When public health systems are news: a comparative analysis of the journalistic coverage in Brazil and Spain

This study aimed to undertake a comparative analysis of the journalistic coverage of the National Health System (SUS) by “Folha de São Paulo”, and the National Health System (SNS) by “El País”. This qualitative study was anchored in the news values theory focusing on selection and construction news values and content analysis. All the contents published during 2013 of both newspapers were analyzed. “Folha” brought 88 covers, with 100 cover stories in total, and “El País” had 37 covers and 39 cover stories. “Folha’s” coverage focused on the “Mais Médicos” program, while most of the news in El País focused on the privatization of the Spanish public health system. The most important news value in both was related to government. As a second category, in “Folha”, controversy prevailed, focusing on the clash between the Federal Councils of Medicine and the Ministry of Health. Impact was the second most popular category in the Spanish newspaper. Concerning the news values of construction, we found that the newspapers used diverse resources. “Folha” adopted simplification in its approach, whereas “El País” invested in personalization and dramatization to sensitize readers with accounts of users, where the background was often the privatization process of health care services.


introduction
Despite the socio-economic, historical, and cultural differences between Brazil and Spain, it is possible to identify similarities in the health reform process in these two countries during re-democratization after years of dictatorship 1 .
In the Brazilian case, the 1988 Constitution recognized health as a social right guaranteed by the State 2 . Thus, the Unified Health System (SUS) was established based on universality, which constitutionally guarantees all Brazilians access to the system 3 . The SUS has advanced a lot and became a large public project with millions of beneficiaries. However, as Paim et al. 4 stress, it still faces significant challenges: the expanded private sector has generated negative results in equality, access to health services, and health conditions.
In Spain, health protection has been a fundamental right of citizens since the 1978 Constitution, and public authorities are responsible for organizing the National Health System (SNS) 5 . However, the 2009 international economic crisis affected Spanish social policies, which led to an SNS reform, marked by "pressures to open the public system to private capital, by privatizing measures and restricted access" 6 , resulting in the publication of Decree no. 16/2012. Known as 'health apartheid' , this rule represented a setback concerning the right to health, a break with the idea of universality and equality, with severe loss of rights [7][8] .
Thus, both systems face similar challenges, such as ensuring universality, surviving funding cuts, and competing with private insurance expansion, setbacks that have also been occurring in other countries, such as Italy, Greece, and Portugal, due to economic or political crisis 9 .
We aim to reflect on how and when the Brazilian and Spanish public systems are news in this context. We observed a few studies [10][11][12][13][14] regarding Brazilian media coverage. In general, these studies identified that the news focused on the periods of hardships and crises of the SUS. In the Spanish case, we noted that few studies prioritized the public system 15,16 ; in other works, the system is one of the variables studied, among others related to health/public health [17][18][19] .
Taking as a parameter those who analyzed some dimension about news production -assuming this is our interest -we find that this approach is even more restricted. We refer to studies that analyzed the criteria of newsworthiness, particularly the news values in the news coverage about these health systems. These values refer to the characteristics or attributes in the facts that would make them clear candidates for news 20,21 .
We were unable to find studies that brought this perspective on the SUS. Regarding the SNS, García-Latorre and Gobantes-Bilbao 22 pointed out that questions about Spanish public health have a high news value in the Social Welfare State context.
This study aimed to analyze the news coverage of Folha de São Paulo and El País about the Unified Health System and the National Health System, respectively, based on newsworthiness criteria. Comparing them could bring up the convergent and divergent elements of the news coverage on this theme.

