health councils and conferences in Brazil : an integrative review

This paper aimed to identify the thinking currents used for scientific production on health councils and conferences, from 1990 to 2017. This is an integrative review of literature carried out at the SciELO, LILACS and CAPES journals portals that resulted in the selection of 152 papers. They were analyzed by year of publication, author’s institutional origin, dissemination media, object and type of study and theoretical approach. We identified that a gradual increase occurred in the number of publications over the study period and most empirical studies (92.8%) do not explicitly state the use of any theoretical approach in data analysis. The structuralist, post-structuralist and neo-institutionalist approaches used were mediated by a theoretical model, medium-range theories and concepts of authors of the European, North American and Latin American traditions. The knowledge produced about health council and conference in Brazil may benefit even more from the density of theoretical approaches to social and political sciences.


Introduction
As the achievement of the right to health, health councils and conferences stem from the political action of the Brazilian Health Reform movement (RSB) 1 .The RSB movement's dialogue dynamics in the power spaces, in both the Constitution and Law 8,142/90, has imprinted these arenas of participation in the political process of health policy planning and management, with the indispensability of social actors.Thus, health councils and conferences are open channels for the participation of civil society in the definition and conduct of health policies, and are a step forward in the democratization of this policy 2 .
In the Unified Health System (SUS), health councils and conferences are a formal exercise of community participation in the construction of health policies.With the perspective of expressing the social and health demands of the population, the conferences define the principles and guidelines that should guide the whole process of formulating health policies.On the other hand, health councils consolidate the decisions defined in the conferences, formulating and strengthening health policies and establishing strategies to enforce, evaluate and control the execution of these policies by the Executive Branch 3 .
The significant amount of these formal spaces for participation in the country indicates greater possibilities for the democratization of health, along the lines of deliberative democracy, while at the same time stirring the growing interest of researchers 4,5 .Since its institutionalization in 1990, the qualified spheres of affirmation of the right to health in Brazil have been widely debated in the scientific literature, mainly regarding the realms of representation, participation modes, interests advocated in these spaces, internal dynamics of functioning and studies evidencing the limits and potentialities of these collegiate bodies [6][7][8][9] .
Literature reviews on the subject, among other things, allowed systematizing the main factors related to the institutionalization process of participation arenas, academia's understanding of society's participation in the health area, and the realms of participation already studied [10][11][12][13][14][15][16] .However, the main theoretical and methodological approaches that have been used in the studies on the subject have not yet been systematized.
Showing how scientific production on health councils and conferences appropriates theoretical currents to think and analyze the concrete reality of these participative spheres is the chal-lenge ahead, especially in the current situation of disrespect to these collegiate bodies, whose participation has been dispensed with in the reformulation of specific health policies 17 .This study proposes to pave the way in this perspective and, while not pretending or even having the competence to exhaust the theoretical debate on the theme, sought to identify the thinking currents used for scientific production on health councils and conferences, pointing out their potential in addressing with the analysis of the areas of dispute of health councils and conferences.

