Reality and myth about legal healthcare support and quality of life in the Brazilian elderly

Realidade e mito sobre apoio legal em saúde e qualidade de vida de brasileiros idosos

Realidad y mito sobre apoyo legal en salud y calidad de vida de brasileños ancianos

Abstracts

The main aim of the study was to evaluate the effectiveness of the government’s social security cover on support and healthcare and its impact on quality of life of elderly in Brazil. We examine discursively in a qualitative study the State’s political commitment towards ageing issues; ageing seen as a social problem; and the government policies to ensure the quality of life in Brazil. Our main finding was that Brazilian’s elderly protection laws will cease to be a myth when these same elders are aware that they need to participate at all levels of government in the preparation of plans and policies and also to put them into practice. In this way the older person will have mastery over what is management and will be prepared to manage conflicts between individual interests and the policies of the government.

Ageing; Discourse analysis; Management; Administration; Health care

O principal objetivo deste estudo foi avaliar a eficácia da cobertura de seguridade social do governo na saúde e na qualidade de vida de idosos no Brasil. Foram examinados, em um estudo qualitativo, os compromissos políticos do Estado em relação às questões do envelhecimento; o envelhecimento visto como um problema social; e as políticas governamentais para garantir a qualidade de vida no Brasil. Concluiu-se que as leis brasileiras de proteção dos idosos deixarão de ser um mito quando esses mesmos idosos estiverem cientes de que precisam participar de todos os níveis do governo na preparação de planos e políticas e também colocá-los em prática. Dessa forma, o idoso terá domínio sobre o que é gestão e estará preparado para gerir os conflitos entre os interesses individuais e as políticas do governo.

Envelhecimento; Análise do discurso; Gestão; Administração; Cuidados em saúde

El principal objetivo de este estudio fue evaluar la eficacia de la cobertura de seguridad social del gobierno en la salud y en la calidad de vida de ancianos en Brasil. En un estudio cualitativo se examinaron los compromisos políticos del Estado con relación a las cuestiones del envejecimiento, el envejecimiento visto como un problema social y las políticas gubernamentales para garantizar la calidad de vida en Brasil. Se concluyó que las leyes brasileñas de protección a los ancianos dejarán de ser un mito cuando esos mismos ancianos tengan conciencia de que precisan participar en todos los niveles del gobierno en la preparación de planes y políticas y también colocarlos en práctica. De esa forma, el anciano, tendrá dominio sobre lo que es gestión y estará preparado para administrar los conflictos entre los intereses individuales y las políticas del gobierno.

Envejecimiento; Análisis del discurso; Gestión; Administración; Cuidados en salud

Introduction

The conditions in which people live and die are […] shaped by political, social, and economic forces. (World Health Organization, 2008)

The conditions in which people live and die are […] shaped by political, social, and economic forces. (World Health Organization, 2008)

The Brazilian government sets out a goal, establishing several public policies since 1974, with Law 6179 on social security cover for persons over 70 years of age ¹ . The main purpose behind this was to provide quality of life for elderly people promulgating rules in this regard ² . However, the effectiveness of the rule on grass root of the society and community is yet unknown. Social justice is a fundamental right of a citizen and Brazilian government has been playing an important role to protect its citizen basic right under human rights legislation ³ , ⁴ (art. 230). Elderly becomes vulnerable in any society and they need social protection from the state level. Thus, a study is needed to understand how accessible ⁵ the government legal support system is available for Brazilian elderly and whether or not any barrier is associated with getting such kind of government legal support. It is believed that having a free legal support from government advocating “for healthy and safe work conditions” has a direct impact on one’s quality of life ⁶ (p. 4).

