The policy in question: the success of the São Paulo's 13th Congress of Public Health

Abstracts

This article summarizes the main issues discussed at São Paulo's 13th Congress of Public Health, held in September/October 2013. It presents the context prior to the Congress, clarifying the discussions held for the definition of the subject, which recognized the growing exhaustion of political and management forms, showing the alignment of São Paulo's public health workers with popular aspirations manifested in the 2013 June demonstrations. The policy theme was discussed during all the Congress, sometimes in a conflicting way, other times in a convergent one, in the following nodal aspects: the tension between a project that aims at the public sphere and the private sector growth in health in a context of consumption and commodification or commoditization of life; internal contradictions to the field on how to produce health within the NHS, in the micro spheres of everyday practices of healthcare, or the macro spheres, which emphasize the state-society relations, state institutions in relation to society.

São Paulo's Congress; Public Health; Policy; Public Health System; State; Society

Este artigo sintetiza as principais questões debatidas no 13º Congresso Paulista de Saúde Pública, realizado em setembro/outubro de 2013. Situa o contexto prévio de realização do evento esclarecendo as discussões ocorridas para a definição do tema, que reconheceram o crescente esgotamento das formas políticas e de gestão, mostrando a sintonia dos sanitaristas paulistas com os anseios populares que viriam a se manifestar nas Jornadas de Junho de 2013. O tema da política pautou todo o congresso, às vezes de forma conflitante, às vezes convergente, destacando-se os seguintes aspectos nodais: a tensão entre um projeto que tem por objeto a esfera pública e o crescimento do setor privado na saúde num contexto de consumo e mercantilização ou mercadorização da vida; as contradições internas ao campo sobre como produzir saúde por dentro do SUS, se nas esferas micro das práticas cotidianas, das ações de assistência e cuidado, ou nas esferas macro, que enfatizam as relações Estado-sociedade, as instituições estatais na relação com a sociedade.

Congresso Paulista; Saúde Pública; Política; Sistema Único de Saúde; Estado; Sociedade

The context

This manuscript is singular.

During the organization process of São Paulo's 13th Congress of Public Health, we decided for holding a final presentation summing up the discussions that took place throughout the congress. A hard task, because it is an event based on some theses that have been formulated, presented and discussed. São Paulo's congresses are events where theses, although present, take place in a freer and more fluid way; they are less defined and delimited than those at health conferences, for instance, where multiple permeabilities are crossed over one another and produce several others, both unexpected and expected, final and open, similar and different. Hence, the idea of a synthesis speech (is this possible?), which encompasses, for all congress participants, their joint production in act.

This was the state of mind which produced the present manuscript, recognizing beforehand the impossibility of such synthesis; therefore, its singularity.

The subject of the 13^th Congress had been established almost one year before it was held in 2013, and so, much prior to the June Journeys,³ that took place in several parts of Brazil. However, it showed the responsive disposition the hygienists from São Paulo had already been establishing towards the wishes of the widest segments of the population. That is the first result of the Congress - its subject was a big hit!

A certain marasmus towards the discussion about politics and public health was disturbing. There was a thirst for discussing, even if concerning multiple divergences, concerns, inquietudes, confrontations. Grounded on the agenda of public health needs and more specifically, of challenges, deadlocks and performing possibilities of the Brazilian National Health System (SUS), the increasing collapse of the political and management forms was noticed. Issues such as actual service offering conditions under the perspective of guarantee of the universality and of integrality of primary care, the 'vampirization' of the health system by the private segment of great capital in the industry, the work conditions and processes in the health area, extremely compromised by the flexibility of the contracts etc., produced inconveniences that forced an afterthought.

Moreover, faithfully committed with the principles of the Brazilian National Health Reform, concerning its basic issue of healthcare right, the hygienists gathered around the preparation and organization of São Paulo's 13th Congress of Public Health were bothered with the increasingly disconnection established among the forms and strategies for implementing health policies and the demands of the population; the collapse of the political and managerial ways established concerning the expression and channeling of the population's interests.

