The contribution of CEPEDOC to the development of the Brazilian Health Promotion Policy

The Brazilian Health Promotion Policy (PNPS, for its acronym in Portuguese), institutionalized in the National Public Health System in 2006 and revised in 2014, resulted from the contribution of various groups, including the Centro de Estudos, Pesquisa e Documentação em Cidades Saudáveis (CEPEDOC) [Center for Studies, Research and Documentation on Healthy Cities], a non-governmental organization linked to the School of Public Health of the University of Sao Paulo, and currently designated as a WHO Collaborating Center. This collaboration took place since before the institutionalization of the Policy through the participation in the development of the practical and theoretical bases that justified the existence of the policy and the mobilization and advocacy for its creation. This article aims to demonstrate the independent participation of CEPEDOC, as an NGO, in the construction of the PNPS objectives through its projects, scientific production, participation in events and that contributed to the development of the PNPS as a key policy and practice for the social production of health with equity.


Introduction
The Brazilian Health Promotion Policy (PNPS) was revised and published in 2014, and it states the general objective of promoting equity and improving life status and lifestyles, expanding the potential of individual and population health and reducing vulnerability and risks to health due to social, economic, political, cultural and environmental determinants.It has been implemented to collaborate, now officially, in facing the issue of exclusion, or rather, health inequities in Brazil 1 .
However, plenty of resources are needed to carry out its mission, which surpasses the limits of the National Public Health System (SUS, for its acronym in Portuguese); the need for integration with other public policies and the support of society stand out, since the public health sector is not able to respond alone with actions on social, cultural, economic and environmental health determinants and conditions.A new proposal by the World Health Organization (WHO) in this regard-Health in All Policies-has been discussed since 2013, and adjusted to the needs and possibilities of country members and analyzed by the Collaborating Centers 2,3 .One of the several national and international collaborators is the Center of Studies, Research and Documentation in Health Cities (CEPEDOC), which has played an active role in the revision process of the PNPS.
CEPEDOC was established in the year 2000 and aims to promote the "social production of health" and social equity with other healthcare organizations, by using innovating, participatory strategies capable of fostering citizenship and social participation.
The article presents a historical review of the actions developed by CEPEDOC to demonstrate the participation of an NGO linked to the University of São Paulo (USP), in achieving the goals of the PNPS through projects, scientific publications, participation in events and mobilizations that have contributed to its development as a key policy and practice for the equitable social production of health.

CEPEDOC: establishment and initial projects
In 1984, an interdisciplinary group of professionals devoted to studying public health, urban planning and sustainability were dissatisfied with the vertical and normative approaches that characterized the health sector at that time.They set up a group and organized the Canadian Public Health Association and the event "Frontline Health: beyond health care."The conference was held to evaluate the advances in health of the Canadian population, and set the principles of a new health promotion proposal oriented toward social participation in the decision-making process on health actions, for environmental sustainability and pursuit of equity; the framework of Healthy Cities was also put forward to propose changes in values and strategies, guiding them toward the social production of health and improving in quality of life and urban health 4 .
During the same period, Canadian public health professionals/urban planners involved in the Healthy Cities proposal, were willing to promote it in Canadian and Latin American cities, at times along with the Pan American Health Organization (PAHO), and were joined by some Brazilian cities [5][6][7][8][9] .
The movement was strengthened by the results of the First International Conference on Health Promotion, held in Ottawa, Canada in 1987, which established the conceptual framework of Health Promotion and committed to its implementation beyond the sector, and therefore demanding partnerships with other sectors of the government and of society 10 .
Almost ten years later, in 1995, Brazil -represented by the Conselho Nacional de Secretários Municipais de Saúde (CONASEMS) [National Council of Municipal Health Departments]  gathered at the Conference of Municipal Health Departments for the Americas, in the city of Fortaleza, state of Ceará -wrote the Charter of Fortaleza.This public document stated the interest of the society representing the Municipal Health Departments in the Health Promotion proposals, which shifted the focus of the health system from disease to production of quality of life, giving priority to the active role of social subjects.They considered that health municipalization could be strengthened by the integrating, participatory and creative experience of building Healthy Cities 7 .