There may be some reasons for the differences between facts and rules ⁵ on health, family and social matters of older adults that prevent implementing Government policy. This study aims to tease out those reasons explicitly for social policy implications. To achieve this, we will delve deeper into the State’s political commitments ⁵ , discuss ageing as a social problem and comment on government policies to ensure the quality of life. In this qualitative study, based on a discursive analysis ⁷ , we articulate topics on how the State performs its functions of providing well-being and how this affects the quality of life of the elderly in Brazil. Based on the findings a robust remedy is proposed that may prevent the lack of practice of government social security in Brazilian society today.

Methods

A qualitative analysis on State’s political commitments: results and discussion come together

The role of the State and its policy is deeply developed on main author thesis ⁵ . In this article we see this role in the field of health, departing from a World Health Organization report “Closing the gap in a generation” ⁸ . According to this report, the Organization ⁸ , through the Commission on Social Determinants of Health, set that “[the] toxic combination of bad policies, economics and politics is largely responsible for the fact of the world’s population does not benefit from the good that is biologically possible” ⁸ (p. 28). This is the way to understand how social justice affects the way people live. What World Health Organization means in this report is that the State has a four-dimensional power - political, economic, social and cultural -, and its role interferes with the causes of inequity in health due to bad politics ⁸ .

The Commission on Social Determinants of Health, is an unconventional mechanism for the protection of Human Rights ⁹ . It is an entity that is above and outside the State and does not have power over this last one. Its role is to make resolutions established by the Charter of the United Nations to maintain a system of special procedures or to formulate recommendations involving preventive urgent measures of protection. The neutrality condition of this Comission gives itself credibility to make a report with some recommendations indicating, as a general solution, a better distribution of power within society, or better saying, Governments should create policies or plans for the assessment of the impact on health equity ⁸ (p. 219). We intend to explore this recommendation – a better distribution of power - in this article, seeking solutions so that the State’s rules on elderly do not only constitute a myth but become reality.

This qualitative study articulates elements of how the State performs its functions in providing socio-legal services and how this can affect the quality of life of the elderly in Brazil. In other words, we seek answers to the following questions: Are legal services accessible to older Brazilian people? What are the barriers to get a government legal service? Do legal services help improving health and quality of life of elderly? What are the possible solutions to achieve World Health Organization recommendation of better distribution of power within society about health care for the elderly in the Brazilian context?

Legislating State and law in health under a discursive analysis

This study on Brazilian law in health focusing the elderly is conducted according to Discourse Analysis Method ⁷ . This theory is based on socio-historical context to clarify our regard through printed laws comparing them with the reality of ineffectiveness of the role of the State in promoting well-being. We work with a mixed method approach that consists on explaining the theory of the functioning of the State about legislating ⁵ and, on other hand, observing the practice on the health legislation focused on the elderly by questioning the inefficiency of some rules in health. After this theoretical comparison, we make some suggestions on health management regulations and principles to make certain health rules to be effective. World Health Organization report ⁸ recommends that the population participate in the State’s power. In order to this participation become real, we suggest the elderly to participate politically in health issues: through the decentralization of sectoral management; the development of strategies and processes to achieve integral health care for the elderly; the formulation and execution of policies that guide the actions of health services.

Discourse Analysis (AD) ¹⁰ is a science that encompasses three regions of knowledge:

It [epistemological framework] lies, in our view, in the articulation of three regions of scientific knowledge:

1. Historical materialism, as a theory of social formations and their transformations, understood here as the theory of ideologies;

2. Linguistics, as a theory of syntactic mechanisms and the enunciation process at the same time;

3. The theory of discourse, as a historical determination of semantic processes.

It should be made clear that these three regions are, to a certain extent, crossed and articulated by a theory of subjectivity (of psychoanalytic nature) ¹⁰ . (p. 163-4)

