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Saúde e Sociedade

Print version ISSN 0104-1290On-line version ISSN 1984-0470

Saude soc. vol.28 no.3 São Paulo July/Sept. 2019  Epub Oct 07, 2019

http://dx.doi.org/10.1590/s0104-12902019180963 

Articles

15th National Health Conference: a case study

Berenice Temoteo da Silvaa 
http://orcid.org/0000-0003-0951-3489

Isabel Maria Sampaio Oliveira Limab 
http://orcid.org/0000-0002-9833-3721

aUniversidade Federal da Bahia. Instituto de Saúde Coletiva. Salvador, BA, Brasil. E-mail: berenicenfer2007@hotmail.com

bUniversidade Católica do Salvador. Programa de Pós-Graduação em Família na Sociedade Contemporânea. Salvador, BA, Brasil. E-mail: isabelmsol@gmail.com


Abstract

This article aims to analyze the participation of the National Council in the construction and realization of the 15th National Health Conference (CNS), as well as the main components of this event, the institutional design regarding its participatory dynamics, and the approved proposals and guidelines, relating this political phenomenon to the Brazilian context. This case study on the 15th CNS had, as data sources, the interviews with 27 national counselors and the documentary review of minutes, news and other sources of the Council related to the 15th Conference. The National Council developed strategies to politicize the elaboration of guidelines and intensified society participation through free conferences. The Health debate in 2015 involved thousands of people in the country - after all, 4,706 municipal and 26 state, district and national conferences were held. The main agendas of the 15th Conference were the defense of democracy and the public financing of health. Nonetheless, the bureaucratic format still prevailed in the 15th CNS. In addition to innovations in the form of conferences, one must increase the permeability of decision-makers to social participation and democratize the health planning and management process.

Keywords: National Health Conference; National Health Council; Social Participation

Resumo

O objetivo deste artigo é analisar a participação do Conselho Nacional na construção e realização da 15ª Conferência Nacional de Saúde (CNS), bem como os principais componentes desse evento, o desenho institucional, no que se refere a sua dinâmica participativa, e as propostas e diretrizes aprovadas, e relacionar esse fenômeno político à conjuntura brasileira. Este estudo de caso sobre a 15ª CNS teve como fonte de produção de dados entrevistas com 27 conselheiros nacionais e a revisão documental de atas, notícias e outras fontes do Conselho relacionadas à 15ª Conferência. O Conselho Nacional desenvolveu estratégias para politizar a elaboração das diretrizes e intensificou a participação da sociedade por meio das conferências livres. O debate em torno da saúde em 2015 envolveu milhares de pessoas no país - afinal, foram realizadas 4.706 conferências municipais, 26 estaduais, a conferência distrital e a nacional. As principais pautas da 15ª Conferência foram a defesa da democracia e o financiamento público da saúde. A 15ª CNS ainda prevaleceu com o formato burocrático. Além das inovações na forma das conferências, é necessário ampliar a permeabilidade dos tomadores de decisão à participação social e democratizar o processo de planejamento e a gestão em saúde.

Palavras-chave: Conferência Nacional de Saúde; Conselho Nacional de Saúde; Participação Social

Introduction

In Brazil, National Health Conferences (CNS) have a history that precedes the creation of the Brazilian National Health System (SUS). They were originally instituted in 1937, in the antidemocratic context of Getúlio Vargas’s Estado Novo; however, the 1st CNS was held only in 1941. They were set as a strategy to strengthen Federal Government control over health actions developed in the country. However, over time, the Conferences have been translating other senses and formats. Linked to the emerging democratic movement, the 8th CNS in 1986 revealed a distinct nature. In the pulsating dimension of the Brazilian Sanitary Reform movement, this event ceased to have a technical-administrative character and acquired the perspective of popular participation (Souza et al., 2013).

The creation of SUS in the 1988 Constitution and its regulation through the legislation on participation - that is, Law no. 8,142/1990 - defined a new institutional design for the CNS. Contemplating the legal and legitimate agenda of civil society and political participation, the CNSs took on the role of assessing the health situation and developing proposals to guide health policies according to the needs of the population. Although integrated into the constitutional purpose, the CNS still do not have within their legal framework the precise definition of what they should be and how they should work, as the functioning of such participatory arena is defined in the internal rules of each Conference. This gap gives rise to different conceptions and, especially, to high expectations, which can result in frustrations due to the low use of their guidelines by stakeholders in the formulation of health policies (Escorel; Bloch; 2005; Souza; Pires, 2013).

Albeit the CNSs have presented some innovations in their format since the Brazilian re-democratization process, especially with the undeniable expansion and diversity in the participation of delegates, they are also showing signs of wear and tear, as well as some innocuity. The expectation about the potential of this participatory arena to have an impact on the formulation of health policies has been diluted (Costa, 2015; Ricardi; Shimizu; Santos, 2017). Faced with this set of elements, one must reflect on the CNS as an important democratic institution, to maximize its results in health policies.

For such reflection, an accumulation of critical analysis by social movements, entities and representations of civil and political society is required, including the academy, so to point out ways to think about new formats and key dimensions to be modified. The reason for being of this article is within such endeavor, and we elect as a case of study the CNS that occurred in December 2015. This study aims to analyze the participation of the National Council in the construction and realization of the 15th Conference, as well as the main components of this event, the institutional design regarding its participatory dynamics and the proposals and guidelines approved, relating such data to the Brazilian context.

