting between the community and the health team, exchanges, experiences, learning and potentialities emerge. Through this research, we sought to rescue part of the process of struggle for the UBS in Vista Bela, emphasizing the agents of change and discussing the importance of social struggles (especially that of women) for the strengthening of social control and, thus, the search for the right to health and the construction of the SUS.

Starting from the premise that science is not neutral, it assumes a partial reading of reality [8]. What are the reasons for the production of certain knowledge? Who does it serve? Who is object and subject? Is lived experience also a source of knowledge? Since both authors and participants actively influence the production of knowledge, it is necessary to present how the author of this text approached the subject of study. A young, white, single, childless woman, living in a middle-class neighborhood, daughter of civil servants, as of March 2020, begins her residency in Family and Community Medicine. The challenges of working in the SUS, already great, multiply with the coronavirus pandemic. Meanwhile, the UBS team approaches community leaders in the neighborhood to learn more about their actions, as well as to develop strategies to combat the virus through health prevention and popular education. In the interweaving of the conviviality and exchange, a relationship of companionship and care took place between the author and some women, with the sharing of many of their stories. This research has a qualitative, descriptive and exploratory character. The material was collected between 2020 and 2023, from official documents, journalistic materials, records on digital platforms, the researcher's field diary and semi-structured interviews with community leaders. The interviewees were chosen for their protagonist in the studied process and their bond with the researcher. The meetings, held between November 2021 and January 2022, were recorded and transcribed in full. To preserve the identity of the participants, here they were called by fictitious names, black Brazilian women who marked history: Benedita, Lélia and Marielle. The data analysis was carried out based on materialist dialectics and decolonial feminism. The materialist dialectic understands that every social phenomenon studied, inscribed in capitalist society, must be understood in its multiple causality and functionality, as well as a product of human practice throughout history and of the structuring reality of the class struggle [9]. Decolonial feminism, on the other hand, offers a perspective of complex analysis of race, gender, sexuality, class, and geopolitics. It is understood that there has been a transition from modern colonialism to global coloniality, since the international division of labor between centers and peripheries, the ethnic-racial hierarchy of populations, and patriarchal gender inequalities persist. A methodology from this perspective legitimizes collective and community processes as a scientific and technological legacy, in the search for social improvements and transformations, articulating training, organization and struggle [10]. The project of this study was approved by the Ethics Committee on Research Involving Human Beings of the Irmandade da Vista Bela with the Certificate of Presentation for Ethical Appreciation (CAAE) No. 26756719.2.0000.0099. of 25 August 2020. It is part of the Research Project "Insertion of the Family and Community Medicine Residency in the Vista Bela Health Care Network". 

The dialogue between the analyzed materials and the theoretical frameworks enabled discussions on several thematic axes, which we will discuss below.