methods
This is an integrative literature review that sought to answer the following question: what are the theoretical-methodological references used and explained in studies on health councils and conferences in Brazil, published between 1990 and 2017?The date of onset of the time-related selection corresponds to the year of institutionalization of health councils and conferences in Brazil through Law 8,142/1990, while 2017 was the final period of the research.
The search was initiated in March 2014 and updated annually until May 2017.In the search updates made in 2015, 2016 and 2017, the variable year of publication was filtered considering the period between the year of the last collection until that moment.In the SciELO, LILACS and CAPES journals portal, descriptors used were "participação social", "participação cidadã", "participação comunitária", "conselhos de saúde" and "conferência de saúde".The descriptors containing the word "participação" were individually cross-referenced using the Boolean operator "AND" with "conferência de saúde" and "conselhos de saúde".Cross-referencing was performed in the advanced forms, and if not existing, in the free forms of the databases.This search strategy was used in the CAPES journals portal with the English descriptors, as recommended in this database.Databases were accessed through the CAPES journal portal, by remote access to the subscribed content through the referred portal for the Federal University of Bahia.
Inclusion criteria were papers published in Portuguese between 1990 and 2017, based on Brazilian health councils and conferences, since the intention was to study these participative collegiate bodies in the social dynamics of the country and, more still, search the deliberative spaces inserted in the singular context of the SUS.
Papers that, even when addressing health participation, did not refer to health councils or conferences were excluded.
Papers were selected by reading titles and abstracts, which allowed the exclusion of duplicated papers, and 364 works were preselected.Following their reading, we excluded papers addressing community participation in non-health community forums; participation of users in therapeutic decisions, in self-care groups and in disease control; participation in management collegiate bodies in other countries; participation in the process of formulating health policies through social movements, without mentioning council or conference; perception of community and health professionals about the council; and works on the participation of society in the enforcement of the budgetary, financial and fiscal implementation of the SUS, from mechanisms other than health councils or conferences.This dynamic process returned 152 papers, of which 84 were from the SciELO database, 44 from LI-LACS and 24 from the CAPES journal portal.
The 152 papers were read in full, with the extraction of a set of information that was included in a matrix.This group had the following variables: identification/title, year of publication, publication vehicle, authors, institutional origin of authors, object of study, health council/conference level, type of study and theoretical and methodological approach used.Thus, in the set of selected works, we could identify those that explained, in their content, the theoretical and methodological reference used.In this study, the conception of theoretical and methodological reference was adopted as an articulated network of concepts linked to a theory capable of providing rupture with common sense 18 .The epistemological rupture with common sense means putting in abeyance the vulgar pre-constructions and the principles generally applied in the realizations of these constructions 19 .

Bibliometric indicators
The scientific production on participation in health councils and conferences evidences a gradual increase in the number of papers during the period studied (Graph 1), although there has been a year-on-year variation with moments of a higher number of publications.Twenty papers were identified in 2012, while other periods did not show a record of publications, such as four years in the 1990s.
The analysis of the institutions, post-graduate programs, departments or undergraduate courses to which the authors of the studies are linked reveals that most of these are bound to institutions and programs in the area of health sciences (122 = 80.3%), and of these, mostly the Collective Health subarea (67 = 54.9%)followed by Nursing (24 = 19.7%).We also identified authors from institutions and programs in the area of human sciences (21 = 13.8%),applied social sciences (8 = 5.2%) and even agricultural sciences (1 = 0.7%).This finding indicates the interdisciplinary way in which SUS participatory levels are being handled by research institutions.It also points to the centrality of the theme of social participation within collective health.
Councils are more frequently studied (92 = 60.5%)than conferences (22 = 14.5%), especially municipal councils (59 = 64%), and no study addresses the National Health Council, whereas, in the group of studies on conferences, papers on national conferences predominate (13 = 59%), as shown in Table 1.The fact that councils are more frequently studied may be related primarily to their quality of being a permanent collegiate body, while conferences occur only once every four years in each sphere of government.Brazil has 5,570 municipal health councils 20 , which explains the significant amount of studies on this collegiate space within the municipal sphere.
The case study consists of the predominant approach (79 = 52%), of which most speak only about council (70 = 88.6%), while documentary research occurs more frequently on conferences (09 = 56.2%),as shown in Table 2.