Method

This is a case study on the 15th CNS. The period of study goes from 2014 to 2016, which is justified because the debates on the Conference have taken place more systematically in the National Health Council plenary from 2014, and the guidelines, proposals, and motions approved in the final stage have been published in March 2016.

Data production was based on 27 semi-structured interviews conducted with counselors who held positions in the National Health Council from 2012-2015 and played a central role in producing the 15th Conference, as well as counselors with seats in the 2015-2018 management. Twenty-nine sources were also used in data collection, including: the Conference’s internal rules of procedure; the guiding document to support the debates; the methodological document; the national report consolidated in the state stage; the Resolution 507/2016, which gives publicity to the proposals, guidelines, and motions approved in the 15th CNS; 24 minutes of meetings produced between February 2014 and March 2016 (253, 256-258, 260-279), which record the debates around the Conference. A matrix of data collection containing the variables “identification of minutes”, “type, number and date of the meeting”, “category - 15th CNS”, “debate held” and “deliberation” was used in the analysis of minutes. News published on the website of the National Health Council between February 2014 and March 2016 were also monitored through a news matrix, recording the date, category (15th CNS), title and summary of the account, as well as its source and link.

Analysis of interviews was carried out through the content analysis proposed by Bardin (2011). After analyzed, the content from the reports was compared with other data sources and the literature. The final document of guidelines and proposals of the 15th CNS was analyzed based on the following categories: form (administrative, legislative) and nature of the guidelines (implementation of an existing policy, formulation of a new policy, improvement of a policy, general public policy, expanded access to an existing policy, monitoring of a policy, inclusion of a specific group in a policy, and extension of a policy or service).

Documents were available on websites of the National Health Council (minutes) and of the 15th CNS (other documents). Interviews were carried out after the interviewee signing the Informed Consent Form and giving prior authorization to record the conversation. The project was approved by the Research Ethics Committee of the Institute of Public Health (ISC) of the Federal University of Bahia (UFBA), under protocol no. 2,235,550.

Results and discussion

Process of construction of the 15th Conference

The need to change the format of the conferences was pointed out by Government representatives, health professionals and the scientific community. The high number of guidelines and proposals in the final report, approved as a priority to guide the formulation of health policies, was highlighted as a hindrance to the effectiveness of the conferences. The conference model with participation focused on the performance of the counselor to the detriment of new entities was also pointed as an aspect to be changed.

Establishing a new mechanism in conferences […]. This model is over, so we all - managers, researchers, social control, health professionals and the population, must start to think about what kind of model we can establish to make our conference more effective. (Interviewee 3 - Government)

There is an absurd amount of guidelines […] it is impossible - nobody will, in the next 4 years, suddenly observe 100 guidelines. The conferences must change […] they must be reviewed. (Interviewee 7 - Social)

Stop reproducing conferences with 400 proposals, that book full of proposals that nobody reads […]. No one will check whether this exists or not. So the goal is to narrow it down, set the axes and leave something more purposeful […] to help design the next health plan. (Interviewee 1 - Government)

We still have a conference model with that vision of social participation guided by acting within the councils, without renewing the militancy within the conferences from other movements outside the Council, so it is very bound to a normative vision […]. We must be able to produce another type of conference. (Interviewee 8 - Social)

The debate on health conferences, held in the National Council plenary between 2014 and 2015, was also marked by the discourse around the need to change the format of this participatory institution. Health Minister Arthur Chioro, as soon as he took office in 2014, in his first participation in the ordinary meeting of the Council highlighted the exhaustion of the conference model:

One must rethink the ways of producing conferences […]. One must be able not only to think the format […] but to know what is wanted of a National Conference, so that it is a clear and objective framework to indicate which are the guidelines for the national system, to guide the PPA itself [Pluriannual Plan] and the National Health Plan. (Brasil, 2014a, p. 28)

At the ordinary meeting of the Council in June 2014, this theme was put up for discussion aimed at accumulating a critical analysis to rethink the Health Conferences and to subsidize the construction of the 15th CNS. Debates pointed to broadening the social base, ensuring the effectiveness of the conference in health policies and the need to innovate the Conference methods. The proposals that came up in the plenary, with a view to substantially changing the format of the event, had a circumstantial dimension and were not widely debated and put to the vote, leaving only the record in the minutes.

The suggested changes were: the National Council of Municipal Health Secretariats (Conasems) proposed to replace municipal conferences at that time with those carried out from the health regions - the argument posed was that municipalities should hold their conferences in the beginning of their government to influence municipal management instruments; the Brazilian Association of Collective Health (Abrasco) suggested reversing the stages of the Conference, starting with the national, followed by state and finally free, municipal and regional conferences - the justification for this proposition was that the guidelines of the national phase, carried out in advance, could be part of the PPA construction (Brasil, 2014c, 2014e).

In the Council’s plenary debates about the 15th Conference, there was therefore a concern to anticipate the event to follow the legal planning time at a federal level, so that its guidelines could support the construction of management tools, especially the PPA and the National Health Plan (PNS). However, the 2016-2019 PPA was prepared in the first half of 2015, since its submission to the National Congress occurs in August, and the National Conference occurred later, in December 2015. The 2016-2019 PNS, in turn, sent to the National Council in April 2016 and approved by the plenary in July of that year, contained guidelines of the 15th CNS.