Material and methods
This qualitative study conducted documentary research through content analysis based on Bardin 23 and adopted the news theory's contributions and the newsworthiness criteria 21,24-26 as a theoretical reference.
The reference newspaper in each country was used as a criterion 21 to choose the media studied, which led us to select Folha de São Paulo and El País. Both have topped for years the rankings of general interest newspapers with greater circulation. They distinguish themselves as outlets that seek to differentiate themselves -as a quality standard -against their competitors and audiences, such as, for example, pioneering the use of ombudsmen (the readers' representative in the newspaper) and a user writing and style manual, which is accessible to the public, explaining the newspaper's profile and standards.
The São Paulo-based Brazilian newspaper was created in 1921 and belongs to the Folha Group, one of the country's prominent media conglomerates. Its editorial line is defined as a critical, non-partisan, modern, and pluralist newspaper 27 . Founded in 1976, Madrid-based El País belongs to Prisa, the largest communication group in Spain. It is defined as independent, national, but with a global and mostly Latin American vocation 28 .
A total of 365 covers published in 2013 were checked, selecting all cover stories related to the Unified Health System, in Folha de São Paulo, and the National Health System, in El País. The covers were visually searched for each newspaper, concerning the Portuguese/Spanish words SUS/ SNS, Sistema Único de Saúde/Sistema Nacional de Salud sistema público/sistema sanitario , saúde pública/salud publica, or reference to public health agencies and their representatives or programs, services, and actions of these institutions, and references to health professionals and users. The cover stories were classified into categories to characterize which themes were highlighted on the first page, showing us what was relevant to the investigated press. The cover stories were classified by preestablished categories, based on typifications of selection news values prepared by Silva 20 (Chart 1) and the construction news values prepared by Traquina 21 (Chart 2) to analyze the news criteria. The former type allows "identifying similarities and differentiations in the selection or hierarchization of events in different media outlets, enabling historical and cultural perceptions about the news production process" 20 . Construction news values 21 are used during news writing and are related to "how-todo" choices 21,26 . They work as "guidelines for the presentation of the material, suggesting [...] what should be a priority in the construction of the event as news" 21 .
Cover stories summarize the main news that the newspaper selects to compose the cover, according to its criteria of importance and interest. They are usually succinct and attractive, depending on the profile of each outlet. A cover consists of the headline (the main title bringing the news featured in that issue, usually accompanied by a subtitle, an explanatory summary, photos, or graphic elements) and other smaller titles that may also be accompanied by these elements 29 .
As a limitation of this study, we assumed not to analyze, for operational reasons, other newsworthiness criteria, such as the judgment of journalists, relationship with sources and audiences, and issues of a political, economic, social, and historical nature 20 .
Regarding the period investigated, 2013 was chosen as the year in which the Brazilian federal constitution -which provided the legal basis for guaranteeing the right to health -completed 25 years. At the same time, this period was marked by street demonstrations, the "June days", in which health was identified as a priority, with the government's response to the creation of the Mais Médicos (More Doctors) Program 30 . In Spain, 2013 was also the stage for street demonstrations, known as Marea Blanca, contrary to the changes triggered by the SNS reform, which occurred a year earlier, and in defense of public health.

results
We verified which facts were chosen to make it to covers, building an edited reality about health systems. Baccega 31 affirms that this process is metonymic -the part for the whole. What the media offers us is an edition of the world.
In 2013, Folha brought the most SUS-related news on the front page, accounting for 88 covers, compared to El País, which presented its readers 35 covers about the SNS. At Folha, the 88 covers had 100 cover stories, 14 of which were headlines. There was more than one cover story related to the theme per cover in 11 issues. In the case of El País, the 37 covers had 39 cover stories, two of which were headlines; there was more than one cover story per cover in just two issues. There were no covers stories on both Folha (75.90%) and El País (89.32%) in most investigated days, showing that this topic -when looking at its annual distribution -was managed peripherally, receiving little attention in the first page.
The news that reached the cover of Folha focused on the Mais Médicos Program, representing 48% of the total cover stories ( Table 1). Most focused on foreign doctors' participation, emphasizing Cubans, as in the cover story entitled Entities say they will call the police against Cuban doctors 32 . The news was not based on any concrete facts, but on assumptions, endorsed by the verb "they say they will call the police". Fontcuberta 33 affirms that this statement characterizes a non-event that implies turning into news a fact that has not been produced, or its occurrence is not yet expected. The author argues that the media increasingly uses speculative information, gaining space in representative National, International, and Economy editorials.
The other group of cover stories focused on service provision (13 cover stories). Most of them focused on facts that occurred in the State of São Paulo, such as reducing beds for drug dependents by the municipality and the state program for compulsory hospitalization of crack users. Regarding this category, the São Paulo Hospital das Clínicas was the most present hospital institution, especially concerning care and surgical procedures: In an unprecedented case, HC removes a giant cyst by cutting the navel 34 . However, there was no reference to the fact that it is a procedure performed by the public health system.
One of the agencies of the Ministry of Health most present was the Health Surveillance Agency (ANVISA), focusing on its actions, mainly the release or restriction of medicines, cigarettes, chart 1. Selection news values (alphabetical order).

