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Ciência & Saúde Coletiva

versão impressa ISSN 1413-8123versão On-line ISSN 1678-4561

Ciênc. saúde coletiva vol.21 no.6 Rio de Janeiro jun. 2016

http://dx.doi.org/10.1590/1413-81232015216.06742016 

ARTICLE

Author-actors and organizational and relational processes in the review of the National Health Promotion Policy

Ronice Maria Pereira Franco de Sá1 

Regiane Rezende2 

Marco Akerman3 

Maria do Socorro Machado Freire1 

Rosane Paula Senna Salles1 

Simone Tetu Moysés4 

1Núcleo de Saúde Pública e Desenvolvimento Social, Universidade Federal de Pernambuco. R. Mariz Vilela 77-402, Cidade Universitária. 50720-270 Recife PE Brasil. ronicefranco@gmail.com

2Unidade Técnica de Determinantes Sociais da Saúde, Riscos para a Saúde, DCNT e Saúde Mental, OPAS/OMS Brasil. Brasília DF Brasil.

3Faculdade de Saúde Pública, Universidade de São Paulo. São Paulo SP Brasil.

4Programa de Pós-Graduação em Odontologia, Pontifícia Universidade Católica do Paraná. Curitiba PR Brasil.

Abstract

This article offers an organizational and relational analysis of the review of the National Health Promotion Policy and aims to understand the role of the cluster that was formed to review this policy, the negotiations needed to achieve the product, the role and type of alliances that were formed, the strategies adopted and interests, and how they influenced results. To do so, a dialogue is created to discuss social capital, organizational and network approaches, and inter-institutional strategies that highlight coordination mechanisms, integration, zones of uncertainty and the type of centralization. Structural, cognitive and relational dimensions were analyzed in the particular historical context. This was a case study with sources of evidence collected in the review process and in the documents examined. The analysis was performed by building conceptual categories by author-actors presented in the process. It highlights the role of the relational dimension represented by strong ties built over time, and ideological identity, based on profession or origin, as factors that acted positively in overcoming conflicts.

Key words: Health promotion; Public policy; Social capital; Case study

Abrasco influencing the development of a national public policy

This article aims to present an analysis of the role of the organizational actors, and especially their relationships, in the review of the National Health Promotion Policy (PNPS). A number of studies and articles have been published about the process to build and review this policy1-8. However, herein we present a novel approach, the aim of which is to foster reflection and further studies. This article is not in itself an analysis of the Policy, or a report and disclosure of the review process, but rather an analysis of this process using an organizational and relational approach9.

We used the classic concept of organization as a social entity made up of two or more people working in coordinated fashion in a specific external environment towards a common goal, with clearly assigned responsibilities and tasks. Thus we looked at the “cluster” created to review the PNPS as an organization, analyzing its characteristics, actors and working processes along the structural (type of organization, control mechanisms, hierarch, partnership creation, networks), cognitive (intellectual capacity, learning, shared visions, shared paradigms) and relational (inter-subjectivity, bets, interests, conflicts, development of ties, trust, standards and sanction) dimensions. Although inspired in the model of Hartman and Serafim10 for analyzing organizational social capital, our proposal considers other assumptions as well.

A key factor when building or reviewing public policies in “developing or recently democratized nations (...) remains the difficulty in creating political coalitions that are able to (...) address the need to drive economic development and promote social inclusion (...)11”. Thus the partnership put together, comprised of the Ministry of Health (MoH), the Pan-American Health Organization (PAHO) and the Brazilian Association for Collective Health (Abrasco), through its Thematic Group for Health Promotion and Sustainable Development (PSDS) (representing academia and professionals) to review the PNPS is justified in that the public policy area brings together the State and studies of its role, supported on Academia and the possibility of scientific reformulation and analysis11. In an attempt to consider the view of academia (in addition to the government’s view), we attempted to determine consistency between concepts and practices (and also include the results of the different groups involved in reviewing the PNPS), to group the different proposals for retaining, amending and/or renewing the 2006 PNPS.