Thus, in order for the Conference guidelines to be minimally made available in a timely manner, at the moment of forming the government agenda, two dimensions need to be considered: the first refers to the legally established technical time for the budget and planning cycle. The second element to be taken into account is the political time of management in the spheres of government. Thus, to increase the possibility of effectiveness of the Conference proposals, one of the important aspects to be considered is that the National Council can adapt its period of realization to the budget and planning cycle. Ricardi, Shimizu and Santos (2017) point out that, although planning instruments are reviewed annually, the temporal mismatch between the Conference and medium-term planning instruments compromises the participatory influence in the elaboration of health policies, although the due time alignment is not an assurance that such policies will be elaborated based on CNS guidelines.

Another aspect raised in the debate was the growing number of proposals approved at the conferences over the years, which, while reflecting the diversity of participation of social actors in these spaces, makes it difficult to identify the priority guidelines to guide health policy, leading to its low impact on policy formulation. At the same time, the persistent challenge of ensuring greater participation in the Conferences was pointed out, especially of those entities and social movements that are not part of Health Councils (Brasil, 2014c).

It is a dilemma arising from the conference itself as a participatory and democratic institution, inserted in the process of building a public health policy that presents as a concrete starting point the limitation of resources, including financial resources, for the implementation of its guidelines. The dilemma refers to the need to ensure participation of various segments of society capable of representing the plurality of interests in the struggle for hegemony in the field of Health, and at the same time to develop guidelines that are a priority for the formulation of policies, maintaining the commitment to its implementation. Gadelha (2015), when discussing the event during the 15th CNS, highlights as one of its main methodological challenges the construction of guidelines that are also enriched by the broad participation of society, without dispersion.

Faced with such impasse, the strategy adopted by the National Health Council consisted in developing actions capable of intensifying the process of mobilizing society, bringing to this space actors hitherto discarded from discussions about public health. Thus, in addition to the traditional municipal, state, and national stages of the CNS, the free conferences were created as a mobilization activity constituted by popular plenaries and are held in the five geographic regions of the country. From the popular plenaries came guests with right to voice - not to vote -, both in plenary sessions as in the working groups of the 15th CNS national stage (Brasil, 2014e, 2015f).

The initiative to mobilize social movements and entities to participate in free conferences, without the formality of being a health adviser, involved a pluralistic part of society. With that, the 15th Conference presented, in its institutional design, a strong participatory dynamic, broadening the representation of minority groups, as shown in the speech of Interviewee 9:

In the construction of the 15th Conference, we managed to bring fishermen and shell-fishers, we managed to bring gypsies, we managed to bring sex workers, we managed to increase and strengthen the presence of LGBT, indigenous women, black people, quilombolas, workers, etc. (Interviewee 9 - Social)

The realization of free conferences, while fulfilling the role of mobilizing social actors beyond those already involved with the health councils network, was also considered by the counselors as a mechanism capable of conferring greater legitimacy to the Conference, insofar as it provided the plural participation of various entities and social movements. The following report is a good illustration of this aspect:

If we legitimize it more, than history shall accredit us. For that, we used free conferences, free registration, we used various mechanisms to incorporate new social subjects beyond those the councils would mobilize, to legitimize ourselves even more before society, to […] not be simply card counselors […] not to say it was a conference only of reds or blues or yellows […] like the dispute in favor or against government was polarized in society, but it was a conference of society. (Interviewee 1 - Social)

Although free conferences are an innovative strategy for broadening the social base of the Conference, the mark of the 15th CNS was still the bureaucratic format, so that entities and social movements mobilized during the municipal and state stages and that were to Brasilia could not participate in debates at the national level, as they were not delegates, invitees or participants. It was also not allowed to bring new proposals and guidelines at the national stage, as this would reduce the time for debate and could affect the legitimacy of the upward voting process of the demands. Both aspects have given rise to debates in some National Council meetings - however, this configuration ended up prevailing in the conference regiment (Brasil, 2014f, 2015a, 2015c, 2015f). The speech of some delegate-counselors at the post-Conference indicates this format was a limiting factor of the event, as can be seen in these lines:

There may have been an excessive bureaucratization of its functioning. Questions could only be debated if they had come from state conferences. So it was a very stern conference from the point of view of bureaucratic procedures, which somehow ended up narrowing the debate objectively. (Interviewee 10 - Social)

Social movements also wanted to enter; social networks, students, people who were heavily mobilized against the PEC [proposed amendment to the Constitution] of the spending ceiling wanted to come to the Conference very much, as a place of political denunciation, of political protest against the proposals of the government and congress. (Interviewee 1 - Social)

Because the job is so difficult and, at the time, you get carried away and you go with a group and, when you get there you simply cannot… […] We could not get into the Conference, it was very disappointing. (Interviewee 11 - Social)

The problem is that we began to build conferences with a certain formality that prevented the renewal of its participants, in other words, made it difficult to renew participants. (Interviewee 1 - Social)

The gradual manner in which the process of opening up this channel of participation is taking place reflects the internal tensions of the National Health Council. Some advisers are concerned that this may favor the agglutination of actors opposed to the strengthening of SUS within the conference (Brasil, 2015a) or, in fact, weaken the council network and the Health Conference, in terms of its representative dynamics. Thus, the broad discussion in the National Council plenary on the inclusion of new participatory profiles at the conferences resulted in some changes in participatory dynamics, such as free conferences, but did not reflect on the representative dynamics of events.