Selection news-value categories concept
Conflict This category is highly valued by the media. It gathers facts related to wars, rivalries, disputes, fights, strikes, and demands. Knowledge Related to discoveries, inventions, and research: widely used in the science and health sections that focus their editorial line on scientific coverage, valuing the discovery of a new medicine or treatment of a certain disease. Government It gathers facts related to themes of national interest, government decisions and measures, inaugurations of public institutions, elections, trips and statements by government representatives. Impact It brings the numerical dimension as a factor that impacts when selecting a fact to become news: the more people are affected by a certain event, more likely is this fact reported. This category also includes the number of people involved in the event and large amounts of money. A certain theft is more likely to be aired, for example, if it involves a large amount. Justice It comprises events related to trials, denunciations, investigations, apprehensions, judicial decisions, and crimes. This criterion may have more strength if, for example, it is related to the criterion of prominence, considering the notoriety of the person involved.

Controversy
This value is related to events involving scandals and controversies. Depending on the vehicle, it is a criterion also highly valued when deciding what will be news. In some cases, the media itself stimulates controversies that do not yet exist. As an example, the case of opposing testimonies of personalities to stimulate a controversy. Prominence It is related to the notoriety of actors involved and their social importance: if they are from the elite or a celebrity. Sometimes, there is no relevant information in the news, but the fact that a politician, for example, is visiting some city is news. Proximity Geographic or cultural. The closer an event is to its audience, the easier it is to be published. Rarity Uncommon, original, or unusual facts are within this category: those escaping the socially established rule. It is one of the classic criteria of journalism whose premise is that the more an event deviates from the standard, the more likely it becomes news. Tragedy/Drama Here they understand disasters, accidents, risk of death and death, violence/crime, suspense and emotion, and human interest. Another criterion that adds more value to this category is whether it is impact, for example, an accident involving several people, or even prominence, the death of someone from the elite or a celebrity.

Consonance
The ability to frame an event in previously existing settings; fitting the news into a known mold, a known narrative; a mental pre-image; reinforces stereotypes. Dramatization The potential for dramatizing history; reinforcement of critical, dramatic and conflicting aspects of the facts. Personalization The potential for personalizing the story; tendency to present the news as phrases in which there is a subject; as a consequence of these people's actions. Simplification The less ambiguous and more direct, the more possibilities the news has to be published; reduce the polysemic nature of the event. Clichés and stereotypes are useful.
but also pointing out the Agency's stances, such as Cord stem cell is not life insurance, ANVISA alerts 35 . Unlike some titles in which other actors "say", ANVISA appears as a more valued actor, as shown by some verbs: defends, releases, approves, stops, relaxes, and alerts.
In El País, news on service provision predominated (Table 2), as in the case of the title Hace siete meses que estoy tuerta 36 [I have been crooked for seven years], accompanied by a summary that showed the total number of people on the waiting list for surgery. This cover story was structured from an individual approach to a case report to expand to the impact of the waiting list increase on SNS users.
The second most common topic was public health privatization, emphasizing dismissals, demonstrations against this process, and the impact on access to health services, as in the socalled La privatización de la sanidad en Madrid causa 322 dimisiones [Health privatization in Madrid causes 322 layoffs] 37 . The news referred to an announcement of collective dismissal by health center managers, contrary to the ongoing process of privatization of outpatient clinics and hospitals. While resignation came from the managers to pressure the government, the focus given by the title made held the privatization process accountable for this fact.
Ruane et al. 38 say a progressive dismantling of the SNS was underway, and with the 2012 decree, the privatization process accelerated according to the neoliberal strategy in force in Spain. It is also important to highlight that the news related to other categories, such as health expenditure, provision of services, and the public health crisis, were also related to the changes triggered by this decree, as in the so-called Los recortes en sanidad disparan cifras record en las listas de espera [Health cuts hit record numbers on waiting lists]. The findings are in agreement with those found by Revuelta and Oliveira 15 . The authors found that the health information published in Spanish newspapers, including El País, focused on a tiny group of topics, and those related to the SNS were leading this list. Costa 16  in El País. Folha's data suggest that most of this coverage seemed detached from the public health system and, by not listing actions and programs as belonging to SUS, contributed to the system's invisibility, as also identified by Machado 14 .