Canada’s Henry Mintzberg12 and France’s Michel Crozier and Erhard Friedberg1313 are the organizational authors selected for our analysis. Their approaches go beyond the conventional four pillars of organization - Leadership, Management, Command and Control (LMCC) -, used by conventional administration. Mintzberg14 proposes six configurations and one non-configuration as a flexible and dynamic type of organization, with basic components, coordination mechanisms, and relationships between actors, ideology and power. There are more than ten schools of thought on how to develop organizational strategies, which explains how and why groups, circles, clusters of people (organizations with a common goal), opt for certain paths to achieve their targets. The configurations proposed by Mintzberg14 are a) simple structure, b) mechanistic bureaucracy, c) divisional structure, adhocracy, missionary structure and policy (non-configuration). The basic elements are classified as strategic cupola, intermediate hierarchical line (coordinator levels), operational nucleus, techno-structure, support (logistics) and ideology. Each configuration highlights one of the components, with its own mechanisms of primary coordination (Chart 1).

Chart 1 Summary configurations. 

Source: Mintzberg14.

Crozier and Friedberg15 propose the organization as a concrete action system with multiple rationalities, as they consider there are as many rationalities as there are groups of actors. For them, no individual is willing to be treated solely and fully as an object to enable an organization to reach its goals. Actor conducts are not predictable, reducible, stereotypical or reproducible as a result of structural, financial or psychological determinants. Their conduct is invented and built based on specific contexts, and focus on precise goals and targets. The main strategic analysis concepts of Crozier and Friedberg are: a) Limited and strategic rationality - although it considers that actor conduct is always rational, the authors define it as limited, strategic and contingent rationality (not only due to economic factors). b) Power - the power of an individual or group to act on another individual or group - these three words - capacity, act and other - demonstrate the relational character of this notion of power. “Power” in this sense suggests reciprocity, where each actor knows his/her strategic “place”. c) Zone of uncertainty - highlights autonomy and power. All actors have a zone where their behavior becomes unpredictable and uncertain from the point of view of the other actors. Increasing power means increasing the zone of uncertainty (control over resources) of one actor relative to another. It means having more autonomy. This is also valid for organizations as a whole. d) Source of power - four sources of power are characterized by different types of zones of uncertainty between actors: 1) linked to having a competence or specialty that is difficult to replace, 2) linked to the relationship between the organization and the environment, 3) linked to how the organization organizes internal communications and information flows and, lastly, 4) linked to awareness and the use of organizational rules.

Here we reiterate that Mintzberg as well as Crozier and Friedberg are considered by some theoreticians16 as members of a functionalist school of organizations (the first one from North America and the other two from Europe), and by others as structural-functional17. One also finds references to current Mintzberg texts as interpretative18 according to the classification of Burrel and Morgan19. The concept of power for them is not a political theory. Mintzberg treats power as a resource for adapting to the environment and being more or less effective, as his focus is organizations. According to Mintzberg, mechanisms of coordination (Chart1) come from three sources: a) hierarchical supervision - management; b) mutual adjustment; c) standardization - which is further split into process, results and competence or expertise standardization, and lastly by cultural standardization (the identify of a culture, identity, ideology). This last is characteristic of missionary organizations.

Crozier20 defends that actor integration within organizations takes place in three ways: a) coercion, when rules are imposed; b) affective or ideological manipulation through discourse; c) negotiation between different actors and/or groups of actors. For him, an organization is a system of structured games. Rules and structures lead to specific power games and organizational behaviors. In this way, actors may or may not collaborate and/or negotiate terms for insertion and for capturing a large zone of uncertainty (resource control) to meet their personal goals and interests. Crozier20 stresses that, nevertheless, by fighting to achieve their personal interests, actors are limited to working within the options provided by the system, which will always ensure that they are fulfilling the organizational goals, even if only in part.