Amidst this favorable environment, as of 1997, and with the power of the results of the four International Conferences on Health Promotion 10 , the ideological movement of Health Promotion related to autonomy, emancipation and intersectoral public policies gained strength.This fact enabled Brazilian public health professors, scholars and professionals to establish the "Permanent Workshop of Studies and Programs on Healthy Cities", at School of Public Health of the University of Sao Paulo, where they could present and discuss their ongoing experiences.This forum worked until the year 2000 promoting discussions to define a theoretical framework to guide the Brazilian Healthy Cities proposal.
The action was twofold: 1)

CEPEDOC and the Brazilian health promotion policy
The founding partners of CEPEDOC built a history based on experiences of the Health Cities strategy.As an NGO, CEPEDOC was free to consolidate the partnership with the Ministry of Health, with the regional PAHO office and with other Brazilian organizations also involved in organizing Health Promotion in Brazil.
The first project of Healthy Cities, carried out in Bertioga, a seaside city of the State of São Paulo, had financial support from PAHO and the Ministry of Health for its development, and from the Sao Paulo Research Foundation (FAPESP) to test the participatory evaluation model 13 .
In 2002, at the end of the government term at all levels, CEPEDOC, with the support of the Ministry of Health, PAHO, and active professionals from the entire continent, held the 6 th Latin American Conference on Health Promotion of the International Union for Health Promotion (IUHPE).In this event, Health Promotion assumptions were discussed, under the emancipatory perspective to foster social equity, and supported by the framework of the social determinants of health 14 .
The first proposal for the Brazilian Health Promotion Policy was included in the discussions, but it was ruled out due to change in government.The First Seminar on "Violence and Children" was also held, with CEPEDOC at the leadership of a movement for autonomy of subjects -in this case, children.Several partners collaborated to the seminar, which had the merit of defining Violence in Brazil as a social epidemics.It influenced the Ministry of Health to plan control actions and later include the theme on documents and actions that guided the future Brazilian Health Promotion Policy 14 .
The project Bertioga Healthy City and the Conference and the Seminar, established the beginning of CEPEDOC´s path and helped to strengthen a national group to face the pressures that the health promotion field was experiencing by its inclusion in the Executive Secretariat of the Ministry of Health.In 2002, several partners, including CEPEDOC, organized the First Brazilian Seminar on Evaluation of Health Promotion Effectiveness, sponsored by Abrasco, ENSP/Fiocruz, PAHO Regional Office and the Brazilian Subregion Workshop of the International Union for Health Promotion.These organizations were at that time very much involved in the evaluation of Health Promotion effectiveness, which is an important tool to legitimate its innovating and expanded approach of quality-of-life related issues.The Seminar was held in May 2003 and was attended by international partners, adding value to the interdisciplinary, intersectoral vision of Health Promotion and the ability of the technicians of the field to foster the democratic and participatory dialogue among several forces -Universities, NGOS and Ministry of Healthinvolved in the critical reflection on the scenario and economic, cultural and environmental determinants of quality of life 15 .
The empowered field reinitiated the process for preparing the PNPS, which was concluded in The ideas driving actions were related to the assumption that improvement in health status and quality of life in a territory goes beyond curing diseases, and requires action on the social conditions that determine health, and on enforcing a new governing order in the city with a goal toward local development with equity.The mayor as a social manager would be the political player conducting the development of public policies in the city, capable of changing the quality of life of the population, promoting what is to be done through intersectoral actions and having the civil society as the main player of equity actions.
The actions in these municipalities represented a major effort of technicians and of the population.There was progress in theories, concepts and strategies, but the experience did not survive the 2005 change in government, and the end of funding.The transformation of players and their empowerment were a major result.There was not enough time for the project to establish a new form of management or for the autonomy of local societies to occur.The idea of building a network of cities was hindered by the long distances among the participating cities.Still, it was a positive and empowering experience for CEPEDOC and its researchers, and a boost for strategies to implement the PNPS, highlighting the strength of the social determination of health and in contrast to the strategies of Health Promotion that only values the adoption of healthy lifestyles.