Such partial opening of this space to non-counselors or delegates did not ensure their effective participation in the debates, inducing a sterile participation that can generate negative repercussions on the participatory process. The expansion of society participation is regarded as a profitable strategy to democratize the institutionalized participation, while also giving greater legitimacy to the participatory process. For Gadelha (2015), extending the health agenda to the Brazilian population consists of, above all, facing one of the challenges that accompanies the construction of SUS, which is about its social roots.

Therefore, the process of building the 15th CNS was marked by efforts of the National Council members to review the Health Conference format. Discussions in the Council plenary on the 15th Conference had an impact on the change in its design, especially on the issue of including new actors, expanding its social base from the free plenary sessions, and about the rationalization of the number of proposals approved for final conference documents since, for example, at the 13th Conference 857 proposals were approved, while the 15th resulted in 560.

Concomitant with the strategy of change in the format of the Conference, the National Council also made efforts to politicize and qualify the elaboration of the event guidelines. Thus, the guiding document to support the debates of the 15th CNS, prepared and disseminated by the national counselors in state and municipal councils and in virtual channels of communication of some entities of the national collegiate, was launched. Still aiming to strengthen the political debate, entities and universities, such as the Brazilian Center for Health Studies (Cebes) and the ISC-UFBA, promoted discussions with entities and social movements, enriched the proposals of the aforementioned guiding document, and reverberated their theses in texts published in free and municipal conferences, favoring the critical construction of proposals (Cebes, 2015; UFBA, 2015).

The politicization of the Conference presupposes considering the historical-political context in which the guidelines would be elaborated, based on a specific concrete reality. Such dimension of the Conference was pointed out by the delegate-counselors as a central element to make it more effective, so to influence the construction of health policy, as shown by the following statements:

The challenge is to bring up the political context, the role of the State, the role of society in a participatory democracy, and within the pre-impeachment context that we were already facing. […] The sanitary issue, because there is a huge sanitary crisis, not only with the epidemic of zika, dengue etc., but the water crisis, the water. (Interviewee 1 - Social)

The issue is not formal, the issue is not of the organization, it is not organizational. See the eighth Conference, with all the impact it had […]; from the formal point of view, it met few bureaucratic criteria and eventually opened up to the participation of people who were generally not formally elected delegates. So you see, the issue is political, it is above all to have leaders and participants […] the ability to be in tune with the political moment […] and to have a clear analysis and well-formulated proposals that can excite people and, from there, to build the basis of a report that is effectively impacting, producing concrete effects on the political struggle. (Interviewee 10 - Social)

Amidst the economic and political crisis and several threats to SUS, the 15th CNS was convened by then President of the Republic, Dilma Rousseff, in December 2014, with the theme “Quality public health to take care of people: a right of the Brazilian people” (Müller Neto, 2015). Thousands of people were mobilized for the 15th CNS in 4,706 municipal health conferences, 26 state conferences, the district conference and the national event, as presented in Table 1. The regions with the highest percentages of municipal conferences held were the Central-West and the Northeast, with 91.86% and 91.14%, respectively. The Southeast region was the one with the lowest percentage of municipal conferences, with 76.14%, Minas Gerais being the Brazilian state with the lowest percentage of municipalities that held conferences (64.48%).

Table 1 Municipal health conference held by federated unit (UF) and region of Brazil in 2015 

UF Number of municipalities Municipal Conference % Region Number of municipalities Municipal Conference %
GO 246 246 100.00 Central-West 467 429 91.86
MS 79 79 100.00
DF 1 1 100.00
MT 141 103 73.05
BA 417 417 100.00 Northeast 1,794 1,635 91.14
PB 223 223 100.00
CE 184 184 100.00
RN 167 167 100.00
AL 102 102 100.00
SE 75 75 100.00
PE 185 143 77.30
MA 217 163 75.12
PI 224 161 71.88
AM 62 62 100.00 North 450 401 89.11
RO 52 52 100.00
AC 22 22 100.00
AP 16 16 100.00
RR 15 15 100.00
TO 139 134 96.40
PA 144 100 69.44
SC 295 277 93.90 South 1,191 971 81.53
RS 497 420 84.51
PR 399 274 68.67
ES 78 78 100.00 Southeast 1,668 1,270 76.14
RJ 92 89 96.74
SP 645 553 85.74
MG 853 550 64.48
Total 5,570 4,706 84.49 Total 5,570 4,706 84.49

Source: CNS (2015)

The fact that 14 states of the Federation held conferences in 100% of their municipalities and 84.49% of Brazilian municipalities hold their respective health conferences demonstrates that in 2015 there was an intense mobilization around the theme of health throughout the country. In this process, new social actors were mobilized for the national public scene, as pointed out in the following speech:

As we had a lot of encouragement, free conferences and free interactive spaces around the conference, Paulo Freire’s tent and other tents of integrative practices; hence, many people from the countryside participated, including many who had no history of participation within the National Conferences. (Interviewee 1 - Social)

Proposals presented and discussed at the 15th Conference

At the 15th Conference, there was a limit of proposals to be sent to the national stage. Thus, according to the methodological guidelines, it was foreseen that each state of the Federation could send a guideline for each of the eight axes and five proposals by guideline (Brasil, 2015g) to the national stage. Although state conferences took place in all states, Pernambuco was unable to vote on the 40 priority proposals and sent 372 proposals to Brasilia. Faced with the impasse and without consensus to vote in the National Council plenary, the national organizing committee of the 15th CNS decided that only the axis discussed and with fewer proposals (35) from that state be appreciated at the National Conference, since the legitimacy to decide which ones would be prioritized and part of the national consolidation of the state stage is not up to the commission but to the delegates elected at conferences (Brasil, 2015d).