methodological approaches
A novelty evidenced in this work is the use of evaluative research approaches in studies on health councils and conferences [21][22][23][24][25][26] .However, the perspective adopted in the evaluative research only addresses specific realms of the implementation and functioning of the council, through criteria, standards, indicators and models, and no research with this methodological design that assess the results of health councils and conferences in the health policy or health of the population are identified.
Although it is fundamentally necessary to know the impact of social participation, especially considering the dimension of these participatory spaces in the Brazilian scenario and the high investment in various spheres (political, economic, social, ideological, cultural, subjective) of society in health councils and health conferences, the results of social participation in the health policy and population health are still hardly known in Brazil 5,23 .
It is a gap of strategic relevance to the field of collective health that can hardly be answered with an isolated study.However, it was possible to identify studies [27][28][29][30][31][32] that have advanced in this direction.The methodological approach adopt-ed in these initiatives was similar and consisted in following consecutively the incorporation of the deliberations of social control into the health policy cycle, considering the joint action of arenas and actors (inter-agency commission, health council and conference, health secretariat and chamber of councilors or legislative assembly) involved in the process of building the health policy.
This strategy allows the overcoming of fragmented and alienating analyses that fail to capture the results of participation obtained over time and end up being overshadowed in the procedures of the various hands that lead decisions regarding health policy.In agreement with Schraiber 33 , it is a question of studying the concept of a delimited totality of participation in health, without this appearing in the idea of exhausting variables.The real possibility of producing knowledge about the results of participation in health policies through a retrospective longitudinal case study, considering the actors and arenas related to the construction of health policy, disallows the arguments that the evaluation of the impact of the participation presupposes necessarily of robust 5 , normative and generalizable models 23 , also because such models would hardly allow apprehending the totality that involves the participatory process and its unfolding, and whose expression also presents itself in the heterogeneous and variant situation of each Brazilian municipality and state.