Beyond the dichotomy of actor-structure, micro-macro, voluntary-deterministic, subject-object, we try to make room for the so-called “new possibilities” (not so new anymore), analyzing how actors play the game and the role of structures in building paths for society. The sociology of organizations and the sociology of relationships give us concepts and terms to analyze group actions. Inspired by Vautier21 and his defense of sociology of relationships, we point to three currents that help us understand how to build our analytical matrix: a) Symbolic interactionism - which emerged from the Chicago School and defends in its essence that the social structure emerges from interactions between individuals. In this case, the individuals in the relationship matter more than the relationships themselves, or the networks developed. Shared standards and values are not at the core of the analysis22.

b) Methodological individualism (together with the actionism of Crozier and Friedberg) - similar to symbolic interactionalism, actor intentions, rationality, inter-relationships and motivations play a more important role. Individuals produce the social and the social changes individual behaviors based on the rationality that exists in principle (intentionality)23. c) Analysis of social networks24 - beyond the concept of networks, it introduces the need to show the temporal or historical dimension25, which is essential to develop lines and relationships between actors (human or not)26, and their findings and analyses. The notion of a network emerging from this approach is linked to complex narratives, and may serve both for the actors and for observers, recording aspects of life as a group. One of the network approaches is related to the concept of capital and its weak and strong lines27. Another approach focuses on translation and socio-technical relationships, as proposed by Akrich et al.28. This approach also finds similarity with the approaches of Boltanski and Thévenot9 in their justification theory, which looks at agreements and disagreements and their justification using model worlds or cities, and their relationships with each other. Depending on the type of study and analyses, these are not discordant. Despite numerous criticisms, Amblard et al.9 were actually daring, and succeeded in convincing a large number of sociologists with a proposal of compatibility across the various sociological schools cited, including the contingency approach of Henry Mintzberg.

For the purposes of this study, from the relational point of view, and to adjust to the methodology used in reviewing the PNPS1, we used a network approach that includes analysis of weak and strong links to the organization’s social capital27, seeking to highlight rules, power games, actor intentionality, bets and interests, based on the organization focuses already prioritized. Amblard et al.9 give us the bases of convergence and dialog between these theories.

To review the PNPS, the “cluster” created brought together people primarily from the Ministry of Health - MoH (the managing and contracting organization in this process), the Pan-American Health Organization (PHO) (articulator, advisor and facilitator), and the Brazilian Group Health Association (Abrasco), with its Working Group to Promote Sustainable Healthcare and Development (PSDS) (the coordinating, inducing, mobilizing, advisory and unifying force).

The role of the MoH and the PHO are easily recognized, as they are indisputable and necessary to build/review a public health policy. In the case of Health Promotion, the PHO has played a protagonist role in Latin America, and in Brazil has supported the initial discussions for designing a national policy. One of the aims of this analysis is to understand the relationship between these institutions and Abrasco’s PSDS WG - predominantly from the point of view of cluster members in the working group -, and recognize the importance of the organizational and relational game in delivering the end result.

What is the role of Abrasco in this trajectory? What strategic role does this working group play in designing and reviewing the PNPS? What is the role of a professional association in a process to design public policies? How did this working group influence the process? What are the links with the Ministry of Health, the Pan-American Health Organization and collegiate stakeholders? What are the forces or factors that influence the possibility of this collective development? What are the dimensions and/or links that drive the development of policies of collective interest?

Methodology

This article presents a cut of the case study conducted as part of the review of the PNPS by some of the authors who contributed to the text. Each one participated in at least three steps in the process, from conception of policy review, through negotiation, methodology, and simultaneous execution of the various moves1, monitoring, designing the triangulation analysis matrix, triangulating movements, cording the systematization movements, drafting partial reports, drafting the final report, feedback seminars, drafting the final PNPS before and after the feedback seminar, creating flow charges and diagrams to explain the PNPS, orientation of Ph.D. theses and drafting and publishing articles1,2,4. We analyzed the documents produced in all steps of the working process, and participated and observed, taking field notes and minutes of meetings and workshops. This ensured triangulation of the sources of evidence29. All members of the “cluster” contributed to the discussions and supported the possibility of analyses performed during the process, either to ensure mutual adjustment of the proceedings, or to serve as a source for future studies and analyses. For this cut, we built an analytical matrix based on organizational configurations (as a structure)14, on the strategic analysis of organizations as a system of concrete actions13, and the relationships created as a starting point and to maintain the policy review process. This fulfills the requirement of an approach based on structural, cognitive (configurations), and relational and cognitive (concrete system of actions and organizational social capital) dimensions. The historical context provides the basis for analysis by signaling relevant events, turning points, links that become stronger or disappear, partnerships, types of records and event registration.