They were also disturbed with the limits and embarrassments that were imposed to the protests and to the democratic access of segments of the Brazilian civil society to the decisions and effective political participation in the country's health segment. It was not due to the non-existence of established channels, but, mainly and specially, due to the fact that the institutional ways consolidated seemed to capture more and more the spaces of protest and popular expression, de-personalizing them, de-politicizing them, or co-opting them, more than listening to them, understanding them, serving them (Carvalho, 2012).

There was, therefore, a diagnosis about the limits of the social and political process in progress in the country, which translated itself crosswise in relation to SUS's practices and policies and to the poverty of political ways - for implementing and defining health policies and actions, the system's management, and the governing ways.

Even before the June Journeys, a certain "limit" to the sanitation project established since 1988 was recognized as an inflection point, where it was important to resume and redefine the sanitarian pact produced in the Public/Collective Health and the Sanitary Reform areas in 1980; a resumption that would discuss the maintenance of traditional ways of producing policy and health at SUS, such as those related to management, financing and technical issues. It recognized the loss of the political horizon and the need of retaking it.

The public issue in the São Paulo's Congress derived from this inquietude, showed both in the discussion about the structure of the health system and in the most general social policies. The retaken of the public in the Public Health. The demand for a political way which is radically democratic and committed with the country's social issue.

A very hard task: producing the synthesis

The impossibility of producing a synthesis has already been mentioned, considering not only the organizational aspects, but, mainly, those aspects concerning the differences, language and report disjunctions, companionship moments among congress participants and scheduled activities, perceptions socially built in act and pre-conceptions already strongly established.

It was five days of intense activities: courses,; workshops, conferences, thematic discussions, round tables, lectures, cultural activities, meetings at the coffee, the halls etc. Many topics and sub-topics were approached and discussed under different perspectives, both concerning the understanding of the phenomena in progress and in relation to their solution and/or confrontation.

Thus, this manuscript results in an empirical report of what was possible to build, being as accurate as possible in relation to the facts, to the fidelity of the observed facts. The listening devices of the Congress's scientific organization staff, which circulated through the whole event, in meetings held at the end of the day's activities, substantially contributed to this report.

Additionally, the participation in and observation of the Congress's activities, as well as informal talking with colleagues and participants in general, made it possible to identify some core issues, which were pulsing during the event, about the public issue in the Public Health.

A tension was clearly revealed between a project of a more collective nature, which aims at the public, the common in the health production, and the increasing consumption in the health segment, produced not only in a more general scope of the society but also inside the Brazilian National Health System itself, in a more and more individual basis (Touraine, 2010). Examples could be discussed in relation to such point, concerning people's participation in Health Committees, which have been object of detailing by both representing and represented bodies, under a perspective of rendering service access/consumption feasible.

It is clear that, today, the Public/Collective Health area is pressured by this paradox, which translates itself, mainly, in the different ways of conducting the sector's practices and policies within the system. In the different events that took place during the Congress, some positioned themselves in favor of one or another perspective; other times, this pressure was expressed in a single activity.

The substratum of such pressure is to understand which public one is talking about, which public concept nature is being dealt with; or better, which public concepts are present today in the Public/Collective Health area; or yet, which public concepts the health system works with. Those who emphasize the access to the services, aiming at the guarantee of the universality, tend to conceive the public in a more immediate way, taking care that everybody, throughout the national territory, have access to healthcare services. By taking this direction, they leave to another time, in the background, the point - also important - of discussing the nature of the services, circumstantiating their actual need, sizing their crucial importance for the capital's pay-up and expansion (consumption producer and reproducer), with all it means: transforming the user-professional relationship into a thing; turning employment contracts and working hours of health professionals flexible; the depletion of financial resources relating to the expansion of this productive park that are the health services etc. To this effect, they tend to neglect an aspect that is present in the society and in the health area, the service consumption, which turns and reinforces the user into a leading consumer.