theoretical-conceptual contributions
Extensive reading of the papers revealed that only eight (7.2%) of the 111 empirical studies explicitly substantiate their analysis in theoretical constructs 27,29,[34][35][36][37][38][39] .Most works (103 = 92.8%)seek, above all, to describe the event of participation.The mere description is a partial contribution to scientific production since it is necessary to consider the empirical and theoretical components of the event in order to construct a scientific object.The negligible publication of studies that showed, in their text, the theoretical-methodological contributions used in the data analysis indicate that the scientific production on health council and conference in Brazil is marked by theoretical or conceptual rarefaction, whose reflection occurs in the superficial knowledge built on the theme 33 .
The theoretical components identified in the empirical studies on health council and conference are shown in Box 1.
The theoretical premises identified in the studies belong to the sociological and political science matrix, and theoretical models, concepts and medium-range theories are evidenced since the use of a grand theory can only be verified through the mediation of more specific ones that can narrow its domain coping with phenomena at the concrete level 49 .The concepts used are related to the structuralist, poststructuralist and neo-institutionalist approaches.It is noteworthy the lack of studies directly adopting the classic social theories of Weber and Durkheim, or approaches that combined, in their theoretical framework, more from an analytical perspective.Works resorted to the approaches of authors such as Foucault, Habermas, Gramsci, Kingdon, Olson, Maslow, Collier, Lourau and Lapassade and Testa, and no studies that made use of social and historical analysis (Bourdieu) were identified.
The adoption of sociological theories based on the tradition of the conflict allows for a fruitful analysis of participation in deliberative levels, since the procedure adopted for deliberation in these spaces is based on voting that, to a large extent, is preceded by disputes of conflicting interests and discourses that are more similar to strategic action than consensus-based rationality.In this perspective, it is considered that Testa's strategic thinking 48 has an analytical potential for the review of the political process of participation in health.Linked to the Marxist current, the central category of this theoretical-methodological contribution is health power, in the way it is disputed and appropriate in the societal and social space of the health sector 50 .
On the other hand, with regard to the categories "power" and "communicative action" for Chart 1. Theoretical approaches used in papers on health councils and conferences.
The structuralist approach is based on the historicity, dynamicity and totality of the Marxist dialectic.It is a systemic theory that allows the understanding of human praxis.From this Marxist matrix, Gramsci 40 develops the concept of extended state, that is, one that accommodates, besides political society, civil society as part of the State.The former is underpinned by the set of mechanisms through which the ruling class holds the legal monopoly of coercion, those usually identified as government.On the other hand, civil society is set as a decisive arena of the class struggle, in which different social groups fight to preserve or achieve hegemony.Micro-power -Foucault 41 Poststructuralist Foucault shows ways of exercising power different from that exercised in the apparatus of the State and whose operation resembles a network of molecular micro-power that extends across society.Governmental agenda -Kingdon 42 The process of setting the governmental agenda, anchored in the public policy cycle theory, articulates three flows, that of transforming a question from the social environment into a problem, that of selecting solutions directed to this problem, and the political influences involved in the inclusion of the problem on the government agenda.Kingdon argues that policy-making and implementation decision-making process is influenced by the involvement of various actors who take advantage of a timely situation to pressure the government to include issues on the political agenda.This understanding is linked to the neo-institutionalist approach whose concern is to analyze the relationships between the State, society and policy formulation, in particular, to explain how institutions develop political strategies and influence political outcomes.Institutional analysis -Instituting/instituted -Lourau and Lapassade 43 The dialectic instituting (process) and instituted (form) is useful to analyze situations of institutionalization.In the case of the analysis of institutionalized participation, this perspective is marked by tensions to acquire more participation and strategic social and institutional innovation.While the former mainly includes participatory directionality and governmental conduct compatible and coherent with the reasons, modes and means of direct and indirect democracy, in the latter, the figurative performance of social control and the direction of government is autonomous, operating with its agenda and dissociated from the participation levels prevails.Critical moment -Collier and Collier 44 It is defined as a critical moment, a period of a significant change whether it is revolutionary or caused by institutional reform, which can last years or even decades; it is a situation of political or economic transition that occurs differently between countries, states, regions or cities.This process of change leaves a legacy that leads politicians to successive choices and decisions over time, in order to reproduce this legacy.Social groups' theory -Olson 45 The theory is anchored in the logic of collective action and seeks to respond to what leads individuals to associate and remain associated.To answer this question, Olson started from the perspective of collective rationality, considering that if everyone cooperated, everyone would win.However, as this does not always happen, individuals act rationally by measuring the costs and benefits of their collective actions in organizations or groups.Therefore, a contradictory relationship is formed between an individual and collective rationality.This approach of social groups is embedded in the theory of rational choice that presupposes that individuals deliberately act to maximize their advantages.Motivational Theory -Maslow 46 This theory starts from the perspective of psychology and seeks to identify the motives that lead an individual to have a participatory behavior in order to find solutions to collective problems.According to this theory, motivation is the result of stimuli coming from the (external) environment or generated internally in the mental processes of the individual (internal) that act forcefully on individuals, leading them to action.Theory of Communicative Action -Habermas 47 Communicative power consists of the possibility of forming political will based on the communicative action of individuals and, thus, can pressure institutions to incorporate demands into their agenda.The communicative action is expressed in an environment in which the participants involved have an equal condition to manifest their opinion, without any coercion.The decision is based on the consensus or the possible agreement on the best argument and its legitimacy is based on the possibility of all interested parties to participate in the communicative process.Communicative action rests its conceptual matrix on the critical theory of the Frankfurt school.Power in health -Testa 48 From a contribution more geared to health, the author analyzes the actual use of power resources within organizations, distinguishing three forms of power in health, namely, the technical, administrative and political power.Technical power can be understood as the capacity of an actor to manipulate and use information (epidemiological, sanitary, administrative).Administrative power is when the actor can manipulate resources (human, financial, technological, administrative) and political power consists of the ability to mobilize social groups.
Source: Own elaboration.the analysis of participation in health council and conference, the pure adoption of communicative action theory must start from the analysis of a concrete case that gathers real conditions for their use, since the perspective of communicative action presupposes a community of dialogue based on consensus and whose unfeasibility operates in a space marked by power asymmetry and predominance of authoritarian, corporate and co-opted traditional political culture.The cautious use of the perspective of Habermas' communicative action in participatory collegiate bodies' studies was also indicated by Muller Neto and Artmann 51 .In analyzing the potential of Habermasian concepts for the analysis of councils and conferences, these authors emphasized the need for these concepts to be mediated and contextualized.
The analysis of the power relations in the internal dynamics of the councils and the spaces of the health conferences, as well as between these channels of participation with the social and state actors that dispute the definition and the conduction of the health policy can benefit from Foucault's and Testa's approaches on power.This is because both perspectives recognize the existence and relevance of conflict as an inherent aspect of the concrete reality of democratic societies.However, the Testian analysis of power, mainly when referring to the typology of technical, administrative and political power, limits the use of power resources to the scope of organizations 39 .From the Foucaultian viewpoint, one can analyze, for example, ways of exercising power different from those in the state machine 35 .
Kingdon's theoretical model 42 is useful for analyzing how a particular social demand becomes a political issue.Thus, it shows the capacity of councils and conferences to include health problems that are priorities in the political agenda of the government 29 .Like Kingdon's theoretical model 42 , Testa's strategic thinking 48 allows the analysis of the participation of councils in the construction of the health policy, for example.However, the central object of the analysis provided by Testa's strategic thinking is the power relation, the political process and its relationships with the production of political facts, including the analysis of situations and their relationships with health policy 52 .Thus, with Kingdon's perspective 42 , it is possible to develop a health policy analysis and a political health analysis with Testa's strategic thinking.
Studies whose central concern is to understand the reasons that lead actors to engage in social movements may be benefited by Maslow's motivational theory 46 and the perspective of collective action in which Olson's theory of social groups 45 is anchored.It is emphasized that these approaches adopt the individual as a level of analysis, so that the central study object adopted in these theoretical contributions consists of the conference advisor or delegate, to the detriment of the council or the conference 7 .
Gramsci's concepts 40 of extended state, civil society, and political society have been used chiefly in reflection studies to understand the channels of social participation since they are hybrid spaces for the meeting of governmental and social actors.However, the operationalization of these concepts in empirical studies on health councils and conferences is hampered by the breadth of these Gramscian categories, which are based on the idea of social class struggle.
Thus, regardless of whether the scope of the theoretical premise used in research on health participation is about broad and medium-range theories (Gramsci 40 , Olson 45 and Maslow 46 ), theoretical models (Kingdon 42 ) or analytical theory-linked categories (Habermas 47 , Testa 48 , Foucault 41 , Collier 44 , Lourau and Lapassade 43 ), it is vital to keep a continuous coherence between the methodology chosen and the dynamics of the object.This epistemological vigilance facilitates the production of estrangement in daily situations, necessary to improve existing knowledge, avoiding automatism that annihilates the reflective power of research 19 .