News values on the covers of FSP and el País
Journalistic production feeds on and, at the same time, feeds the daily routine. The sedimentation of what are known as newsworthiness  criteria contributes to choosing, among various facts, those that can be transformed into news, "giving to these strata of the real the status of reality" 39 . The newsworthiness criteria contribute to the social construction of what is meant by reality. When analyzing the news values used by the two newspapers, we found that the investigated newspapers share eight of the nine categories of selection news values, however, with entirely different frequency, as specified in Table 3. The government was constant news value in both vehicles. At Folha, most cover stories were related to decisions and measures, specifically regarding the federal government. In El País, the government was also a significant news value. These findings are in line with the work conducted out by Gans 40 . The author concluded that the news that dominated American news coverage and magazines was linked to government affairs. They were about conflicts and disagreements, government decisions and proposals and ceremonies, and public office seats' changes. The President of the USA, for example, has always been in the news, regardless of whether he has done anything significant or not. When analyzing the covers of two local newspapers in Santa Catarina, Algeri 41 found that the sub-item with the highest percentage was government decisions and measures, concluding that these newspapers were mainly based on official news, press offices, and information from the Municipality and City Councilors. On the other hand, when analyzing the cover stories from the Jornal Nacional and Jornal da Cultura of São Paulo, Franzon 42 concluded that both highlighted events related to prominence, government, and Justice.
However, unlike Folha, in which the government's decisions or actions gained strength to be put on the newspaper's cover, El País brought government actions when they were mainly added to another news value: impact. The newspaper ran news endorsed by expressive numbers that involved many people affected by the events, such as in the title Las urgencias rurales cierran para 100.000 castellano-manchegos [Rural urgent care services close their doors to 100 thousand citizens of Castilla la Mancha] 43 .
According to Traquina 21 , journalists attach importance to the news that concerns many people involved, thus making the events more notable. Rojo 44 stresses that the impact value is decisive in the news that describes events with essential effects, influence, and consequences. The author believes that this is the case with facts with many people affected by a health problem or by a political measure in matters of health.
This dimension of the impact that a political health measure can bring to society was more evident in El País than in Folha de São Paulo. The Spanish newspaper focused more on the facts from the population's perspective than in the case of Folha, highlighting the manifestations against health privatization: Miles de personas protestan en varias ciudades por los recortes [Thousands of people protest in several cities against the cuts] 45 . While most of the cover stories were related to a government program, which proved to be an alternative to take doctors where there were none, Folha did not bring the population to its covers. The newspaper did not mention how these measures would represent or impact the people who would be directly affected as it was not included in the titles, lines of support, or the summaries. Its absence on the newspaper's cover draws attention if, as highlighted by Souza and Bahia 46 , we start from the premise that one of the essential components of any public health system is the population because it shows how much this system can solve their health problems.
This lack of users' legitimacy shows that they were not considered important voices on the public system in Folha's coverage. It is also relevant to reflect on which audience these newspapers target or communicate to. In the national printed version, Folha's reading public is mainly class B (44%) and C (37%) 47 . Charaudeau 48 argues that each means of communication makes choices related to its audience, considering issues such as social class and age group, but the author points out that these aspects make up an idea of what this audience would be, which, however, proves to be diverse and changeable. From this perspective, we can infer that Folha readers are not seen as an audience using public health services, which does not mean that they are not. As highlighted by Teixeira et al. 49 , even those who believe that they do not use the SUS, because they pay for health plans, are users of this system by benefiting from epidemiological, health, and environmental actions from public health services. Institutions such as the Ministry of Health, Federal and Regional Medical Councils, and AN-VISA were present in Folha's cover stories. Unlike what may happen in Spain, despite the current SNS deficiencies, the system is less stratified and more comprehensive, covering 95% of the population 50 . We can assume that El País still speaks to an audience that uses the health system as it gains prominence in the cover stories: Me negaron el antitumoral por caro [They denied me the antitumor drug because it was expensive] 51 .
According to Camacho 52 , in the last 30 years, the Spanish media have increased their attention to health issues. With the arrival of democracy, the media began to take an interest in the health reform, peaking in the 1990s, when, according to Jurado Salván 53 , health information became a health event. At this moment, interest turns to the guidelines related to the waiting list and care shortcomings, reflecting a period of political deterioration in the last years of the socialist government. According to García-Latorre and Gobantes-Bilbao 22 , health is one of the pillars of the Spanish Social Welfare State [Since the 1980s, the State of Social Welfare has been structured in Spain around four main areas: health, education, social security, and social services], and therefore has high news value. As it arouses the interest of the population, it is a constant content in the news coverage. Compared to other European Union countries, Spain has medium-low social expenditure with high deficits in most services' quality, except for health 53 . Matos-Silveira 54 makes a reservation regarding the changes resulting from the 2012 decree, which impacted foreigners' access to the system and reduced investments in the field.
García-Latorre and Gobantes-Bilbao 22 affirm: It is not surprising that Public Health is an area of journalistic interest, since it covers issues closer to the street and citizen-readers [...] since they directly affect the population and do so in greater numbers than the discovery of a gene or a new therapy.
In Brazil, the SUS also emerges as a Social Welfare policy, when health becomes a right 48 . Castellanos 55 argues that the Brazilian case has specificities: its formation and implementation coincide with the neoliberal wave in Latin American countries, due to the intense global economic crisis and the elite and financial capital dispute to define what economic and social policies would be. Such factors hindered the natural sedimentation of the Brazilian Social Welfare State.
Another quite recurring news value at Folha was controversy, mainly addressing issues and disputes related to the Mais Médicos program, the most reported topic. However, it is crucial to consider that, from this approach, the very newspaper could build or even fuel these controversies. When analyzing news that covered events on European children's well-being, Ponte 56 identified several news values, but controversy was one of the most used attributes. However, in the case of El País, this value was hardly present or was a secondary value.
The news values must be understood considering the models about society and its consensuses 57 . They are more than a list of news attributes because they help build society as a consensus, setting the limits between "normal" or "deviant", requiring a consensual knowledge about society 18 . Curto 58 says the shared convictions, events, and daily life expectations would underlie our sense of reality. This framework of assumptions and expectations of daily life give meaning to the news.
Campos et al. 59 affirm that the news of an event is simultaneously supported by two foundations: on the one hand, on the related social expectations; on the other, as per the specificities of news production. Authors 59 argue that they operate as social decoders of unusual, peculiar, unpredictable, conflicting, and problematic facts; they absorb them while building social consensus. Society must understand its increasingly segmented, specialized, and intricate surroundings.