PNPS' specific action of sustainable development continued in another project with the subdistrict of Capela do Socorro, in the City of São Paulo, which was beginning a project called "Healthy Capela" in its territory.Planning actions and the dynamics of the steering group of the Project, and the final participation evaluation were registered in a book funded by the São Paulo Research Foundation (FAPESP).The evaluation technique called "experience systematization" was included in an international book on evaluation, and in another publication of the National Council of Health Departments (CONASS) [19][20][21] .At the end of the term-in-office, in 2005, even with the change in the subdistrict´s administration, the proposal continued with another name -"Capela in action and the integrated and participatory management of public policies"-still funded by FAPESP.The aim was to evaluate the management model of the subdistrict of Capela do Socorro, located in the southern region of the city of São Paulo.Along with the local management team, a conceptual and operational model of the experience was built and participatory evaluations were carried out.Moreover, the leadership network -groups, movements and organizations working in part of the subdistrict territory -was identified, the relations established and how much they favored actions to improve quality of life in the region were analyzed.It was another great learning experience, on the management scenario and on the possibility to sustain counter hegemonic projects in municipal spaces.It enabled better understanding of the internal dynamics of municipal policy, of partisan management and of the interests that motivate it.Thus, it continued to influence the direction of PNPS and its priority projects, advocating sustainable development to become an important aspect of intersectoral management in a territory 21,22 .
The area of the PNPS in which CEPEDOC collaborated directly at first was prevention of violence and fostering a culture of peace; the themes were the foundation for another regional Seminar on Violence and Youth.The event gathered intellectuals and representatives of movements and of the society in general, and resulted in a book that enabled the general public to acknowledge the statistics that defined the severity of the problem and consequent social and political topics.The strategies to act upon the problem were discussed again and expanded, directing them toward those ideas related to restorative Justice and conflict mediation 23 .
The objective of the PNPS of "promoting sustainable development" received another kind of support from CEPEDOC, from the coordination of a group appointed by the Ministry of Health to set up a National Network of Healthy Cities.The document developed a proposal to strengthen this specific objective of the Policy, but again the efforts did not result in tangible actions 20 .

The challenge of assessing health promotion effectiveness
The opportunities for CEPEDOC to contribute to the progress and consolidation of the PNPS were in playing a role to carry out and organize counter-hegemonic experiences at sites that were near each other, albeit distant in terms of the theoretical reference orienting proposals.Such was the case of projects conducted by the City Administration of São Paulo and, later, by the State Health Department of São Paulo.This was the PNPS itself and its actual implementation, exactly at sites near CEPEDOC head quarters.There were two projects: evaluation of Health Promotion at the City Administration of São Paulo, which aimed to collaborate in training and evaluation of Health Promotion proposals for the city, focusing on Non-communicable Diseases (NCDs).The other multicenter project was designed to evaluate actions developed by the social agendas under operation in different regions of the country, using the Millennium Develop-ment Goals (MDGs) as indicators, and with the participation of universities of all regions of the country.
The project with the City Administration of São Paulo was challenging.The team responsible for the control of NCDs chose two approaches for training in Health Promotion: primary care unit professionals and other individuals who provided services related to violence control.The participating planning -NCDs team and CEPE-DOC team -concentrated on building an agenda; at phase 1, preparing a theoretical and practical course on Health Promotion, and at phase 2, monitoring the preparation of Health Promotion evaluation projects.A final evaluation showed that the professionals of the Municipal Health Department began a new discourse in relation to Health Promotion, closer to the foundations proposed by the PNPS in effect, and attained the theoretical and practical tools to perform activities aiming at the social determinants of health.They also were involved in activities related to the social production of health policies in actions of physical activity and on the social determinants of domestic violence and environment-related problems 24 .
The results of the multicenter project Health and local development: analysis of progress regarding the health-related millennium development goals, in Brazilian cities undertaking social agendas, in which seven universities of all regions of the country participated, showed that some agendas, such as Healthy Cities and Agenda 21 have been developed in the country in the past 20 years, mainly in the South and Southeast region, with an impact on the living and health conditions of Brazilian cities.The creation of a network of universities that work in Health Promotion, the techniques to evaluate effectiveness and the use of indicators were the highlights of this initiative, which privileged the social determinants of health and used the MDGs indicators that Brazil and the United Nations agreed upon.Part of the results can be found in articles published on the study 25 .
