Participatory construction of the State Health Promotion Policy : a case from Minas Gerais , Brazil

Minas Gerais started the development of the Minas Gerais Health Promotion Policy (POEPS-MG) based on the review of the National Health Promotion Policy (PNPS). This is a case report based on the documentary analysis of the material produced in the 38 workshops with a participation of 1.157 members across the State. The first workshop was intrasectoral and took place at the State Health Secretariat (SDH-MG). The second was an intersectoral workshop with the participation of several State Health Secretariats of Minas Gerais. The final workshop counted on the participation of State Regional Technical References. Another 35 workshops were developed in the 28 State Regional Administrations. Results were systematized and consolidated from the Analytical Matrix used in the PNPS, generating the base document of the POEPS-MG. It is important to highlight that, the specific regional requirements identified during the Policy’s construction process reinforce the enriching moments of developing in an innovative, democratic and participative way actions that may provide some meanings to Health Promotion in the State of Minas Gerais. The State Policy seeks to bring life to the PNPS, adapting it to the reality of the territory and strengthening it with the assurance of budgetary resources.


Introduction
The concept of Health Promotion was established 30 years ago at the First International Conference on Health Promotion in Ottawa in 1986 and has been discussed worldwide since 1,2 .In Brazil, in that same year, at the Eighth National Health Conference, the expanded concept of health was adopted, which seeks to overcome the mere lack of diseases and to approach the Health Promotion concepts, prioritizing life care-focused policies 2 .
Regarding the historical development of Health Promotion in Brazil, the 1986 National Health Conference defined it as the concept that articulates the mobilization of public and private, technical and scientific and sociocultural institutional and community resources for the social production of health in the daily life of the population and that combines actions, developed jointly by different sectors of government and civil society to improve living and health conditions, promoting equity and the development of citizenship 3,4 .Buss and Carvalho 2 also highlights principles and guidelines of the Unified Health System (SUS), defined in the 1988 Federal Constitution, which are focused on Health Promotion and reinforced in 1992 by the establishment of the Family Health Program (PSF) with its multidisciplinary teams.Until 2006, some isolated programs of healthy eating, traffic violence and physical activity stood out as Health Promotion strategy.The preliminary version of the National Health Promotion Policy was elaborated in 2002, but the actual institutionalization of this approach to health occurred only in 2006, establishing, therefore, more robust initiatives 2,[4][5][6][7] aimed at changes in society that directly influence the health situation of the population 8 .
The policy review process attended by the various sectors of society 9 brought broader conceptual and strategic approaches, transcending individual co-responsibility for individual and collective health towards citizenship.With regard to SUS purposes, Health Promotion actions seek to reduce regional gaps and open the possibility of access to these services in a more equitable way 10 .
In order to operationalize the Health Promotion actions, it is necessary to consolidate practices aimed at the individual and the collective, from a multidisciplinary, comprehensive and networked perspective, considering all the needs of the population, under the perspective of public policies 10 .
In the national setting, Health Promotion strategies gained strength in 2014 with the PNPS review, through a participatory and democratic process with the purpose of attuning it to the new health demands and, above all, strengthening Health Promotion as a strategy to promote care, with broad participation of managers, health workers, counselors, representatives of social movements and researchers linked to educational institutions 10 .
In The construction of the State Health Promotion Policy of Minas Gerais (POEPS-MG) was motivated by the implementation of reviewed PNPS actions, aiming at accelerating the introduction of Health Promotion actions into the daily routine of PHC services in Minas Gerais municipalities.In addition to the inductive effect inherent to Public Policies, it provides these professionals continued education practices through dissemination/discussion in the instances of the Unified Health System (SUS).This construction built on internal discussions of the Health Promotion Board when PNPS actions were implemented and with a diagnosis of ongoing health promotion actions, which signaled the need to add state specificities to PNPS, which culminated then with the interest and political decision of strengthening Health Promotion in the SUS-MG.
This work aims to describe this construction process, highlighting the values and principles, the foundations, the operational and cross-sectional strategies and the proposed financing model to support the implementation of the POEPS-MG.