el País and Folha strategies in the construction of news
The newspapers studied adopted different strategies to present their news. We turn here to the covers stories that most expressed the characteristics and qualities valued while elaborating the news. Focusing primarily on the participation of Cuban doctors, Folha resorted to the simplification of news value, somehow reducing the program to Cuban doctors or even "Dilma's doctors", as in the headline, Mayors will fire local doctors to receive Dilma's 60 . We could also verify that the program lost its contextualization during the coverage, simplifying the adopted approach. Ericson et al. 61 believe that the more an event is devoid of ambiguity and complexity, the more possibilities the news is noticed and understood, which would support this type of choice in preparing the news. According to Traquina 21 , preconceived ideas, stereotypes, and clichés arise from this standard approach.
El País used other strategies to highlight and present its news, such as the values of personification and dramatization, to build its relationship with the reader. Personification is a fundamental value in journalistic discourse 62 51 .
Personalization is a strategy to seduce readers to identify themselves because people are interested in people. "The more personalized an event is, the more possibilities the news has to be noticed, as it facilitates the identification of this fact "negatively" or "positively" 21 . Another news value was dramatization, using an emotional appeal, emphasizing the news with a certain amount of drama 62 . In the case of the title already mentioned, "Hace siete meses que estoy tuerta" 35 , El País resorted to personalization and dramatization, focusing on human drama, bringing to the cover elements that could sensitize its readers. Personalization and dramatization have already been identified as associated resources by Ericson et al. 61 . However, they were not identified in Folha's coverage of the topic investigated.
The news must be in line with socially shared norms, values, and attitudes, and pre-existing opinions and attitudes are implicated. It is easier to understand and accept news in line with journalists' and readers' attitudes, that is, with the ideological consensus of a society and a particular culture 20,50 . This value tends to fit an event in existing frameworks, incorporating "fresh" news into an already known mold, in a mental preset imagery. Ericson et al. 61 argue that this mental preset imagery can contribute to sedimented stereotypes in media coverage, and believe 61 that the meaning of an event can be judged beforehand, to the point that the reporter sees what will happen and produces predictable news, building stereotyped knowledge.
In the case of health, the behaviors and attitudes towards the public system, as highlighted by Silva 62 , are not defined only by the characteristics of the care network underpinning the system, but also the cultural values of a given social environment: the configuration of the system can itself be the expression of the dominant values in a given society, against which the media assume a relevant role in its dissemination and legitimation.
We are interested in reflecting on which molds can sediment stereotypes concerning the investigated public health systems' coverage. Paim 63 identifies that four SUS coexist: the formal one (ensured by the legislation, although distant from the daily life of citizens and health workers); poor-oriented (linked to liberal ideology and derived from focused policies where lack of resources is the rule); the real one (subordinated to the designs of the economic areas, where pragmatism thrives, reconciling clientelistic, partisan, corporate, and economic interests); and the democratic (conceived by RSB, linked to a substantive democracy committed to the rights of citizenship, with political participation and equality, solidarity, and emancipation values). We can assume that the SUS preset imagery is possibly related to a poor-oriented system, not as a citizen's right, and this perception is in line with Tavares et al. 63 . Random interviews with citizens revealed that the public health model's recurrent conception was from the SUS as a service provider for the needy population 64 . In the Spanish newspaper, we noticed that the news narrative was built to focus on the issues and hardships faced by the system. Each new story was embedded in the same mold.