Another important project was Evaluation and monitoring of Green and Healthy Environments Project(PAVS): building integrated public policies in the city of São Paulo, developed  between 2005 and 2008, and since its conception characterized as an intersectoral action.It was developed throughout the city of São Paulo through a process of training and qualifying roughly six thousand outreach health agents and social protection agents linked respectively to the Municipal Health Department and to the Social Development and Care Department.Seven CEPEDOC researchers had the role of monitoring and evaluating the PAVS in the city of São Paulo, in real time and in a participatory fashion.Very positive results were attained, because when outreach agents received ongoing feedbacks on activities performed, they felt valued and encouraged.It was an important opportunity to produce knowledge about effectiveness assessment.
CEPEDOC has recently developed projects aimed at social inclusion, and experiences with evaluation models and methods, building knowledge and carrying out experiences in the "Building Health Promotion support environments" strategy, to promote peace and non-violence, as a strategic contribution to PNPS.An example was the partnership with the Osasco City Administration, in the State of São Paulo, with the purpose of responding to a request from the employees involved in Social Projects to evaluate their actions 26 .In a second phase, there was a response to an initiative of the Ministry of Justice that launched an initiative for cities to present project proposals to educate youth in vulnerable areas.Approximately 400 young individuals, aged 15-years, participated in three weekly meetings with educators, from February 2009 to January 2010.They were encouraged to develop critical thinking, self-esteem and autonomy.Using different languages, such as theatre, video, literature and music, among others, the group discussed some themes regarding citizenship, including identity, diversity, tolerance and solidarity, rights, culture and history, social movements, health and violence.They also had Information Technology classes, and as encouragement received a monthly scholarship.As their project conclusion work, they developed a social survey in their own neighborhoods on topics like alcohol abuse, drug abuse and adolescent pregnancy, in which they were able to develop a critical and investigational vision on the problems of their communities.Thirteen CEPEDOC educators and three coordinators took part in the project 27  A new project to evaluate the effectiveness of exercise, headed by the same DVDCNT, is under development.It is an evaluation of the Health Academy Program in the state of São Paulo, based on health promotion.Launched countrywide by the Brazilian Ministry of Health, the goal of the Health Academy Programs to contribute to health promotion and producing care and healthy lifestyles for the population.It is an action carried out in the country to complement integral care and to boost health promotion actions, linked to Family Health Strategies (ESF), to Family Health Support Centers (NASF) and to health surveillance (especially related to chronic NCDs).From a wider perspective, the implementation of Health Academies in the territories presupposes linking strategies and policies of the Brazilian Public Health System with health promotion and PNPS guidelines and assumptions.The evaluation process in Health Promotion, ongoing since July 2015, proposes to evaluate health promotion committed to decision making and to the transformation of scenarios, making the evaluation process itself an opportunity for collective learning in Health Promotion strategies.
Monitoring the Health Academy program takes for granted an interesting challenge to guarantee that its poles become ample spaces for health promotion and profit from the experiences accumulated so as to, in addition to its activity axes, generally respond to the following PNPS priority theme areas: healthy eating, body practices/exercise; smoking prevention and control, reduction in morbidity and mortality due to alcohol or other drug abuse, reduction of morbidity and mortality due to road accidents, violence prevention and culture of peace.At this time, CEPEDOC, with its experience and accumulated theory, free to develop projects that did not seem to link to the priorities of the Ministry of Health and with policy implementation, is capable of coming closer to the "healthy lifestyles" theme without the risk of interfering in subjects' autonomy, denouncing the constant naturalization of the issue of domination and submission, fostering, along with promoting healthy behaviors, reflection on the unfair conditions that allow poverty and violence to persist, preparing health sector employees to identify alienation and conformism with inequalities, sensed as natural or normal.
The appointment of CEPEDOC as a World Health Organization Collaborating Center, in 2008, at a stage of greater intellectual maturity and practice, represented an opportunity to develop new proposals and to project CEPEDOC in the international arena through collaborative projects with other countries, especially in Latin America and the Caribbean.Space was opened for a Latin America NGO to participate in the implementation of projects and policies that support participatory processes in the Region and in wider horizons, by establishing new partnerships and spreading the advantages of having a PNSP, whose activities result in improving health status of the communities in their territories.
