(Dis) connections between health councils and audit: advancements and challenges in the democratization of public health management

1 Centro Universitário INTA (UNINTA) Sobral (CE), Brasil. 2 Universidade Estadual do Ceará (UECE) Fortaleza (CE), Brasil. 3 Secretaria Municipal de Saúde Cruz (CE), Brasil. Trabalho realizado nas secretarias municipais dos 24 municípios que compõe a Região de Saúde de Sobral (CE), Brasil. Endereço para correspondência: José Reginaldo Pinto – Centro Universitário INTA (UNINTA), Rua Cel. Antonio Rodrigues Magalhães, 359 – Dom Expedito Lopes – CEP: 62050-130 – Sobral (CE), Brasil – Email: regis.med@hotmail.com Financial support: none. Conflict of interests: nothing to declare. Abstract Background: Aware of the importance of consolidating social control in the qualification of the Brazilian government’s Unified Health System (SUS) management, it is important to highlight that the audit must implement technical cooperation actions with the municipal, state and national health councils and with the three management spheres. Objective: Analyze the interaction between the Municipal Health Councils and the SUS audit service. Method: The research, with a qualitative approach, had the participation of 20 municipal health counselors, who worked in the largest health region of Ceará, Brazil, composed of 24 municipalities. The thematic content analysis data were collected using self-administered questionnaire. Results: We observed a weak interaction between the Municipal Health Council and the SUS audit sector in the municipalities. Conclusion: Counselors are unaware of their competencies and the functions of the municipal audit sector.


▄ INTRODUCTION
Brazil went through a long process of social mobilization to construct a democratic model, resulting in the creation of the Brazilian Federal Constitution of 1988, which established a lasting involvement of civil society in the management and control of public policies.The population, through elected representatives, exercises its power through referendums, plebiscites, councils and projects/actions of popular interest 1 .
In the context of public health policies, Law number 8.142, published in 1990, provides the community participation in the management of the Unified Health System (SUS) and the intergovernmental transfer of financial resources in the health area.This law created collegiate instances, Health Conferences and Health Councils, and formalized the public participation in the strategy formulation and in the implementation control of health policy.
The Health Council has a permanent and deliberative nature, and is a collegiate body composed of government representatives, service providers, health professionals and users.It is present in each governmental sphere and works in the corresponding instance, including the economic and financial aspects 2 .
It is noteworthy that the health counselor, a social agent able of interfering into health issues, is the representative of the various social entities with legal support to take action in the Municipal Health Council (MHC), with the aim of performing the social control through the democratization of the public health sector 3 .
The MHC is the highest deliberation authority of the municipal health policy, meeting the parity criterion between service providers, government, health workers and users.Thus, it must carry out its functions properly, aware of the health budget, acting as an agency of transparency and control in the decisions and actions of the public power 4 .
Therefore, MHC needs to interact with the accounts and public health policies auditing.The auditing may be understood as a systematic and independent review of the facts, since it includes the monitoring and measuring of an element or system, in order to observe the requirement adequacy proposed by laws, regulations and planned actions 5,6 .
In Brazil's Unified Health System (SUS), the audit aims to improve access, care integrality, equity, health indicators, humanization of care and inclusion of social control, allowing transparency and ensuring information and accountability to society 5 .It contributes to monitor the implementation of the public health budget, optimizing the service management processes in the country, as well as the development of public policies through the participation of users of the system 4,7 .
The audit includes one of the guidelines for monitoring and assessment of SUS management and was regulated by the National Strategic and Participatory Management Policy (ParticipaSUS), which has four components: OuvidorSUS, SisaudSUS, ParticipanetSUS and SargSUS 5 .
The above normative acts strengthened the relationship between social control and auditing of accounts and public policies 5 .However, these two authorities should routinely interact throughout their work processes.
Aware of the importance of consolidating social control in the qualification of SUS management, it is important to highlight that the audit must implement technical cooperation actions with the municipal, state and national health councils and with the managers, in the three management spheres 8 .In the field of municipal management, information sharing is the main objective of the audit service, in order to contribute to the development of public health management, also resulting in the improvement of the public quality of life 9,10 .
Considering the positive evolution of the social control organization, in the different federal instances of SUS, and recognizing the importance of the association between MHC activities and the municipal audit sector, this research aimed to analyze the interaction between MHC and the SUS audit service in the Municipal Offices in the Health Region of Sobral, Ceará.