Final considerations
This study aimed to find similarities and differences in the coverage analyzed. We found that Folha brought more cover stories than El País. However, its focus was precisely on one event, the Mais Médicos Program, with its unfolding. In El País, the central theme was health privatization, but it consisted of several events, such as the contrary demonstrations, employee dismissals, and health expenses.
The criteria that led us to select 2013 for analysis in Folha -the 25 th anniversary of the constitution, which guaranteed the right to health, and the health claims in the June demonstrations -did not subsidize the cover stories. The news-paper did bring the demonstrations to the covers, but without focusing on health. The right to health was also not considered a relevant angle to compose its covers.
In El País, our choice was guided by the changes that occurred due to the decree-law, published in 2012, which imposed cuts and restrictions on access to health. The Spanish newspaper's coverage was more aligned with the impact of such a measure on the population, bringing repercussions and developments resulting from these changes.
We also found that newspapers used different resources in the process of writing the news. Fol-ha used simplification concerning the approach adopted on the Mais Médicos Program, which, to a certain extent, was reduced to "Cuban doctors" or "Dilma's doctors". El País invested in personalization and dramatization to sensitize readers by bringing users and health professionals to their covers, in which the background was often health privatization.
It should also be noted that other studies must be carried out, including new media formats, analyzing whether, in these dynamics, the processes of selection and construction of news undergo changes and how they adapt vis-à-vis the available technologies.

collaborations
A Langbecker produced and analyzed the data and wrote the paper. MEP Castellanos and D Catalán-Matamoros revised, corrected, and made suggestions for the manuscript.

acknowledgments
The first author is grateful to the University Carlos III of Madrid for the opportunity to refine her knowledge in health communication, and especially to Dr. Catalán-Matamoros for his teachings and companionship.
To the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes) for the financing of a sandwich scholarship. This article is the result of the doctoral thesis of the first author.