The first Project performed under a Letter of Agreement with PAHO was named Popular health care practices in communities and was a qualitative study that the Ministry of Health, Strategic and Participative Management Department (SGEP) was interested in.The objective was to organize information, knowledge and the models of intervention necessary to face health inequities, at the national level, that affect communities of Candomblé religion yards, focused on popular care practices and their interfaces with the healthcare system.The project ran between 2013 and 2015.The study results have not been published yet, but are already being used as drivers of discussions on social equity, especially those related to race and religion.
Another initiative of the WHO Collaborating Center is the international cooperation project between CEPEDOC, the Pan American Health Organization and the Colombian Ministry of Health and Social Protection (MSPS), initiated in November 2015.Three Letters of Agreement were signed by the organizations aiming to prepare or update national guidelines on three priority themes: Healthy Cities, Healthy Surroundings and Exercise.The three projects comprising the initiative are solidly anchored on the assumptions of the health promotion reference in respect to the development of healthy environments, oriented toward thinking over the construction of physical and social spaces that enable quality of life.PAHO and the MSPS are concerned about analyses of the proposals and opportunities to promote public healthy and intersectoral policies, which are tuned with CEPEDOC proposal and the revised PNPS assumptions.

Discussion
Given CEPEDOC is an NGO, it has always acted with freedom to choose projects, giving priority to actions that pursue the development of subjects' autonomy and social equity.Both are very necessary to attain quality of life, from the process subjects' perspective, and from the Healthy Cities set of ideas oriented toward social production of health and improvement in the quality of life and of urban health 4 .Funding and advancement of a more democratic proposal, concerned with empowering subjects to be capable of mobilization to demand actions on the social determinants of health represented a major difficulty, albeit in theory aligned to the Policy.
In 2011, when called upon to evaluate the PNPS for its revision, the CEPEDOC official representative verified the proposals of the Ministry of Health and stated that many Health Promotion principles, especially intersectoral aspect, had been developed through local programs on exercise, nutrition and violence control, as were financed by the Ministry of Health.However, the issues of participation as well as development of subjects´ autonomy were not emphasized very much, which suggested the PNPS was being implemented with a more behavioral appeal, without much creativity and mobilization of local players who repeated what they had always done.The analysis of the territory related to territorial materiality in its multiple dimensions, to relations of power, to the bases of the economic production, to relations that consider symbolic issues, to social relations and to building subjectivity and personal identity has not been the object of projects developed as a function of the PNPS.Moreover, the application of this concept in facing health issues, along with the concept of social vulnerability that yields social-spatial inequalities, environmental degradation and environmental injustice, have been applied even less.The conception of territory applied to health promotion in Brazilian cities, would allow visualizing the fragmentation, the loss of identity and the acknowledgement of place by people, issues that need to be recovered and faced in the coming projects to be funded as a function of PNPS.These concepts are always included in CEPEDOC projects, but had not been tried in projects selected to be supported by the Ministry of Health in several national sites.This fact demonstrates that CEPEDOC fails in its partnerships with this organization, not demanding space for exchang-ing experiences and reference points regarding the PNPS, to face the normative culture still very much present in the implementation of the policy.Throughout CEPEDOC history, its managers created mechanisms to promote joint action between public authorities and civil society organizations, and between cities and the Ministry of Health, but it has always faced major resistances to come into effect.
The only alternative known to expand the movement was an invitation, made in 2006, by CEPEDOC to seven Brazilian universities located in the five regions of the country, and engaged in Health Promotion, to answer to the initiative MCT-CNPQ/MS-SCT-DECIT, in support to the Social Determinants of Health.Then, the multicenter project already mentioned "Health and local development: analysis of progress regarding the health-related millennium development goals, in Brazilian cities undertaking social agendas" was conducted.According to Zioni and Westphal 29 , the universities could together feel like living in a society that asks itself about its objectives, that prepares a new representation of itself, that pursues new discourses on man/society, man/ nature, health/society relations.The agendas, as well as other Healthy Cities projects developed by CEPEDOC, are actual experiences and present themselves as space for building citizenship and their grassroots, since they enable several subjects and social players to express themselves and participate in its construction by setting the action agenda for local authorities, with the prospect of an associative democracy that mobilizes groups and collectivities to participate in and integrate actions.