▄ METHOD
In order to analyze the main characteristics of the interaction between MHC and the SUS audit services, an exploratory and descriptive research has been chosen, with a qualitative approach conducted in the Health Region (RS) of Sobral, Ceará, selected for having the largest territory in the State and covering 24 municipalities.This study's scenario region gathers a hierarchical and regionalized healthcare network of Brazil's SUS, with installed capacity to perform services in its different levels of complexity, constituted by a population of 613,104 inhabitants, being the second most populous 10,11 .
The participants of this research were 20 municipal health counselors, elected for mandates between 2014 and 2016 in municipalities with a SUS auditing sector in the health region, representing the categories of users and service providers.Counselors representing the government, health workers, substitute members of all categories represented in the MHC were excluded.We also excluded councilors from 06 municipalities that did not present the audit service.
The data collection was conducted in 2015 through a semi-structured and self-administered questionnaire, sent by mail to the MHCs.The themes were: (i) counselors' knowledge about SUS audit service; (ii) joint work between counselors and auditors; (iii) facilities and limits of the working relationship between health councils and SUS auditors; and finally; (iv) counselors' knowledge about the information systems used in the auditing and social control services.
The open questions were analyzed using the analysis technique of thematic content.The answers of each interviewee were transcribed and typed in text format in Microsoft Word software.We conducted a fluctuating reading of the document, and the sentences and paragraphs were grouped into Record Units (UR) dealing with similar topics.The URs were codified into themes, and regrouped into categories or subcategories, due to their similar characteristics 12 .The results were presented by clipping the texts and constructing a figure that explains the relationship between the MHC and the audit service.
In order to ensure the research participants' confidentiality and anonymity and to avoid the identification of the municipalities, the data obtained were coded according to the following nomenclature: Municipality A (MA), Municipality B (MB), Municipality C (MC) and so on.The most representative parts of each category were highlighted in the discussion.
The research was approved by the Research Ethics Committee, under the Opinion number 889,089.The research obeyed the regulatory study's guidelines and norms involving human beings, outlined in Resolution 466/12 of the National Health Council 13 .

▄ RESULTS AND DISCUSSION
The topics and categories constructed in the process of codification and categorization process of qualitative information are discussed below.

Counselors' knowledge about the functioning of the auditing sector in municipalities
I am not aware of the auditing service in my municipality and of the tasks it must perform [...] (MC).

The audit works in demand resolution, such as: complaints, irregularities in verifying facts [...] (MJ).
The participants revealed that they do not have knowledge about the SUS audit competencies in the offices.The service was mistaken with the ombudsman sector or restricted to the control and regulation area.
The Ombudsman Sectors have a different function from municipal auditing because these are bodies that receive citizen users' claims, suggestions, requests, complaints and compliments 14 .The control and regulation sector is one of the management instruments that control the relationship between users and health service providers.This sector is responsible for knowing the demand for health services and providing, in an orderly manner, the available supply in a regionalized and hierarchical way 15 .The control structures the system and the regulation organizes the demand for the services according to the offer.
The audit is an articulated instrument for the health service, and aims at the adequacy and privacy of the data and information coming from the health information systems.Moreover, it monitors and assesses, in accordance with current legislation, at the federal, state and municipal levels, the management performance of public administrators, in order to qualify public management.When requested by a competent authority, or determined by the Eminent State Court of Auditors, the audit sector assesses the non-supported application of resources transferred to municipalities, the occurrence of embezzlement or misuse of money, public assets and values, or even the practice of any illegal, illegitimate or uneconomical act that results in damages to the Treasury 16 .
The audit verifies the processes of work, governance and social control, in an attempt to adapt the health care model to the current legislation in that territory.It becomes especially necessary in national public and universal systems to improve access and reduce costs.
It is important that municipal health counselors participate in the municipal audit sector to strengthen a participatory enterprise and social control, since some of the social functions are oversight and monitoring the application of funds passed to the municipal health departments, as well as the verification of the performance of the management of public health policies.

Joint work between the audit sector and social control
There is no interaction, and I think this audit would be very good to work with the Council, to clarify many things in which that counselors have doubts [...] (MH).

I think it would be very good for the counselors to be closer to the audit, to inform about resources and projects (MF).
Most of the interviewed counselors acknowledge that there is little or no interaction between audit services and MHC, although some participants point out that, sometimes, there is contact at meetings promoted by health offices.
The MHC participation in the management of health services is guaranteed by Law number 8.142/90 but in practice it is incipient, since counselors are not aware of the forms of interaction with the sectors of the municipal health office.
It is important to highlight that in most municipalities the counselors are excluded from the decision-making processes, which causes their alienation in relation to health practice planning activities.It is worth mentioning that the consequence of this, in this reality, is a way of doing management in which decisions are taken in an emergency manner 17 .
The democratization and broadening of participation in the management requires that those agents involved be active in the operation dynamics and appropriate information, means and conditions, in order to effectively constitute themselves as main agents in the decision-making process 18 .
The councils must act in the planning and control of governmental acts, and it is, therefore, essential that the public administration should be accountable for its acts.Thus, they should be aware of public audit services.Within this context, accountability should highlight the government performance and its results, so that they can be assessed and controlled.
In this sense, Federal Law n. 8689/1993 requires that the manager of the Unified Health System, in each sphere of government, report to the Health Council on a quarterly basis.Even if the legislation establishes the obligation of accountability of the government to the councils, there are obstacles to the effective use of instruments as useful tools to the counselors 19 .
In order to ensure the audit engagement in the management improvement, it is necessary to guide the manager regarding the efficient implementation of the health budget, which should reflect improved epidemiological indicators, social welfare, access and humanization of services 20 .
The joint work between the audit service and MHC stimulates in the SUS institutions shares decisions, and facilitates the participation of civil society in the monitoring of the management of public health policies.