Thus, 208 guidelines and 1,040 proposals from 25 state conferences were sent, in addition to the district, from which the national rapporteurship committee consolidated 36 directives and 541 proposals that were part of the list of proposals available for voting in the working groups and in the final plenary session of the 15th CNS, plus another guideline and 35 proposals from Pernambuco, which came late to be included in the national consolidation of state conferences, but were appreciated in the national stage of the 15th CNS. Finally, at the National Conference, 37 guidelines and 560 proposals published in Resolution No. 507 of the National Health Council were approved in March 2016 (Brasil, 2016b); until June 2019, its final report was not published.

In an attempt to indicate priority proposals and guidelines, the organizing committee decided to record in the final document of the 15th Conference the percentage of approval obtained by the proposals and guidelines in the voting held in the final plenary or in the working groups of the national stage. This data was organized, in Table 2, into three accepted acceptance ranges: (1) 50% to 70% of approval, (2) 71% to 89% of approval, and (3) 90% or more approval. Thus, 201 (35.9%) proposals and 15 (40.6%) guidelines had approval equal to or greater than 90%.

Table 2 Percentage of approval of the proposals and guidelines accepted by the working groups and final plenary, by axes of the 15th CNS, 2015  

Axes of the 15th CNS Guidelines and proposals % approval of proposals and guidelines % ≥90%
50 to 70% 71 to 89% ≥90%
1. Right to health, guaranteed access and quality care 108 proposals 15 35 58 53.7 %
5 guidelines 2 2; 1 20.0%
2. Participation and social control 70 proposals 14 28 28 40.0%
8 guidelines 0 8 0 0.0%
3. Valuing work and health education 86 proposals 14 44 28 32.5%
3 guidelines 0 1 2 66.6%
4. Financing of SUS and public-private relationship 62 proposals 8 40 14 22.0%
2 guidelines 1 1 0 0.0%
5. SUS Management and health care models 50 proposals 4 22 24 48.0%
4 guidelines 0 0 4 100.0%
6. Information, education, and communication policy of SUS 42 proposals 1 25 16 38.0%
4 guidelines 0 0 4 100.0%
7. Science, technology and innovation in SUS 84 proposals 12 42 30 35.7%
7 guidelines 0 3 4 57.1%
8. Democratic and Popular Reforms of the State 58 proposals 14 41 3 5.1%
4 guidelines 0 4 0 0.0%
Total 560 proposals 82=14.6% 277=49.5% 201=35.9%
37 guidelines 4=10.8% 18=48.6% 15=40.6%

Axes that obtained proposals accepted with the least amount of approval in the interval 3 were the cross-section of democratic and popular reforms of the State and the one of SUS financing and public-private relationship. Thus, only 5.1% of the accepted proposals in the area of democratic reforms obtained approval equal to or higher than 90%, and only 22% of proposals accepted in the financing axis showed 90% or more approval. The highest number of proposals in interval 3 was the right to health, guaranteed access and quality care, with 53.7% of their proposals accepted with approval equal to or greater than 90%, and SUS management and health care models, with 48%, as presented in Table 2. As for the guidelines, the axes that did not have any of their guidelines with approval equal to or greater than 90% were those of democratic reforms, financing and social participation.

The preference for certain demands, far from being a disinterested process, reflects the game of interests of the set of actors that participate in the Conference. Thus, although a proposal achieves a high percentage of approval, this does not necessarily mean that it is prioritized by the delegates. This may effectively mean that the dispute between interest groups about an axis was more consensual. This explains why the axes of democratic and financing reforms have fewer proposals with an approval percentage equal to or above 90%, given the politicization of the debates and the fierce dispute that may have taken place around these issues. Thus, the percentage of approval of proposals is not a good indicator of priority.

The 15th Conference was an effectively political phenomenon and the cross-cutting axis of democratic and popular reforms contributed to this by mobilizing into the conference the political debate about structural changes around policies that are strategic for health. This axis included proposals for economic social justice, such as the following proposal: to carry out public debt audits and tax reform (Brasil, 2016b). The following report illustrates this political-ideological character:

The dispute over the economic redistribution of produced riches. Because the EC [Constitutional Amendment] 95 was nothing more than a way of not redistributing the wealth produced by the working class. Because when you have money raised by the Union and the Union offers it as a public service to the population, this is income redistribution. […] The struggle to tell where the wealth produced by the […] working class had to be invested. (Interviewee 1 - Social)

The 37 guidelines and 560 proposals approved in the national phase of the 15th Conference were classified in this study, as to their form, into administrative and legislative proposals. Administrative proposals refer to those presenting demands directed to the Executive Branch, i.e., proposals that require Executive Branch action for their execution. An example of an administrative proposal may be the one that provides “to implement, guarantee and effect the National Humanization Policy in all health services” (Brasil, 2016b). Legislative proposals, however, require the Legislative Branch to comply with them. Thus, an example of a legislative proposal approved in the final document of the 15th CNS in “to revise the Fiscal Responsibility Law (LRF) to differentiate and expand the limit of expenses with personnel under SUS”, or to recommend the “end the Unbundling of Union Revenue (DRU) and the Unbundling of State Revenues (DRE) for the social security budget”(Brasil, 2016b).