The issue of setting up intersectoral networks is another major challenge for implementing the PNPS, and CEPEDOC did not progress very much in this aspect.The last joint attempt of the National Centers dedicated to Health Promotion, to set up a Healthy Cities Network Forum required major development work, and the event was not held.Thus the current hope of changing the way to apply Health Promotion references in the national territory faded.Today CEPEDOC is directing efforts towards understanding how the new WHO proposal "Health in All Policies" 3 aligns to theoretical assumptions and principles of health promotion to set up intersectoral networks.
The revision of the PNPS was another activity in which the leaderships of this Center participated, performing a survey with professors of other universities engaged in Health Promotion actions.Changes in objectives and actions proposed and other suggestions were appointed using the Delphi method.They were also virtually inserted in general discussions and in the formulation of the new PNPS, bringing excellent contributions.

Conclusions
CEPEDOC is one of the first Brazilian NGOs dedicated to Health Promotion, and throughout its 15 years of existence, has always been concerned with the Health Promotion set of ideas and the values and principles defended since the Charter of Ottawa.It has made an effort to be a constant partner of the Ministry of Health and of PAHO/WHO.The organization developed several projects with different characteristics and changed its initial profile with time, considering the experiences undertaken and supported by specialized literature.
The present brief presentation of its initiatives shows that both the contradictions and the agreements generated satisfactory results, and during the paradigm transition, there were also distortions.It is worth underscoring that the projects developed most of the time did not represent choices of the Ministry of Health, but were always aligned to the explicit reference and to the objectives of PNPS.Hope now concentrates on the possible effects that the International Conference to be held in Curitiba, in May 2016, may bring toward a fundamental change in the background of Health Promotion practices that this revised policy should implement.
The struggle for hegemony does not stop and CEPEDOC, committed to counter hegemony continues fighting, along with other NGOs, universities and other organizations, for more space to develop new ideas using Health Promotion reference points.

Collaborations
MF Westphal led the writing of the manuscript and MCT Franceschini contributed to its content and both worked in the general review of the labor.
2005, and officially approved in 2006.At this point in time Health Promotion had already mi-grated to the Health Surveillance Department.In order to operate the cross-sectional aspect of the PNPS at SUS and develop mechanisms of co-accountability and co-management, the Ministry of Health established the PNPS Management Committee, in 2005, involving representatives from different areas of the Ministry of Health (Health Surveillance Department; Health Care Department; Strategic and Participatory Management Department; Health Education and Work Management Department; Science, Technology and Strategic Input Department; Executive Department and INCA).The committee had the task of proposing the policy and consolidating the National Health Promotion Agenda.Afterwards, representatives of the National Council of Health Departments (CON-ASS), the National Council of Municipal Health Departments (CONASEMS),and the Brazilian Collective Health Association (Abrasco) joined the group16  .Hence, the cross-sectional aspect of Health Promotion in Policy management was guaranteed; in its implementation, specific actions related to food, exercise, smoking and violence were given priority.However, sustainable development is associated to social determinants of health, social participation and autonomy of subjects, which are aspects related to CEPEDOC mission 11 , and were drawn down.The Health Promotion professionals of this NGO kept a simultaneously close and distant standing on this change in Health Promotion paradigm, as a field of knowledge and practices.Paradigmatic tension was managed by engaging the organization in other projects related to the development of the Healthy Cities strategy, always seeking an association with the Ministry of Health and PAHO.The project "Expansion of Health Cities in the State of São Paulo" was funded by the Ministry of Health, during the 1998 to 2002 government, and carried out between March 2003 and December 2005.It comprised the cities of Bertioga, Lins, Motuca, Itaóca and Ribeira17,18  .The social production of health was expected by an ethical and technical action in agreement with the municipal governments of the five cities.
. More recently, some projects have been developed along with the State Health Department of São Paulo, Chronic Non-communicable Diseases Division (DVDCNT) of the Epidemiological Surveillance Center (CVE), of the Disease Control Coordination (CCD) [acronyms in Portuguese].The first effort was a Project Assessment Training, in a course held in 2013, for representatives of the DVDCNT.A total of 28 Epidemiological Surveillance Groups (GVE, acronym in Portuguese) and 17 Health Regions Offices of the State of São Paulo took part.A book was published, funded by the State Health Department, and describes the relevant contribution to practicing Health Promotion from the standpoint of effectiveness evaluation and of the social determinants of health 28 .