In principle, the matrices were not designed to present the categories, as we attempted to triangulate the sources of evidence and perform an argumentative integration of the theories presented (using the matrices as the markers of integration in the theoretical apex), the baggage of the authors (speculative apex) and the field findings (empirical apex). The conceptual categories presented as outputs adopt the path proposed by Paillé and Mucchielli30.30. To ensure precise analyses we attempted to follow the decalog proposed by Minayo31.

Proposed analytical scheme inspired on the convergence of the assumptions of Mintzberg14, Latour26, Crozier and Fridberg13 (Figure 1).

Figure 1 Inspired on the convergence of the assumptions of Mintzberg14, Latour26, Crozier and Fridberg13. 

Historical Context

The Working Group has officially existed since 20021. However, the seed of the WG emerged as an interest on the part of the then Health Policies Department (HPD) in the Ministry of Health in implementing a project to research the Baseline of Health Promotion in Brazil32 (Project BRA 98/006). Cruz3 reports that, ever since, the development of a Health Promotion Policy was one of the anticipated deliverables of this project, along with a nation-wide survey of the experiences in health promotion in Brazil, fostering studies and research, training teams, and defining indicators and financial incentives to develop the area. Since late 2000, and throughout 2001, “PS disseminators”33 were invited to participate in PHO meetings in Brasília to discuss the conceptual and theoretical framework, and share knowledge of the reality of Health Policy practices in the different regions of Brazil. An approximation with Abrasco (of which most were already members), and with the practices of the then- National School of Public Health (NSPH) and its project for Local Integrated and Sustainable Development in Manguinhos, strengthened the idea of creating a future WG at that association, which happened over the course of time, each time the group met. The former SPS is also responsible for the Health Promotion Project aimed at formulating a National Health Promotion Policy, with managers and professionals coming from SUS and civil society. A preliminary document with this intent was produced in 2001-2002, following the management report of that SPS32.

The PSDS working group has a seat on the National Health Promotion Policy Management Committee (CGPNPS), and has participated in meetings since mid-20101. Conquering this space has enabled the development of a trust-based relationship between the Working Group and the members of government administration involved in promoting healthcare in Brazil. These ties are essential for developing the proper social capital27 and deliver a substantial review of a national public policy. Likewise, members of the MoH and Pan-American Health Organization are part of the Working Group, strengthening the ties that are essential for completing efforts involving shared values, principles and world visions14.

Between 2002 and 2010, the working group’s trajectory was made up of many meetings, reports and attempts at regional and national efforts with the Ministry of Health, many of these not at all successful, and others of only moderate usefulness. While preparing the 2006 PNPS occasionally involved WG members, but now the MoH decision makers are far more involved. WG members have led projects with different institutions in various parts of Brazil (Intersector Actions to Promote Health - AIPS, an Abrasco/ENSP/CPHA/CIDA-Canada partnership34), and multi-center research with the University of Sao Paulo and universities in different parts of Brazil, among others35.

It is up to the CGDANT (General Coordination of Non-Transmissible Diseases and Conditions), part of the Health Vigilance Department (SVS), to the Environmental Health Vigilance Department, and the DSAST (Worker Health), part of the SVS, to agree on a seat Abrasco on the PNPS WG, as a professional entity and representative of civil society. This seat on the PNPS management committee marked a turning point in the involvement of the Abrasco WG in the decision making spheres and those that define public policy. With a major concern in promoting fairness and equality, and in regionalizing, developing and implementing legal frameworks that are equivalent to those in the territorial bases, the WG representatives on the Policy Management Committee started to develop more robust relationships with all participating Institutions. These relationships are based on competence and regular and influential participation.

Structural dimension: “A chameleon-like cluster” searching for major transformation

For the purposes of this article, and based on the authors cited, the MoH was classified (with no specific in-depth analysis) as a government entity coordinated by standardized results, whose starting point is its intermediate hierarchical line (miscellaneous departments and coordinating bodies). In this case, a divisional configuration predominates, at risk of falling into a political configuration unless there are “career civil servants” committed to the continuity of the organization beyond the political context.