The focus of discourse analysis theory ⁷ is not only the transmission of information but the relation of subjects who, affected by language and history, suffer and produce meaningful effects on each other. Thus, one does not seek to study the strict meaning of words, but rather the opacity of meaning that materializes in discursive unity, in language-and-situation. According to Orlandi ¹¹ (p. 136), we can infer that the discourse of Health establishes a certain value in the information. Our analysis displaces the importance of this information to highlight language as an instrument of reiteration of processes crystallized by the State, which keeps the subject “in a constant return to the same sayable space: the paraphrase” ¹¹ (p. 137). We also investigate discourses on health issues that stay on an ideal place and we point to a rupture with this transparency, leaving a dominant discursive formation, that determines what can and should be said from a social place historically determined. There is no center, which is the literal sense, and its margins, which are the effects of meaning. There are only margins. By definition, all senses are possible, and under certain conditions of production, there is the dominance of one of them. The literal and crystallized meaning is a discursive effect. What exists in health legislation is a dominant sense that becomes institutionalized as a product of history: the ‘literal’. In the process that is the interlocution, however, the senses are replaced by time, in a multiple and fragmented way ¹¹ (p. 144). We intend to show, through a discursive analysis ⁷ , how barriers prevent effectiveness in getting a government legal service work in day to day experiences on elderly health. For this goal, we compare administration and management in health care sector in order to find out the appropriate space in which the elderly would exercise their participation in the management of health services.

Brazilian State policies and ageing as a social problem

Old age is seen as a stage of human life’s decline, of decrepitude preceding the end of life. The elders are related to poor health and loneliness and aging is associated with a process surrounded by fears, myths, and beliefs. Aging is a stage of life in which the individual has a decrease in their physical and cognitive abilities, and a higher incidence of basic pathologies such as diabetes, hypertension, heart problems, which, at a given moment, may require special care due to aging of the organic system ² , ¹² .

Brazilian laws on the protection of the elderly, have policies directed to 23,5 million elderly people, in order to give them better conditions and quality of life ² . Brazilian Federal Constitution ⁴ established the protection and legal protection of the group, but only pointed out the broad principles and did not establish specific policies for this part of the population. Brazilian Law number 10.741, dated October 1st, 2003 ³ , has contributed to the growing interest of people over 60 years old in relation to their effective social insertion. These laws regard older people as an absolute priority; ensure for them all the fundamental rights inherent to the human person, all opportunities and facilities for the preservation of their physical and mental health and their moral, intellectual, spiritual and social improvement, in conditions of freedom and dignity ⁴ (art. 230) ³ ; ( art. 2).

Although there are legal efforts to prevent the old people from being subjected to any kind of negligence, discrimination, violence, cruelty or oppression, and from any violation of their rights, by action or omission ³ (art. 4), it is observed that there is a lack of measures for these laws to fully comply with them ¹² . There were, in the first half of 2014, 13,752 complaints about violation of the rights of the elderly in Brazil ¹³ . Are elderly groups being fragile because they are not aware of the laws that protect themselves or because the law is not effective? In this way, we investigated some barriers that prevent older people from enjoying full State protection of their rights. The State has made protective laws (the Elderly Law) ³ , but society has not given greater concern to the elderly in relation to their well-being and the realization of their rights and guarantees ¹⁴ . Only awareness of their rights does not lead to the realization of their well-being. It is necessary to add an action of this group, in the sense of concretizing everything that the law advocates. This is a way to escape the indifference of the State and of the society. In order to promote the proper care, we suggest changes related to the degree of education of elderly: they themselves have to act so that the policies favorable to the group are effective, starting from the neighborhood where they live, increasing to the city and, finally, opening up the country the production of a protective structure for the elderly. There must be an interference in the power of the State to make the older people participate with a political contribution to search for improvements and to provide accessibility in health policies. How to interfere then?