Regarding the nature of the demands, in addition to the proposals and guidelines for policy formulation (19.1%) - the main purpose of the conferences, there were still those demanding the implementation of an existing policy, program or law (36.5%) and improvement of a policy or service (20.3%), as well as guidelines for a general public policy that exceeds the scope of the health sector (12.6%), as presented in Table 3.

Table 3 Proposals and guidelines approved at the national stage of the 15th National Health Conference, 2015 

Regarding the form of the guidelines and proposals
Directed to the Executive Branch Directed to the Legislative Branch
N % N %
480 80.5 117 19.5
Total = 597 (100%)
Regarding the nature of guidelines and proposals
Implementation of an existing policy/program/law Formulation of new policy Improvement of a policy/service
N % N % N %
218 36.5 114 19.1 121 20.3
General public policy Extending access to an existing policy Policy monitoring
N % N % N %
75 12.6 10 1.7 17 2.8
Inclusion of a specific group in a policy Expansion of a policy/service Total = 597 100%
N % N %
6 1 36 6

Source: CNS (2015)

Thus, one can see that most (80.5%) demands approved in the 15th CNS were directed to the Executive Branch, with a view to implementing an existing policy. On the other hand, the proposals that demanded Legislative competence occurred especially to improve an existing policy or service and to structure public policies that affect the health sector in some way.

Among the proposals that depend on the competence of the Executive Branch for their execution, there are those that are shared or exclusive responsibility of sectors other than health. There are still those that, even if they are located in this sector and need the Executive Branch to be induced, for their concretion they depend fundamentally on the distribution of power within the institutions and the forms of organization of the work process in health services. Thus, there are proposals in the final report that, due to various factors, will hardly be implemented, especially in a four-year period, which favors the repetition of proposals in subsequent Conferences. The counselors highlight this perspective in the following sections:

Obviously there is deliberation that ends up being… No matter how legitimate it is, it may be even incoherent, or however legitimate it may be, it becomes unfeasible. And there goes the dispute beyond the conference. (Interviewee 1 - Social)

Look, 50% [of the proposals] is unconstitutional and 50% is very difficult to implement. So we need to think of more effective mechanisms to use such an important space to produce results. (Interviewee 1 - Government)

In considering the cycle of health policy, Pinto, Vieira-da-Silva and Baptista (2014) affirm the implementation of a policy involves a set of aspects ranging from technical, political, economic, and social conditions to the diversity of agents and their degrees of involvement in the process. Within this range, there are several elements that make it difficult to implement a policy, such as formulators’ commitment to their viability, the low degree of coordination between formulators and implementers, the understanding of the policy by the agents responsible for its execution, and the amount of changes required for implement it.

Also noteworthy are the programmatic constraints, the difficulties in adjusting the technical and political times, and the legal or budgetary impediments that are placed as limiting factors so that the demands of the conferences can be institutionalized, implemented or improved in a health policy. In addition, another equally shocking element that involves the process of constructing a health policy consists in the political dimension of this process, expressed in the correlation of forces within the state apparatuses and in the pressure mechanisms of society. Thus, the CNS is a political phenomenon inserted in a broader political and institutional arrangement, being one of the alternatives to express the interests in dispute of the social actors in the definition of health policy (Souza et al., 2013).

Therefore, the results of health policy conferences depend not only on their format, but on a set of factors, including the sensitivity of the manager to the issues of society participation in the democratization of policies. The following statements allude to the political weight of the CNS for managers:

But, effectively, the conference is not owned by the Government. The conference is owned by society […] and it is up to the Council to use the elements of the Conference to dialogue with the Government - whether it will be respected or not, it is the Government’s problem. It may not respect and bear the burden of not respecting […], and it can respect and use the elements to build a new navigation chart. (Interviewee 1 - Government)

One [can] see today that, for most managers, the Conference is merely a formality. They do not have the courage to face the population, to face the organized society to say the Conference is not worth for them or that it is worth very little. (Interviewee 1 - Social)

Health conferences play a key role in conferring legitimacy on health policies, as well as on government action in the health sector. A concrete example of this political role of the Conference is the reformulation of the National Basic Attention Policy (PNAB). This was one of the proposals of the 15th Conference. However, the changes made by the Tripartite Inter-agency Committee and, say, the National Council of Health Secretaries (Conass), the Ministry of Health and the Conasems in this policy did not please the social societal entities that are part of the National Health Council, provoking a strong reaction contrary to the proposed reformulation, to the point the draft of this policy was approved by then Minister Ricardo Barros without the proper appreciation and approval of the largest body of social control in the country (Brasil, 2016a, 2017a, 2017b; Parlamentares…, 2017; Projeto…, 2017). Although the reformulation of the PNAB differs from that envisaged by the social actors of the 15th Conference, the representatives of the management affirm the change in this policy consists of a legitimate demand of the society, made with social participation, since it comes from the CNS.

Importance and political significance of the 15th Conference in the context of 2015

The June 2013 mobilizations, which led thousands of Brazilians to the streets throughout the country, despite being marked by spontaneity, nonpartisanism and the heterogeneity of diffuse demands, had, in addition to criticism of representative democracy, health as one of the main concerns, being named by 45% of Brazilians as the main problem of the country (Alencar, 2013; Gohn, 2015; Leite, 2014; Magno, 2015). These manifestations are not dissociated from the success of the National Movement in Defense of Public Health in collecting more than 2.2 million signatures. Known as “Health + 10”, this movement was created in 2012 and gave rise to Bill 321/2013 -Popular Initiative Bill - which provided for the effective and full repayment of 10% of current gross revenues gross of the Union for health (Brasil, 2013).