This contradiction restates the need of discussion, in a current context, about the idea of access beyond the boundary of services shortage and/or exiguity. It replaces the need of discussing this concept within the context of a consumer society, where access can mean, as it means more and more, the transformation of the user into a consumer, last object of capital pay-up in the sector. Considering this scenario, SUS, beyond the social right, could become a powerful arm in the capital reproduction; the reversion of the first project, where the assumption of the right-bearing user would turn to the background. In this context, the challenge would be facing the public nature of the access to health services.

On the other hand, there are those who try to rescue the public discussion more strictly linked to the idea of right. Under this perspective, the possible ways of producing health - in all action levels, in the user-professional relationship, in the manager-population relationship and in the inter-federative spheres etc. - should foster the production of the common, shared ways of producing knowledge, care, actions and management strategies.

However, there was no discussion in the Congress that did not express the success of SUS! A success understood beyond the common sense of the one who wins, of who is the best, the unbeatable, who comes out on top, or something similar. Success in the sense of performance.

There is a very strong perception that SUS is a powerful structure, a wide productive machine that encompasses all social, economic, political and cultural spheres. A structure built with and on the efforts of its workers, scholars, managers, researchers, ideologists, servers, users. A structure-project in progress.

It is also successful because, in addition to being powerful, it is the only public policy that survived from the country's re-democratization process⁴ - which is quite a lot in terms of political continuity in a country like ours that prioritizes the old-boy system in politics and the control of the State by capital-associated upper classes (Carvalho, 2012).

Success resulting from the effort of its first designers, who within an adverse context, still under a dictatorial government, were prepared to face the challenge and build a propositional platform intended for health, a public social policy in the country.

According to (Fleury 2009), SUS rearranged the country's executive power through the following processes and instruments: the mechanisms of participation and social control - represented by the Health Committees at each government sphere, in an equity representation between the State and the civil society. Since then, these mechanisms became part of the state apparatus and the institutional machinery.

Aside from this instrument, there are also the political will building mechanisms, the Health Conferences, regularly held on all levels of government. A communicative and deliberative exercise mechanism that puts the actors to interact, and consists in the subject's learning and social recognition, with the perspective of strengthening the organized civil society.

As, finally, there are mechanisms of shared management, negotiation and agreement among the federated entities involved with the decentralization of the health system. The institutional committees - Bipartite and Tripartite Inter-management Committees, for instance - are spaces intended for negotiating the differences and creating management agreements, an innovation in the Brazilian federative model. A different form of federalism, which, within this management model layout, opens a space for contemplating regional differences, while leveling the decentralization, agreement and participation mechanisms.

In face of these processes, it becomes clear how much the implementation of SUS has produced new public institutions, both in the health area and for the Brazilian State, turning the Sanitary Reform's political-ideological thinking into public policy.

The Congress also presented issues related to the moment of political changes the country is currently facing. Recognizing that the Public/Collective Health area is currently being pressured by the political action paradox, which shows itself in the different ways of leading the sector's practices and policies from inside the system, the Congress expressed itself in a bipartite way - not necessarily contrary or divergent. There were differences on how to produce health within SUS, and about the political ways of this production. In this brunt, concepts and territories faced themselves, indicating the representation crisis. There are those who prioritize daily practices, care attention, micro-power and micro-political environment in the production of health. And there are others who emphasize State-society relationships, political-state institutions, social institutions and social movements as the spheres that define the health production.

As above mentioned, these positions are not necessarily contrary; they are not mandatorily in opposition to each other. However, they express the pressure between the macro and the micro, between the system's institutionalized ways of production and the non-institutionalized ones, between the State and the civil society. It is a discussion to be faced on the level of ideas and actual daily practices, but which cannot be stirred up by minor divergences.

We can say that São Paulo's Congress, by expressing such pressure, encompassed it democratically under the perspective of a fraternal, open debate, without the crystallization or hardening of the positions. Within this context, the picture of the sanitary reform forerunners - our traditional hygienists - resurfaces; professionals, managers, scholars, students etc. who knew, during the hard times of lack of freedom and oppression, how to face their divergences around a common project. Perhaps, this new moment of inflection requires, as then, a new solidary sanitary agreement.