Periphery: gender, race, and class

Regarding the interviewees, Benedita considers herself a black woman, is single, studied up to the fourth year of elementary school, has a child, is an Adventist and a member of the Casa de Esperança Social Project. Lélia also considers herself a black woman, single, has completed high school, has three children, is evangelical, is a civil servant and is a member of the Vista Bela Residents' Association. Marielle considers herself black, married, mother of five children, incomplete high school, evangelical and member of the Amvibe Collective. She says that social engagement began through rap in the 1990s, and that she improved her political knowledge in a course she took on citizenship in 2003 at the State University of Londrina. United throughout the process of formation of the territory, which includes the community struggle, the interviewees have characteristics that make them unique as subjects, but many others that make them similar. The three represent the predominant profile of Vista Bela's female heads of household: black working-class women and single mothers. Subjects who soon realized the inequalities to which they were exposed. Among the primary difficulties in the formation of the neighborhood, the main ones were related to urban mobility, daycare centers and schools, children's nutrition and health care. Permeating the reports is also the theme of urban violence that arrived in the neighborhood due to the presence of drug trafficking and police repression in the first year of the project. "Frames", harassments, shootings and murders, concrete violence that affected thousands of families. In Brazil, the areas deprived of essential services continue to be the peripheries, as if people did not exist in these spaces, despite being immensely inhabited. The value of the individual depends on his or her place in the city, having more or less access to the broad urban network of services, both public and private, contrasting extreme unequal realities [11]. The places of living in the cities, in relation to work, housing and social relations, are not the same for blacks and whites. The separation is wide open, even if myths such as racial democracy try to show that the opportunities are the same [12]. The map of the city of Londrina itself shows the highest concentration of black people in the peripheral and poorest regions of the city, neglected in investment, marked by infrastructure problems and lack of access to rights [13]. The families destined for Vista Bela came from more than 150 neighborhoods in all five regions of the city [4]. Migration forced to Vista Bela brought families with different origins, cultures, histories and experiences to the same territory [14]. In the peripheral territories of the cities, largely occupied by the black and brown population, it is black women who face the greatest vulnerabilities. According to the Black Women Dossier, it is this group that has the lowest average monthly income, the highest unemployment rate and informal services, and is more exposed to domestic services and other services characterized by the sexual division of labor, poorly paid or unpaid. In other words, it is essential to recognize that black women suffer double discrimination, configuring the base of the pyramid in social hierarchies [15]. In conclusion, in the case of Vista Bela, it is possible to note the emergence of a territory from the forced migration of a large number of families, most of them headed by low-income black women, relocated according to a state housing program.  in a peripheral area and without basic urban equipment and services for access to the right to the city and other social rights.

Right to health: Unified Health System under construction

Like the set of social rights, the right to health appears in the 1988 Constitution and, later, in the Organic Health Law No. 8,080/90 [16]. The SUS is the Brazilian public health system conquered by social and political struggles, with an important role played by the Brazilian Health Reform Movement and the Popular Health Movement between the 1970s and 1980s. These movements had the participation of health professionals, students, religious and community leaders, among others, aiming to improve the health of the Brazilian people and advocating that access to services be universal, against the logic of commodification of health [17]. In addition, the Brazilian Health Reform Movement was based on the concept of social determination of the health-disease process, a perspective that is no longer Eurocentric, but Latin American. The health-disease binomial is understood as a process determined in a socioeconomic structure, namely, capitalism, with exploitation and oppression being sickening mechanisms in their sociability. This way of seeing health believes in the radical transformation of the current model as essential to guarantee a healthier life for the population [18]. The 8th National Health Conference, with the presence of more than 4 thousand people, was decisive in the construction of the SUS, the result of mobilization in municipal and state conferences [19]. Its final report pointed to redefinitions of the concept of health and to the reform of the public health system and its financing. In order to make the right to health concrete, the SUS assumes the doctrinal principles of universality, equity and comprehensiveness, guided by decentralization, hierarchization, regionalization and social participation [16]. In a little more than 30 years of SUS, it is possible to follow advances such as the capillarization of the Family Health Strategy (ESF) teams and other services of excellence such as the Mobile Emergency Care System (SAMU), the blood products and organ transplantation program, immunization, and assistance to the population living with the human immunodeficiency virus (HIV/AIDS). However, there are also setbacks, as a result of neoliberalism, which leads to the precariousness of public services and has hindered the construction of social policies. And it is in the territory that citizenship takes place, that changes in the management and use of the territory take place, that it is possible to achieve social justice and freedom. The territory is not only a sum of objects with which the residents work, circulate and live, but is also built on the basis of language, communion and solidarity [11]. Thinking about the relationship between the SUS and the territories, the role of the FHS in the context of PHC and the Local Health Councils (CLS) can be highlighted. The first, composed of teams of doctors, nurses, dentists and community health agents spread throughout the country, in cities, in the countryside, in forests, etc., has gained intense capillarity in recent decades [7]. It was a strategic leap in the reorganization of the Brazilian public health system, allowing the theme of the territory to expand beyond an administrative resource (geographical division). becoming essential in health work and with great potential for approximation and integration with the community. Some examples of the attributions of FHS workers are: territorialization and mapping of the area of operation, recognition of populations exposed to greater vulnerability, home care, health actions according to local needs, therapeutic groups, health education, and promotion of community mobilization and participation, seeking to effect social control [7]. UBS teams play a fundamental role in fostering social participation, Because, once linked to the community, they are able to identify the main health problems and also the material reality, providing the planning of joint actions. One of the possibilities is through the creation of a CLS, an experience presents in some Brazilian municipalities. The Health Councils are spaces for popular participation and social control with the aim of democratically realizing the right to health through the implementation and regulation of public policies. They were created by Law No. 8,080/90 and Law No. 8,142/90, with federal, state, municipal and local councils. They are permanent collegiate bodies and spaces that allow dialogue between users, workers, managers, and service providers [20]. There are many challenges in transposing, from paper to practice, both PHC guidelines and social control. With regard to the CLS, the obstacles range from little support from the municipal administration to conflicts and power disputes between residents, UBS workers and managers, such as the difficulty in understanding the principles and mechanisms of social participation. However, there are also potentialities, such as the presence of UBS leaders and teams willing to dialogue, experiences of Popular Education and positive results in the collective construction of these spaces [21].