Possible solutions to achieve World Health Organization recommendation on better distribution of power

Regarding healthcare of elderly, in order to achieve the World Health Organization recommendation of better distribution of power in the Brazilian context, there is a need to develop the health education work to raise awareness among small groups about their rights. This could be achieved by creating spaces for discussion in which democracy is exercised as the relationship between the State and civil society is established and institutionalized: the participation of the elderly in public health policies and practices of vigilance and less bureaucratic control. Based on the principle of the Brazilian Federal Constitution ⁴ (art. 206) on the democratic management of public education, we suggest to the health system to establish rules for democratic health management in which there is participation of the elderly in the elaboration of projects to improve the attendance and participation of them in municipal councils to promote quality of life. These proposals would be a condition for the establishment of democratic management in the health system, integrating progressive degrees of autonomy of the Municipal Health Councils. This work of education would depend on establishing the difference between two fundamental concepts: health administration versus health managing. This knowledge can lead to actions that solve the different needs of elderly people of different generations, demanding different assistance policies.

Administration and Managing

Subtle differences between the concepts of administration and management ¹⁵ - ¹⁷ that can be useful in delineating the political participation of citizens in the Brazilian Health Councils. In Brazil, Law 8142 of 28 ^th of December 1990 ¹⁸ creates Health Councils as collegiate bodies in all spheres of government, providing for the political participation of the community with a deliberative character. Although this legal provision exists, there are problems, since the law does not specify how this would happen, it does not say how this process should be brought to the knowledge of the population.

The concept of management is linked to a systematization of knowledge about how to manage, form plans and policies, set goals, imposing rules and regulations ¹⁹ . Bureaucracy, planning and organization are the most relevant characteristics in the concept of administration and are present in law 8142/90 ¹⁸ , whose forecasts and bureaucratic plans are unknown to the majority of the population.

The concept of management, on the other hand, is linked to how to implement objectives, how to maximize effectiveness by working in groups to implement something of interest to all, and for that, it is necessary to plan, organize, coordinate and decide ²⁰ .

While the Administration is linked to the role of high government authorities, decision-making attitudes, public policy formulation, decisions about what needs to be done and when it should be done in the legislative plane; Management is linked to functions of mid-level and low-level authorities, policy implementation, decisions about who will do the work and how it will be carried out in the executive plan ²⁰ . Because of these differences, the management is more appropriated to the expected involvement of the participant in the space of the Health Councils, as a teaching-learning space in the field of health education, conducive to the democratic performance of the elderly with respect to their own well-being, as provided by the law ¹⁸ .

Administration vs Management (Managing) in elderly health care

If there is a State, in its role of administration, in charge of planning and organizing the health of the elders by publishing laws or establishing policies, we may think, on the other hand, that a group can be trained to put them into practice: management takes into consideration the directing and controlling functions of the healthcare. Although with the passage of time, the distinction between these two terms is getting blurred - as management includes planning, policy formulation, and implementation as well, thus covering the functions of administration -, we emphasize the substantial differences can help us to develop some actions. The most important point that differs management from the administration on health care is that the former is concerned with directing or guiding the operations of the interested people (elderly in this case), whereas the latter stresses on laying down the policies and establishing the objectives of the State in health care.

Although the health of the older population began to gain visibility in the 1990s, with the concern of giving them more quality of life and placing them on the Brazilian Public Health agenda, the victimization of this group still remains a social problem ²¹ . Why? Things are at the ideal level as long as they only involve the formation of plans and policies within the administrative framework. Managing people happens at another level: the functional plan for implementing policies. While the government agency takes important decisions, framing policies and setting objectives, management plays an executive role in the organization, focusing on managing people, making the best possible use of the organization’s resources ²⁰ .

According to Surbhi ²⁰ we can infer that while management takes care of people in a functional level, of plans and actions focusing on policy implementation; administration configures set of objectives, policy formulation and an act of health administering by a group of people, in a high-level activity. Management functions are executive, looking after the management of the health care, and administrative functions are conversely legislative, responsible for the administration of health care, making the best utilization of country’s resources. The barriers to legal service be accessible to older Brazilian people are in the way they choose to get a government legal service: legal service will help improving health and quality of life of elderly when there is better distribution of power in the Brazilian context, when elderly act for achieving a common goal by using whatever the law specifically dictates for them.