The Health + 10 movement, headed by titular entities in the National Health Council, had PL 321/2013 modified, appended and finally shelved by the Chamber of Deputies (Brasil, 2014b, 2015b). In 2015, this project was unshelved - however, in four months it was again filed. In its place, EC No. 86/2015, the Tax Revenue Law, was approved, which, contrary to the provisions of the Popular Initiative Bill, requires that up to 1.2% of the net current revenue of the previous year be destined to parliamentary amendments, and half of this resource needs to be invested in health and this amount must be deducted from the Federal Government budget allocated to the Ministry of Health. This amendment also repealed the legal provision that established the allocation of 25% of the resources acquired through the exploitation of the pre-salt to health, as well as staggering in five years the reach of the 15% percentage of the resources of the Union, beginning with an application of 13.2% from 2016 (Brasil, 2015e; Golpe… , 2014).

The accumulation of political forces around the issue of public health financing was channeled into the 15th Conference. Thus, in the process of building the 15th CNS, there was a deliberate attempt by the National Health Council to unify all its segments around the demand for health financing, in order to make it the main agenda of the Conference. There was even a movement within the Federal Government, articulated to entities, social movements and the National Health Council, to secure more financing for health.

Our attempt was to build unity among the three segments, including the private sector and the scientific community […]. We tried to unify, we tried to work with priorities; one of the priorities was health financing, so this greatly unified workers, users and managers […]. Managers were very mobilized by the financing agenda, they wanted and prioritized this, and the agenda was also a strategic agenda for us [users] to make the dispute against the PEC of the spending ceiling and the freezing of social spending. (Interviewee 1 - Social)

When the start was made for the 15th, there was a great possibility of facing the central issue of underfinancing, even because President Dilma herself waved at it; since the possibility of rebuilding the CPMF, […] she was beckoning, she was calling us to this. She received the entire National Health Council in an audience, in my management, which I consider remarkable, in the Planalto Palace. […] We who were in the Government and were members of the Council, we foresaw the 15th as an event that would be the apex of a process of mobilization to confront and find a solution to the situation of underfunding of health in Brazil; […] it would be a turning point, due to the signals we received from President Dilma, […] the Minister of Planning, the head of the Civil House. It had a very interesting conjuncture. (Interviewee 4 - Government)

The legitimacy of the Federal Government among the legislators was already showing signs of wear and tear at the end of Dilma’s term (2011-2014), signaling a major shudder in Executive-Legislative relations. In May 2014, the National Social Participation Policy (PNPS) was sanctioned, through Presidential Decree no. 8243, whose objective was to strengthen the spaces of participation and social control - and, therefore, participatory democracy - through the presence of these institutions of public policy and management in a more articulated and systemic way. Although it did not bring substantial changes to the participatory institutions, especially those with a solid trajectory in public policy such as health, the PNPS was interpreted by the Federal Legislative Branch as a threat to the Brazilian representative system, because, according to the critics of the Parliament, it was about the creation of another Power in the Republic, eliminating the Legislative from the discussions of public policies. This proposal was barred by the National Congress (Alencar; Ribeiro, 2014; Gadelha, 2015), demonstrating a change in the correlation of forces between the Executive and Legislative Branches, in the direction of a weak Executive and a strong Legislative. Based on the ordinary meeting of the National Health Council, the plenary approved a motion to support the policy and endorsed the manifesto in defense of the Presidential Decree, launched by the 1st Inter-council Forum of the PNPS (Fórum…, 2014; Brasil, 2014d). The following speech alludes to the impasse surrounding this policy:

At that time, a strong bombing began on a policy of social participation. […] The right-wing parties called it the Bolivarian Law of Social Mobilization and, in fact, what the bill said was all that is in the law, it did not say anything else, only institutionalized the social participation. And that was bombarded any way possible. (Interviewee 1 - Government)

From the economic crisis and the political crisis that marked the history of Brazil, especially from 2014, and culminated with the impeachment of President Dilma in 2016, the political conjuncture became a central issue in the national stage of the 15th CNS. The imminence of the parliamentary coup, whose consummation represented a threat to Brazilian democracy itself (Domingues, 2017), made the Conference an area of political expression in defense of the president’s mandate and the democracy. The public financing of health remained a priority issue of the event, but under an unfavorable situation. Health came to be the target of the conservative attack of the National Congress with the “bomb-schedules,” materialized, for example, by PEC 451, of December 2014, by deputy Eduardo Cunha, which intended to make health plans mandatory for all workers. The following statements demonstrate this dynamic:

Throughout the production process of the 15th, we have already perceived a substantive change in the position of the Congress: the conservative forces gathered around the then budget reporter, who was the current minister Ricardo Barros; the extremely important protagonism in the conservative agenda of Eduardo Cunha, now as president of the Chamber of Deputies. […] The Conference played an important role, but I think it would play a role in an out-of-crisis setting and ended up with another. (Interviewee 4 - Government)

The conjuncture determined much beyond a structured, planned agenda of the structuring question of SUS, which is financing; we were also very moved by the current situation. (Interviewee 1 - Social)

The strength of the discussion was still the issue of funding […], the discussion of funding for health policy, and the issue of the threat to President Dilma’s mandate. The political instability posed at that time were the two strongest issues within the Health Conference. (Interviewee 2 - Government)

In this way, the Brazilian conjuncture of 2014 and 2015 reflected in the 15th CNS, being in line with the concern of the National Health Council to make it more politicized, to bring elements of the Brazilian conjuncture into the event, so that the Conference was not detached from reality. The national stage was initiated in the midst of a march in defense of the SUS, a political act followed by several other demonstrations during the four days of the conference (Costal; Conceição, 2016). The acceptance of the request to open the process of impeachment of the President of the Republic by the Federal Chamber reverberated in the plenary of the 15th Conference, provoking in the delegates a reaction to defend the democratic regime.