Methodology
In order to substantiate the proposal for the formulation of POEPS-MG, the Theory of Communicative Action, elaborated by Jurgen Habermas, specifically the concept of democracy that it engenders, whose pillar is the praxis of autonomy of those involved was adopted 11 .A brief description of the theory to introduce its main elements starts from the basic concept of communicative action, understood as language-mediated interaction that develops in the context of daily life in which stakeholders agree with each other to coordinate their actions 11,12 .
This communicative practice carries in itself argumentation and unfolds in its reflective form the discourse 12,13 , so that it begins here and now, in the daily context, but can proceed, overcome boundaries, embrace all involved and achieve universality [14][15][16] .In its dialectical relationship with communicative action, discourse is the only place of rational will, since it brings autonomy and universalization 16 ; it transforms social stakeholders into authors 11 ; it articulates micro and macro-space and decompresses life's world: in the words of Habermas "[...] life's world opens up whenever at least two subjects meet and are willing to act cooperatively" 11 .That is exactly why health promotion was thought in an articulated way to the praxis of autonomy 17,18 , and the entire formulation process of the POEPS-MG built through workshops, with broad participation of various social stakeholders and decision-making levels.
The methodology used by this study is case report built from the documentary analysis of the products developed during the elaboration of the State Policy of Minas Gerais.
Thirty-eight workshops were held and organized by the Health Promotion Board of the State Health Secretariat (SES-MG).In all the workshops, themes were selected by participants through the prioritization procedure called Taking Stock, proposed by Fetterman 8 .The methodology used in the workshops proposed the broad participation of individuals and, thus, contributed to a democratic and participatory policy construction movement 8 .
Of these workshops, three were held at the central level, the first was intrasectoral, with professionals from the State Health Secretariat of Minas Gerais (SES-MG).The second was intersectoral, with the participation of Minas Gerais State Secretariats and with the participation of professionals who are Health Promotion techni-cal references at the State Regional Administrations.Health managers and workers, representatives of the Municipal Health Secretariats Council of Minas Gerais (COSEMS-MG), the School of Public Health of the State of Minas Gerais (ESP-MG), the Federal University of Minas Gerais (UFMG), as well as professionals from other State Secretariats and institutions with an interface with Health Promotion, as per Chart 1.
The other 35 workshops took place in the 27 Regional Health Administrations and counted on the representation of 508 municipalities (61.80% of the total of the municipalities of the State) and the participation of 966 professionals.These workshops were distributed across the State and regionalization was set forth in the Regionalization Master Plan (PDR) as a guiding process 19 , as per Chart 1.
Products obtained in the 38 workshops were systemized as shown in Chart 1 using the matrix developed in the 2014 PNPS review and adapted to the state reality, entitled "Matrix of connection between the components of the National Health Promotion Policy, Brazil, 2014", described in a 2014 study by Rocha et al. 9 .After the systematization, the POEPS-MG Minutes were jointly drafted by the POEPS-MG Working Group (GT-POEPS-MG) in face-to-face meetings on January 27-28 and February 03-04, 2016.