The access to information, disseminated in various ways, is what facilitates today [...] (MJ).
It is necessary to exchange more ideas between counselors and auditors, in order to achieve a more productive work, where both could obtain, see and review the manuals and the needs of the assisted population [...] (MA).

A negative aspect is the health counselors' lack of knowledge to hold office. I think there should be more training [...] (MD).
The counselors' lack of participation in the meetings hinders the work process, and impairs the strengthening of social control.This is something that needs to be reviewed [...] (MC).
Access to information on municipal expenditures, disseminated online through health information systems, was pointed out as an advantage to the joint work between MHC and municipal audits.The limits of carrying out social control in conjunction with the audit were: lack of training, lack of participation of council members in meetings, resulting in a lack of commitment to SUS management processes.
It is plausible to consider that the following are limitations imposed to the effectiveness of social control: (i) political interference in the choice of counselors; (ii) neoliberal tendency towards the health policy dismantling conceived for the SUS; (iii) counselors' lack of information; (iv) disarticulation between counselors and their basis; (v) mobilization fragility of the represented entities which, in turn, are reflected in the society demobilization; co-optation of leaders, in exchange for favors; and finally (vi) managers' lack of transparency in the use of resources 21 .
The fragility of the user's participation in the Health Councils, of the simple man who does not have refined knowledge about public health, legislation and management, makes his citizen participation unfeasible as an expert in the problems of his community 22 .Counselors' training and qualification of continues to be one of the bottlenecks for effective participation and, therefore, social control, indispensable for the functioning of SUS 23 .
Dialogue in the area of health councils is essential for building citizen participation, but dialogue can only be leveraged from the perspectives of those involved.When councilors are unaware of their social role, communities lose, because there is a lack of discussions based on the needs of the population, on the capacities of the public service and its workers, as well as on the norms guided by the current legislation 24 .
Counselors' knowledge about the information systems used in the auditing and social control services I am not aware of these systems, nor as they are called by, and I think they are not used [...] (MH).

I am not aware of them; I do not know their name or their use [...] (MI).
There is no communication, and no information systems are presented [...] (MA).

We use SIAB, SIA, SIH, SINAN, SIM and we have a new one, e-SUS, but they are not presented by the audit at our council meetings [...] (MF).
We observed that municipal counselors are not familiar with health information systems, which should be used by this body to monitor the MHC health system performance.This distancing impairs the appraisal process of project implementation, control of health resources and deliberation of public health policies.Within this perspective, the municipal health councils' activities are performed with improvised procedures.We verified, based on the counselors' experiences, that the analyzed municipalities' MHC have not yet appropriated the information and communication technologies, in order to foment their work processes in their cities' strategic and participative management.
In the last decade of SUS construction, health information has presented great evolution, not only in the expansion of the number of information systems and in the improvement of information technology, but also in the development of skills to use these systems, to produce knowledge and act in different circumstances 25 .
Information systems have been considered as a strategic tool to improve the efficiency of public services, producing greater savings for the state, a greater transparency and more quality in meeting the citizens' demands 26 .
States and municipalities need to be partners in considering the former's historic expertise of information technology in relation to the latter.The State has a strategic position in the organization of health management and should therefore provide technical support in assisting the municipal administrative organizations.Thus, the qualification of the social control teams is one of its tasks, through courses, trainings and lectures 27 .
The information access, through online and public domain health information systems, facilitates the development of a partnership between MHC and municipal audits.However, the weak interaction between the MHC and the SUS audit results from the counselors' lack of knowledge about their competencies and the functions of the audit service.
Audit in the SUS needs to be further discussed by health counselors, with the aim of improving the mechanisms for organizing and monitoring public policies.It also adds power to the work of counselor the appropriation of information and communication technologies to promote their work processes in the strategic and participatory management of their municipalities.
Therefore, we recommend the optimization of the permanent education of municipal health counselors, focusing on the knowledge of public health expenses and revenues, as well as on the role of different agents and various institutions involved in the area, and the use of information systems as a tool to improve social control.
The research raised observations and reflections on the effectiveness of the social control exercised in the municipal sector, in the context of a health region.The information found enabled the reduction of gaps in the knowledge of the relationship between these important members of the health system.It is necessary to develop complementary researches, in other contexts and considering the perception of other agents, in order to verify the impact of the joint work between these two sectors.