Community Struggle

In the first months of Vista Bela's formation, women heads of household perceived common demands and began to meet to discuss them. According to the interviewees, the first demands were: to bring the government's milk to be delivered to the neighborhood, to build a daycare center and a UBS in the territory. One of the first self-organized groups was the "Time to Live Women's Collective." United by needs, but also by affinities and affections, these women began to meet around the search for better living conditions. This space created a possible environment to validate, welcome and amplify these voices. The group became a reference. It provided support and guidance to women, collected and distributed food, held educational and leisure events, among other actions. In addition, it formed bridges between families and institutional agents, such as the Social Assistance Reference Center (CRAS) and the Guardianship Council. It is possible to understand the emergence of the collective by analyzing the social movements in Latin America and the black feminist movement. A social movement is one that creates identity based on common needs and desires, with political recognition occurring through the process of struggle rather than an identification forged from the top down. In addition, political mobilization is observed, since there is popular demand and organization in order to demand from the State the realization of rights and social mobilization, since it acts for immediate reparation, such as the fight against hunger [22]. The black feminist movement is closely related to a legacy of stories of struggle; the work of mothers, teachers, artists, community leaders; integration between gender, race and class; and the fight against stereotypes of control. It is characterized by the set of experiences and ideas shared by African-American women about society [23]. Although it does not call itself an ethnic movement, it is possible to perceive such characteristics in the women's collective of Vista Bela, as in other Brazilian peripheries. It aims at active and articulated resistance, visibility to projects led by black leaders, the search for human rights and the improvement of community health [24]. From 2014 onwards, another powerful space was the Integrated and Sustainable Territory Development Project. The general objectives of the project were territorial management and governance, job and income generation, environmental management and economic dynamism. Several vocational courses, as well as elementary and secondary education, were offered [25]. According to the interviewees, the project lasted two years and had an impact on the lives of many families, encouraging citizenship. The residents understood the need to draw attention at the municipal level, so that their demands could be met. Some tactics implemented were: direct actions; participation in institutional policy discussions; petitions; and media presence. The group began to occupy the Vista Bela City Council in protest. Some councilors began to listen to them. Little by little, this made it possible for members of the Chamber to move in favor of the cause, especially from the so-called "Lipstick Bench", composed of councilwomen. The Special Commission called "New Life, Beautiful Look" was created. In April 2013, the construction of the health unit was favorably forwarded [26], and its construction were authorized the following year [27]. In order for the community to participate in the decisions, one of the councilors advised the creation of a Local Health Council in Vista Bela. The leaders of the women's collective made the electoral commission possible and made the document calling for the assembly to form the Council. During the assembly, the first slate was elected, with the positions of coordinator, vice-coordinator, secretary, vice-secretary, treasurer, secretary of sports and leisure, secretary of health education, secretary of communication and dissemination. The Council met periodically with the city hall to define issues of the unit's physical space, choice of equipment and team of professionals. One interviewee recalls, for example, when she was able to help choose the high-tech refrigerator, which still stores the vaccines today. The UBS was inaugurated on August 28, 2015. In newspaper articles, it is possible to observe in the front, in the photos, the mayor, health secretary and councilors; the community, in the background. Regarding the community struggle, only one article was found that made the record and showed its importance [28]. The main actions of the first management of the Local Health Council were: monitoring the construction of the UBS; supervision of the work of employees, including employees who were treating patients poorly; regulation of materials and inputs; intermediary between the public service and the community. This history of struggle makes us reflect on the different narratives about what "human rights" are. International declarations in the ninth and twentieth centuries posited that they were universal, but who in fact were the "human rights" who deserved access to dignity beyond white Europeans? We can also understand the construction of human rights as a constant and popular struggle, an African and Latin American struggle, of indigenous and black peoples, of transgender people, dissidents, for whom the right to exist is still denied, even though declarations and treaties have been written [29]. It is women like those of Vista Bela who daily construct the broadest and most real notions of what social rights are. As of 2017, reports point to a weakening of the CLS's performance. It is possible to correlate this fact with the post-coup period and the period of popular demobilization in Brazilian territory. An attempt was made to reorganize the council between 2018 and 2019, by workers and users, but the process was run over by bureaucratic and assistance demands. Soon after came the pandemic of the new coronavirus, which channeled energies into fighting the virus and socioeconomic problems. Among the challenges and needs pointed out by the leaders would be the resumption of the work of the CLS.