Results
The products obtained after systematization of all the workshops through the elaboration of an analytical matrix assisted in the construction of the Minutes of the POEPS-MG, which were later submitted to deliberative bodies such as the State Health Council and the Bipartite Interagency Committee (CIB).
The The organization of the intersectoral workshop was prompted by Health Promotion based on a socio-environmental approach, where health is considered as a daily production, with influences on the social, economic and cultural conditions (Social Determinants of Health) in which individuals are inserted.Therefore, the responsibility for promoting health is not limited to the health sector; intersectoriality triggers increased health gradient, with suprasectoral decisions materialized through programs with a real impact on the health and quality of life of the population.Intersectoriality provides for the articulation of knowledge and experiences in the planning and implementation of Health Promotion actions, with a view to achieving integrated results in complex situations 1,2,20,21 .
In the State Health Promotion Policy of Minas Gerais (POEPS-MG), values, principles, guidelines, cross-sectional themes, operational axes and competencies that portray recommen- dations, suggestions, perceptions and visions of the social stakeholders that participated in the POEPS-MG are covered.All PNPS principles and values were also included in the workshops and new ones that emerged in the policy-making workshops were validated in the Working Group (WG) to define which ones would be included in the Policy as show in Chart 2. The values and principles incorporated were creativity, respect, perseverance, belonging, amorousness, horizontality and environmental justice.
The "Guidelines" outlined in the PNPS were renamed "Foundations" in the POEPS-MG, but the concept remains the same and is understood as the basis for the action and is related to its purpose, understood as a draft, general project line or plan 10 .The foundation that was added to include Minas Gerais demands was Popular Education in Health, through the political-pedagogical and participatory construction of knowledge oriented to Health Promotion, stimulating the empowerment and self-care of the population.
The Cross-Sectional Strategies are conceptualized in the POEPS-MG as those that should be used as reference for the establishment of Health Promotion agendas and the adoption of strategies.Operating in line with the principles and values of the SUS and traversing all Health Promotion actions, within the scope of the State of Minas Gerais, they are found in the PNPS, under the title of "Cross-Sectional Themes", with a new reference to the Promotion of Equity in Health (Chart 3).
The "Operational Axes" of the PNPS are called Operational Strategies in the POEPS-MG and they aim to achieve the development of Health Promotion practices, respecting values, principles, guidelines and objectives that are the same as those of the National Policy.There was only one change in the PNPS, namely, "Social Communication and Media" to "Mobilization and Social Communication", where social mobilization is an action that aims at establishing subjects and groups in favor of more solidary
-Cross-sectional themes: Social Determinants of Health (SDH), equity and respect for diversity, sustainable development, health and care production, healthy environments and territories, life at work, peace culture and human rights.
-Cross-sectional strategies: Social Determinants of Health (SDH), health care, sustainable development promotion, life at work, equity in health promotion.
-Operational axes: territorialization; intrasectoral and intersectoral coordination and cooperation; healthcare network; social participation and control; Management; education and training; surveillance, monitoring and evaluation; Production and dissemination of knowledge; Social communication and media.
-Operational strategies: territorialization; intrasectoral, intersectoral and interagency coordination and cooperation; healthcare networks; social participation and control; management; education and training; surveillance, monitoring and evaluation; production and dissemination of knowledge; Mobilization and Social Communication.
-Priority themes: continuing training and education, appropriate and healthy food, bodily practice and physical activities, coping with tobacco use and derivatives, coping with alcohol and other drugs abuse, safe mobility promotion, peace culture and human rights promotion, sustainable development promotion.
-Themes: coping with alcohol and other drugs abuse, appropriate and healthy food, bodily practice and physical activities, peace culture and human rights promotion, worker's health promotion, continuing training and education, and popular education in health.
societal arrangements, considering participation as an act of freedom, as per Table 1.Mobilization and popular roles collaborate to raise awareness about the importance of the relationship between health and living conditions and the possible actions to reduce inequities and advocate the right to health.They value the diversity of knowledge and cultures, integrating popular knowledge into the daily life of health services.
The "Priority Themes" of the PNPS were called Themes in the POEPS-MG and are described in Chart 3. The process to define them was similar to the PNPS review 9 .Themes were ranked according to the number of votes of the participants of the 38 workshops (managers, technical references, leaderships and other participants) and in how many workshops each topic was recurrent, as described in Table 4. Finally, products were systematized by the Working Group (GT-POEPS-MG) during the preparation of the minute.Themes will bear references for the establishment of health promotion agen-das and the prioritization of strategies in Minas Gerais, and should be in line with SUS principles and values.After the publication of the POEPS-MG, there was a return movement to the regions to show the policy and provide support to implement it.
The model proposed in the Brazilian public health system is successful in theory, however, the financing model is unable to ensure the necessary resources to maintain the system.That is why it is so important to support the funding of public policies, so that it accompanies the expansion of services, ensuring the comprehensive services to citizens.Equity in financing ensures reduced regional disparities and resources for PHC 22 .One of the great challenges of public health is funding health actions and services, not only due to budget constraints, but also the increasing prevalence of the burden of chronic diseases 23,24 .
Thus, the POEPS shows the specific budget assurance for Health Promotion as an innovative aspect, which is a great advance, since this b) Popular education in health: theoretical perspective oriented to the educational practice and social work intentionally directed to the promotion of people's autonomy.

2-Adequate, Healthy and Sustainable Food
Actions aiming at an environment that generates practices and customs that favor healthy choices and that are environmentally, culturally and socially sustainable.