final considerations
Brazil has a vast production of papers on health councils and conferences.However, these studies have low conceptual density; that is, they poorly articulate between the empirical formulation and a given theoretical reference 33 .The theoretical rarefaction of these studies also indicates that the knowledge produced on the subject is still superficial, requiring a more significant epistemological in-depth analysis than can produce contextualized interpretations of the empirical data.
The analysis of participation through more than one theoretical perspective (structuralist, post-structuralist, neo-institutionalist) indicates that there is not a single, unanimously accepted finalist model to approach participatory spaces.Thus, the construction of knowledge about councils and conferences can benefit from the contributions of social and political sciences and also from concepts and models developed by health planning authors.This study's limitation is having used only the production of papers as a research source, leaving aside theses, dissertations and books that, admittedly, have a relevant critical mass on the subject.It is also essential to consider that, despite efforts to gather all published studies on health council and conference, the search was only performed in the three primary bibliographic databases, and, therefore, the methodological strategy adopted does not presuppose an exhaustive review of all the already produced papers.Finally, it should be highlighted that papers that made use of theo-retical contributions were considered only those that explicitly stated the references in their text.
The study sparks some crucial aspects to be further analyzed by Brazilian scientific production on health councils and conferences.These aspects lie within the scope of the impact of institutionalized social participation on health policies; besides the occasional issue of the existence of few studies on the national health council, the highest level of participation in the national health policy, of strategic importance to the SUS; and especially the low theoretical density of studies on the subject.These elements open new perspectives for future research.

Collaborations
BT Silva collaborated in the conception, analysis and interpretation of data, writing and critical review of the article.IMSO Lima contributed in the planning, interpretation of data, critical review and approval of the final version of the article.

table 1 .
Distribution of papers by object of study.Trendline of Brazilian scientific production on health participation since Law 8,142/1990.

table 2 .
Distribution of papers by approach and type of study.