Current Challenges and Perspectives

Based on the statements of the interviewees, it was possible to outline some common anxieties. The leaders point to the need for 24-hour health care close to the neighborhood. Regarding the services offered at the UBS, the demand for pediatricians and gynecologists was discussed. A third common issue concerns the difficulty of access to specialty outpatient clinics, given the length of the waiting lists (reaching more than seven years, for example, for orthopedics). Regarding the mobilization of the neighborhood, the leaders point to the potential for growth of women's collectives, the Residents' Association, among other organizations, despite the frustration of witnessing fewer participants than they would like. In addition to praising the community struggle, it is necessary to understand the impact of these battles on the lives and health of these individuals. The leaders had a huge energy demand to swim against the tide, shout about the obvious and fight for the minimum. The process of illness of several women along the way is noticeable. Some participants of the collective left for another neighborhood, leaving the house they had dreamed of. Another relevant point is the inherent difficulty of working women to maintain themselves in political spaces due to the demands of unpaid domestic service and paid external service, in addition to the material reality of often lacking the essentials of life. This article was written based on the Residency Completion Work, released in 2022. Since then, some changes have taken place. There was the resumption of the Local Council, the beginning of the participation of residents in the Council of the Northern Region and in the Municipal Council. There was the participation of leaders in pre-conferences, Municipal, State and National Health Conferences. It is planned to deliver 24-hour service near the neighborhood by 2025. It can be seen in the professional, militant and personal interaction that the leaders also have, today, greater mastery and depth over the SUS and the mechanisms of participation.

The importance of the community struggle, through social and political mobilization in the community of women's collectives, for the achievement of the UBS in Vista Bela is evident, which represents a great step in the realization of the right to health, as provided for in the constitution. The performance of the FHS in the UBS, with the presence of a CLS, is an important milestone in public health policies that are directly related to the territory and that promote equity. Thus, in relation to the permanent search for social justice and rights, it is essential to defend the SUS, to implement social control - with special attention to the Local Health Councils - and to strengthen community and popular movements.

Thanks

I thank the Vista Bela community for all the stories and affections shared, for having greatly impacted my professional training and my life. I cared for and I was cared for. Life only makes sense in the collective.

Conflicts Of Interest

Nothing to declare.