The 15th happened at a time when we had a democratic government, with all the contradictions the government of President Dilma, the PT, or the coalition government presented. We had a 15th at a time that preceded the impeachment, with much political, economic and social tension - at the time of sanitary crisis with the issue of the zika virus epidemic, at a time of social crisis as well. (Interviewee 1 - Social)

The 15th Conference took place […]. It was already in the early pre-coup movements […]. Brazil already begins to feel the taste of a process of rupture. It was a very tense process. (Interviewee 1 - Government)

The Conference was already at the stage of threat to President Dilma’s mandate […]. Hence, that moment was used to […] discuss a lot of partisan politics and the political moment Brazil was going through. […] It was a moment of strong and fiery demonstration by the counselors who were there […], a very strong political moment. (Interviewee 2 - Government)

The 15th happened in the middle of the coup process […]. We had the opportunity, in this Conference, to bring the President of the Republic, Dilma Rousseff, in a warm welcome to the nearly 5,000 participants of the Conference, to support and strengthen the legitimacy of the vote for which she was elected. (Interviewee 2 - Social)

It was a conference that was very focused on political support for President Dilma. (Interviewee 12 - Social)

Dilma Rousseff attended the last day of the Conference, marking the 15th as the Conference that was attended by the President of the Republic itself. She was greeted by the plenary, despite arid restrictions and criticism against aspects of her economic, social and even health policy. But there were also attempts at booing with her arrival at the 15th Conference. At that time, the Chamber of Deputies authorized to initiate the process of impeachment of the President of the Republic (Campos, 2016).

Final remarks

Some limitations were identified in the 15th CNS. From the point of view of its institutional design, despite having mobilized both the network of councils and social movements that were not part of the social control, becoming a Conference with relevant participatory dynamics, a bureaucratic format still prevailed since the partial opening for the company’s participation (not adviser) in the event was regulated and limited. It is necessary to radicalize the democratization of health conferences in the country and make strategic use of this participatory channel to further strengthen the social base of the SUS. Another weakness is the holding of the Conference outside the appropriate period to interfere in the preparation of the PPA. In addition, although its guidelines are part of the PNS, it was drafted and approved belatedly in relation to the PPA and the Budgetary Law of 2016.

On the other hand, the effort to improve the elaboration of the guidelines by politicizing the debates and limiting the number of proposals and guidelines sent for appreciation in the final stage of the 15th CNS is recognized. Thus, from the perspective of the current legislation, the 15th Conference fulfilled the role of assessing the health situation, since much of its guidelines go towards proposing the improvement of existing health policies and calling for the implementation of policies previously formulated. The 15th Conference also maintained the lead in proposing guidelines for new health policies, and was also a source of political pressure to address one of the SUS bottlenecks, which is the historical public underfunding of health. In addition, this event was the scene of the defense of democracy at the crucial moment of the parliamentary coup of 2015-2016, since the strengthening of the SUS presupposes a democratic political system.

However, it should be noted that there is an expectation that the CNS will do more. Just as the guidelines of the 8th Conference guided the National Constituent Assembly, 30 years ago, and became constitutional articles in the chapter on social security (health section), defining the directions of the Brazilian health system, there are those who expect, at each Conference, that its impact is equivalent to that of the 8th. The historical and political conjuncture, the social, political and market actors, the situation of the health system and, therefore, the challenges are different. Today, SUS is a reality and has positive impacts on the health of Brazilians, although it presents relevant fragilities (Paim et al., 2011; Viacava et al., 2018). The alignment of the Conference debate with this concrete reality of the health system is a necessary but not sufficient condition for its effectiveness - that is, for the CNS guidelines to actually be implemented. The results of this article demonstrate that the 15th Conference expressed this alignment.

However, the politicization of the Conference debates, innovations in participatory dynamics and the temporal alignment with the planning and management instruments do not guarantee that its guidelines will guide the construction of health policies. Returning to the initial question of this study, it is not enough to rethink the Health Conferences themselves. In addition, one must reflect on mechanisms that make decision-makers more permeable to the demands of society expressed in these events, beyond the political pressure of social movements and the work of the Health Council. One of the ways may be to democratize, in fact, the planning process and health management. This would contribute to strengthening the role of the Conference in the dispute with the other actors around the definition of health policy.

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Received: December 27, 2018; Accepted: April 22, 2019

Correspondence Berenice Temoteo da Silva Rua Basílio da Gama, s/n, Canela. Salvador, BA, Brasil. CEP 40110-040.

Authors’ contribution Silva conceived and structured the research, analyzed and interpreted the data, and drafted the manuscript. Lima guided the research project and critically reviewed the article.

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