The Pan-American Health Organization is an organization of the professional bureaucracy that advises governments in Latin America. It is coordinated by standardized competences and qualifications, based on the assumptions of Mintzberg14.

Abrasco, as a professional bureaucracy par excellence, tends to be highly decentralized, both vertically and horizontally, which is ideal for this type of organization, whose strength is its operating core as a mechanism to coordinate and standardize the qualifications/competences of its members. Recognition of the level of professionalism and specialization of the members of an organization of this type make Abrasco an important ally in building a national public policy in any of the Theme Groups that make up the consultative and advisory structure, together with the Forums and Committees36.

Part of Abrasco, the PSDS WG, is at times an adhocracy (not much formalization or organic structure, with a more horizontal and flexible structure), and sometimes a missionary organization (actions taken around a shared ideology). The flexible, innovative, horizontal, regionalized and “missionary” character, standardized based on competences, makes it easier for the MoH to interact with the Pan-American Health Organization. As mentioned above, since 2001, many of the members of the three institutions have worked together towards a PNP and to map the reality of health promotion in this country, also trying to build the conceptual, theoretical and methodological frameworks for this area. The emergence of the WG reinforces the concept of a hybrid missionary-adhocratic structure to implement actions, conduct studies and plan collective activities of an inter-regional character. Among what went right, and what did not, over the almost 15 years of these partnerships, trust-based relationships were built, and the “missionary/militants” became resilient, persisting in each of the institutions involved, including universities across Brazil, enabling a review of the PNPS, eight years after it was first published.

The “cluster” resulting from the involvement of all three institutions created a hybrid adhocratic-professional-divisional organization, coordinated by mutual adjustment between peers as well as standardized competences and the results expected of the various simultaneous movements1: FormSUS, DELPHIs (Inter and Intra-sector and Universities), Regional Workshops, Workshop with the National Board of Health, Systematization Workshops, Feedback Seminar.

In his book entitled Strategy Safari37, Mintzberg et al. suggest that the best strategy school for this type of confluence is the “configuration school”, represented by a chameleon. This school favors adhocratic and missionary organization, as these seek transformation (reformulation, revitalization, review). The message this school aims to give is integrate and transform. The message to be received is aggregate and revolutionize, rather than adapt. Those who defend it agents of change, aggregators and integrators. Mintzberg mentions that this type of school is more popular in the Netherlands and Germany, but its main sources are Chandler, the McGill group (including Mintzberg himself), and Miles & Snow. It is based on history and does not negotiate to propose or develop strategies in the absence of a time line or a historical process.

This definition of the configuration school is a good way to explain the strategies adopted in reviewing the PNPS, where at each disappointment or hurdle, the importance of integration and maintaining the principles and values that bind the “cluster” were reinforced, enabling the search for new options to implement the action. This discussion of the study leaves no question that the team leading the review actually created an adhocratic-missionary-professional configuration, where the professional component was not the prevailing one. It was not the merit or qualifications that weighed in to continue the revision process. It was the combined strength around a shared vision of the world, and the desire to integrate and aggregate, more than the desire to adapt or hierarchize and classify that drove the process, and the configuration schools is based on this experience. At times, due to issues of proximity and structural ease, some clusters met more often than others, but the systematization workshops (for monitoring, updating, information sharing, decision making and conflict resolution) leveled and reduced the “zones of uncertainty” of who appeared to have (and sometimes did have) more power in the process.

Cognitive dimension: a pretext for meeting? Diluted expertise?

The intellectual and cognitive baggage, which at first glance would seem to be the strongest point in common in a cluster of professionals with different degrees in a given area, appears more as a “pretext for meeting” than as the “glue” that promotes integration around shared interests. According to Serafim and Dias38, the values and interests of the actors involved in designing public policy are the fundamental elements, and become the specific focus of attention when analyzing public policies. This premise reinforces our findings and notes showing that not much use was made of specialized knowledge or hierarchical structures based on academic merit. It was the values, principles and interests, more than knowledge of the discipline itself or, in this case several disciplines, that made a difference.