A Brazilian experience on non-formal health education which takes place in the Local Health Councils ²² meets the necessary conditions so that the population of the older ones actively participate in health policies. The popular participation in these Health Councils approximates the concept of managing, since it allows the citizen to choose priorities and make suggestions regarding health services. While the head of the Local Health Council’s administration is concerned with “what will be done” or “when it will be done”, the role of health advisors is to manage and oversee the functioning and application of resources, better saying, “who does” and “how it is done”.

This participation of the elderly in the Local Health Councils cannot be confused with popular participation. It consists of a social participation ⁴ (art. 206, VI) because there is a popular representation in the State managing body, in the form of surveillance and control practices. These Councils are understood as public spaces that function within the structure of the Executive Branch ²³ .

The law does not regulate the Local Health Councils’ role of educator and replicator of the knowledge, and this is precisely the action that would enable the empowerment of society to participate in public policies and supervising health care ²² . Even though the Councils have been designed by law with relevant functions, they have low power of participation in the Brazilian social reality, being limited and fragile in their capacity to democratize public policies ²⁴ .

The solution would be in a complex process that involves the learning of managers, users and health professionals, that is capable of: transforming and empowering citizens to give their opinions on health decisions; mobilize managers towards an active participation in order to educate and inform users about their rights, sharing knowledge that gives rise to a socio-cultural interaction. This objective can be achieved through non-formal education practices applied to the Local Health Council spaces, similar to what occurs in social organizations, training programs on human rights, citizenship, struggles against inequalities and social exclusion. This allows for the gathering of ideas and knowledge produced by the sharing of experiences that generate knowledge through reflection ²⁵ .

Conclusion

One of the main findings of the study is health education as a mechanism to develop the empowerment of Brazilian society in decision making at the level of health strategies and thus, ensure the effective performance of the population, and specifically the elderly population. This empowerment guarantees the effectiveness of the organic law ¹⁸ that defined social participation as a fundamental guideline of the Brazilian health system. Although there is a perception among researchers that “qualitative research is ‘second class’ research” ²⁶ , this study covers important aspects of healthcare policies that can be reproduced anywhere. We found that the differentiation of the concept of administration and management brings to light the understanding of how the political participation of the elderly should be made effective in the execution of health policies defined by the government.

Health education is one of the health policies of the Brazilian government ²⁷ , ²⁸ , contributing to the monitoring and evaluation of policies implemented. The Brazilian Constitution ⁴ guarantees the health of the elderly, the law on the protection of the elderly, guarantees their rights, but does not establish guidelines to develop the capacity of the old people to effectively participate in decision-making of their interest. That is, an educational action that would develop in the individual the ability to critically analyze his reality and decide joint actions to solve problems and modify situations. This will only be possible if there is room for discussion and reflection that has repercussions on transformation in health processes. In order to concretize this action, in which the community of the elderly can participate in a democratic management, the health system may assure, to the members of a determined community, a progressive degree of administrative and financial autonomy: this is the only way to escape from the mythical formulation of plans and framing policies and goal setting to move to the realm of putting plans and policies into action.

Brazilian’s elderly protection laws will cease to be a myth when these same elders are aware that they need to take action to participate at all levels of government in the preparation of plans and policies and also to put them into practice. This action may not be restricted only to spaces intended for health care but may extend also to the community, seeking improvement in the quality of life. The elderly person who has mastery over what is management and is instructed in skills and abilities in the search for solutions to the difficulties that are particular to him will be prepared to manage conflicts between his interests and the policies of the government.

Acknowledgements

We specially thank Prof. Dr. Ashok Pundir, of National Institute of Industrial Engineering, Mumbai, India, who contributed to the discussion on the difference between Administration and Management and suggested references on these topics.

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Publication Dates

• Publication in this collection
  19 Aug 2019
• Date of issue
  2019

History

• Received
  10 Mar 2019
• Accepted
  28 June 2019