3-Bodily practice and physical activities
a) Body practices: human beings in movement, assigning senses and meanings to content and intervention; b) Physical activity: any form of bodily movement, with energy expenditure above resting levels; c) Leisure activities: to practice pleasant activities, for rest, fun, recreation and entertainment.

4-Peace culture and human rights promotion
Includes promoting, articulating and mobilizing actions that foster coexistence, respect for diversity and differences in gender, sexual orientation and gender identity, between generations, ethnic-racial, cultural, territorial, social class and related to people with disabilities.

5-Álcool, Tobacco and Other Drugs
Actions to reduce the consumption of alcohol, tobacco and other drugs, with the co-responsibility and autonomy of the population, including educational, legislative, economic, environmental, cultural and social actions.

6-Worker's Health Promotion
The promotion and protection of formal and informal workers' health, as well as surveillance of work environments and processes and stimulating workers' role.

7-Equity in health promotion
Respect for sexual and gender diversity, ethnic-racial, cultural and territorial diversity, as well as breaking down institutional barriers that hinder access to health.happens for the first time since Health Promotion was established in the SES-MG.In order to receive the mentioned financial incentive, the municipality signed the Term of Commitment in the Indicators, Commitments and Goals Management System (GEICOM).
This financial incentive transfers financial resources to the municipalities by means of a fixed amount and a variable amount corresponding to 50% of the total amount of the financial incentive for each party.The variable amount is accounted for proportionally to compliance with five selected indicators that will guide the monitoring and evaluation of Health Promotion actions carried out by the municipalities, as well as the implantation and implementation of the State Health Promotion Policy in the State 25 .

Conclusion
The State Health Promotion Policy is a way to strengthen and expand the PNPS and, instead of reviewing it, provides its detailed study and incorporation into the work routine.It complements and strengthens and reaffirms its purposes, adds specific characteristics of the territory and ensures its legitimacy with the linkage of budgetary resources and the introduction of health promotion actions in PHC through continuous monitoring and education activities.
The POEPS-MG was built in decentralized and participatory fashion, with a work methodology that ensured the effective involvement of stakeholders.The elaboration process stood out because it considered the specific regional demands identified during its construction and reinforces the enriching elements of its devel- opment built in an innovative, democratic and participatory way, enabling planning of actions, the proposal of indicators and use of the financial incentive as reliably as possible with the realities found in the municipalities of Minas Gerais.In addition, it provided greater ownership of the POEPS-MG by all the people involved in its construction process and who participate in the movements that implant and implement the Policy in the territories.
The actions that will be developed are based on the Themes and Guidelines defined in the POEPS-MG and aim to cover all the municipalities of Minas Gerais, generating increased health of individuals, improving the way of living, increasing the empowerment of individuals and communities in the search for reduced inequalities, vulnerabilities and health risks by acting on the social, economic, political, cultural and environmental determinants, for which purpose it has budgetary and financial allocation from the State for the implementation and implementation of the POEPS-MG, which was a great advance, since this is unprecedented.

Collaborators
DS Campos, MA Turci, EM Melo, VA Guerra, CGM Nascimento, CA Moreira, EM Paschoal, NRM Beltrão and KR Silva contributed to the construction of the manuscript.

Chart 2 .
Comparison between National Health Promotion Policy (PNPS) and State Health Promotion Policy (POEPS-MG).

Chart 3 .
State Health Promotion Policy Themes.training and education: promoting training for managers, health workers and other sectors.
the State of Minas Gerais, Health Promotion has been in place since 2007, when the Health Promotion Management was created through State Decree N° 44.479, of March 9, 2007.In 2009, Decree Nº 45.038, of February 6, 2009, established the Health Promotion Advisory Office under the Sub-Secretariat of Health Surveillance.In 2011, through Decree Nº 45.812, of December 14, 2011, it was renamed as the Health Promotion and Non-Communicable Diseases Board and allocated to the Superintendency of Epidemiological, Environmental and Occupational Health Surveillance.In 2015, in order to increase and strengthen State Health Promotion actions, the sector was reassigned to the Superintendency of Primary Health Care with a proposed elaboration and implementation of the State Health Promotion Policy.

Chart 1 .
Summary of the types of workshops, number of participants and respective objectives for the elaboration of the State Health Promotion Policy (POEPS-MG).

Table 1 .
Themes that emerged in the Elaboration Workshops, with participants' votes.