Perhaps a certain level of homogeneity in terms of theme baggage, or the existence of a small group interested in Promoting Health (with already strong ties), worked to dilute the cognitive factor, making it a supporting element in the review of the PNPS. We should point out that this group was comprised of people very knowledgeable in the theme. Would it them be the obviously explicit expertise shared by most members the factor that made it appear invisible during the review?

Relational dimension: starting with “us” and developing strong ties

This dimension showed itself to be the most important for all steps of the PNPS review. If “cluster” members came together because of the trust based on the proven competence of each one (professional bureaucracy premise), which leads to so-called weak ties or bridge relationships27, they remained due to the trust created by solidarity (minority, profession, geographic origin, ethnicity, the friendship developed and a common origin, all of which create strong ties (binding relationships).

Actor integration was the result of “discourse and ideological and affective manipulation, as well as negotiation20”. Despite financial and thematic rules and limits, coercion was not the prevailing force. This is why the effort went far beyond the initial government proposal. Listening to the interested population in all five regions of Brazil strengthened the ideological integration and gave members of the “cluster” the role of population representatives. We thus found that the five regions in Brazil have different demands and priorities when it comes to Health Promotion39. These are the following: a)Southeast - themes of urban health, mobility, quality leisure, damage reduction and horizontal management; b) Northeast - territoriality, sustainable development, sustainability, well-being, love, worker health, subjectivities; c) North - access, mobility, fighting violence, basic sanitation, regionalization; d) South - life at work, healthy and suitable nutrition, happiness, protagonism, sustainability; e) Middle-West - vigilance in the use of agrochemicals, sustainable development, respect for culture, governability, social vulnerability.

Regional demands and the proposals received from different simultaneous movements are the “us”, when they move beyond the line of MoH governability, meaning when a need for intervention beyond healthcare has been identified. We found to be present in almost all of the demands. Thus, it was the strong ties and relationships based on training, ideology and shared origin that initiated adjustments in the PNPS text to minimally meet the demands and expectations of the distal participants in the review. The Feedback Seminar demonstrates the reach of this target.

Final Considerations

This proposed analysis of “clusters” created to review the PNPS shows the strategic role of Abrasco as a professional organization capable of creating trust by signaling a standardization of the qualifications and competences as a starting point for developing partnerships to advise the drafting or review of public policies. Further studies are required to confirm this analysis. Likewise, the existence of a specific Theme Group with an adhocratic and missionary structure – sharing values with other organizations responsible for coordinating, drafting and enforcing the working process seem to have acted as a facilitating and strategic factor to ensure and influence the inclusion of proposals originating in the citizens themselves.

This study shows the strength of actor interests and bets, their interactions40 and system of concrete actions. The intersubjectivity found and described worked, in this case, in favor of managing conflict41,42. The “chameleonic cluster” is truly a cluster43, given that the actors are bound by strong ties and common values. In the case of drafting and reviewing the PNPS, this type of configuration was positive. However, because of its dissemination and advocacy, the most important links are the so-called weak links, as they are the ones required to bridge different clusters. The use of social networks, regional workshops, expanded connections and interactions based on theme interests create the required weak links. This implies in an urgent expansion of this collective beyond people who share ideology and values, but who have the goal of disseminating healthcare promotion, using the approach they feel is most relevant.

Of the dimensions analyzed, the structural dimension served as a basis and showed a direct link to the relational dimension, which was the prevailing dimension, especially regarding the generation and maintenance of strong links in actions of this nature. The cognitive dimension, perhaps because it is a dimension where intellectual capital was considered a “given”, serving to standardize and as a gateway, did not reveal itself as important as expected, leading to a question regarding the alleged polarization between meritocracy and shared values.

Acknowledgements

We would like to thank all of the members of the central review group for the National Health Promotion Policy.

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Received: February 5, 2016; Revised: March 3, 2016; Accepted: March 5, 2016

Collaborations

RMP Franco de Sá helped with the design, theoretical review, analysis and interpretation of the data, and also helped draft the article and approve the version for publication. Rezende helped with acritical review of the article and final approval of the version for publication. M Akerman drafted the abstract and helped with a critical review of the article and final approval of the version for publication. MSM Freire, RPS Salles and ST Moysés helped with a critical review of the article and final approval of the version for publication.

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