Another aspect relating to the current moment of inflection refers to life's mercantilization or commodification; as pointed out above, the integration through consumption, leading to the split of the social tissue, of fraternal relationships (Hobsbawn, 2013). Conceived by the productive sphere of capitalist relationships, this commodification of life has caused great difficulties and embarrassment concerning the public sphere - understood here as not only the state, but also the common one.

By recognizing this fact, the Congress debates aroused possibilities for overcoming this situation. Focusing on people's strength (SUS's professionals and managers, as well as users), in the articulation areas, professional education, shared work processes, and partnership relationships, aiming at the demercantilization of health, the demercantilization of life. Health as a right to life. Health as a guarantee of life for everyone.

It was also clear how much health, as a public policy, is on a knife's edge between mercantile interests and those of social and public nature - a fact that cannot be overshadowed.

At last, in the aftermath of June Journeys (the congress was held between August and September, 2013), it was clear how the agenda proposed by São Paulo's hygienists was right. It was very clear the importance of not missing the historical opportunity created by the social movements which, once again, were intense and massively characterized by the right to health as a national subject. Recognizing the fact that it was the popular masses who took the subject of right to health to the streets means an excellent opportunity to firmly resume the issue of health as a social policy in the country, its incorporation to the agenda of more general social policies, breaking down the idea of compensatory sectorial policies which prove themselves insufficient.

Final remarks

São Paulo's 13^th Congress of Public Health was successful both concerning its organization and as a singular meeting moment for professionals, servers, students, teachers and managers who act in São Paulo's public health area. And, mainly, aside from such accomplishment, the Congress, through the choice of subject, was capable of unleashing the proposed issues to the most.

The synergy among the participants grew day by day, and the discussions got wings and consistency throughout the scheduled events. The balance is the area's vitality, the very strong and present social commitment, the wish for changes. And, more than that, the faith that everything is possible.

• CARVALHO, J. M. Cidadania no Brasil: o longo caminho. Rio de Janeiro: Civilização Brasileira, 2012.
• FLEURY, S. Reforma sanitária brasileira: dilemas entre o instituinte e o instituído. Ciência & Saúde Coletiva, Rio de Janeiro, v. 14, n. 3, p. 743-752, 2009.
• HOBSBAWM, E. O novo século: entrevista a Antonio Polito. São Paulo: Companhia de Bolso, 2013.
• TOURAINE, A. Pensar de outro modo. Lisboa: Instituto Piaget, 2010.

• 1
  A referência às Jornadas de Junho, ocorridas no Brasil em 2013, diz respeito às manifestações desencadeadas pelo Movimento do Passe Livre (MPL) pela reivindicação de suspensão do aumento da passagem de ônibus na cidade de são Paulo. Essas manifestações estenderam-se por todo o país, tendo sido ampliada a agenda de reivindicações à medida que outros movimentos sociais incorporaram-se às jornadas pautando suas reivindicações. Desde então, a questão social, na forma de manifestações populares, foi reposta na agenda nacional, com a realização frequente de atos e paralisações nos mais diversos recantos do país.
• 2
  A referência ao processo de redemocratização da década de 1980 diz respeito ao período de abertura política ao final do regime militar, instaurado no país com o golpe de 1964.
• 3
  The reference to the June Journeys (Jornadas de Junho), held in Brazil in 2013, refer to the protests unleashed by the Free Pass Movement (MPL) intended for demanding the suspension of the bus fare increase in the city of São Paulo. Such protests spread throughout the country, and the agenda of demands increased as other social movements joined the journeys and stated their demands. Ever since, the social issue, by way of protests, was the answer in the national agenda with frequent acts and stoppages being held in the most varied corners throughout the country.
• 4
  The reference to the redemocratization process from the 1980s refers to the period from the political opening to the end of the military regime, established in the country by the military overthrow in 1964.

Publication Dates

• Publication in this collection
  Apr-Jun 2015

History

• Received
  16 June 2014
• Accepted
  04 Aug 2014