Health councils and dissemination of SUS management instruments: an analysis of portals in Brazilian capitals

Abstract

Coparticipants in the performance, planning, and control of public policies’ implementation, Health Councils are public spaces aiming at the participation and social control of health actions concerning the community. Access to information is a crucial condition so that not only advisers but also civil society can propose, monitor, and evaluate the actions taken in health. Based on this understanding and the guidance provided by Law N° 141/2012 on the visibility of SUS management instruments, this study aimed to verify how the municipal portals of Brazilian capitals have disseminated their Health Councils and the necessary instruments for analyzing, monitoring, and following-up on the health policy. While recommended by law, the research showed that dissemination occurs differently between capitals. Only 14% of the investigated portals make SUS management instruments available on the council pages, and 33% do not disclose information about the council or management instruments. The lack of such content can weaken the council’s institutionality and, ultimately, participatory democracy itself.

Key words
Health council; Access to information; Planning instrument; Participation and social control

Resumo

Coparticipantes na atuação, planejamento e controle da execução de políticas públicas, os conselhos de saúde constituem espaços públicos que objetivam a participação e o controle social das ações em saúde que dizem respeito à coletividade. O acesso à informação é uma condição imprescindível para que não só conselheiros, mas a sociedade civil como um todo, possa propor, monitorar e avaliar as ações empreendidas na área da saúde. A partir desse entendimento e da orientação advinda da Lei 141/2012 sobre dar visibilidade aos instrumentos de gestão do SUS, o presente estudo buscou verificar como os portais das prefeituras das capitais brasileiras têm divulgado seus conselhos de saúde e os instrumentos necessários para a análise, o monitoramento e o acompanhamento da política de saúde. Apesar de recomendada por lei, a pesquisa mostrou que a publicidade é dada de distintas maneiras pelas capitais. Apenas 14% dos portais investigados disponibilizam nas páginas dos conselhos os instrumentos de gestão do SUS e 33% deles não divulgam nem informações sobre o conselho nem sobre os instrumentos de gestão. A ausência de tais conteúdos pode levar ao enfraquecimento da institucionalidade do conselho e, com isso, da própria democracia participativa.

Palavras-chave
Conselho de saúde; Acesso à informação; Instrumento de planejamento; Participação e controle social

Introduction

“The Brazilian Unified Health System is a powerful force for equity. The fact that all services and products, including medicines and vaccines, are provided free of charge is a strong foundation not only for better health, but for development. It’s also very impressive that ordinary citizens have a voice in shaping the health services that are delivered to them. The fact that community-based health councils are involved in approving health plans is a model for other countries to follow. ”¹

In the statement above, Dr. Tedros Ghebreyesus¹ refers to citizen participation and social control established in the Brazilian public health system since the 1988 Federal Constitution. An institutional innovation already recognized in the academic world^2-5, Health Councils stand out among the mechanisms of popular participation in health. They were established as a deliberative collegiate body and permanent locus of the State-Society dialogue in health policy at the federal, state, and municipal levels⁶. The 5,633 Health Councils currently existing in Brazil (5,569 municipal councils, 26 state councils, of the Federal District, and 36 district councils)⁷ are responsible for formulating strategies, controlling, and overseeing the implementation of the health policy, including economic and financial aspects (art. 1, § 2⁸).

Despite the deliberative character of these spaces, there is consensus on the theorists’ perception of the existing difficulties for councils to realize citizens’ participation in the health policy, as provided by the Constitution^5,9-11. Besides the low incidence of councils in the health policy^10,12-14 and the excessive use of technical language in meetings^15-18, several research results in this domain point out restricted access to the information necessary for decision-making or even ignorance of the management instruments governing health policy^19-25.

The information allows promoting more suitable choices and, from an individual perspective, realizing a set of rights – including health. In this sense, it can be assumed that “access to information is a right that precedes all others”. It provides conditions for their claim²⁶, and is, therefore, a sine qua non condition for democracy, the redistribution of power resources, and State democratization^26,27. Access to information is a diffuse right of the community and can result in gains for the community in general in the public context.

Knowing the information held by the State allows the monitoring of decision-making by government officials – which affects life in society. Closer social control hinders the abuse of power and the implementation of policies based on private motives²⁶.

Guaranteed by the Brazilian Constitution (articles 5, item XXXIII, 37, § 3, items II and 216, § 2²⁸) and regulated by Law No. 12.527/2011, the Information Access Law²⁹, the implementation of the right of access to information requires that public actors disclose and give transparency to the information in their possession. However, it is necessary to recognize that, by their own will, government officials do not have sufficient incentives to disseminate information that may be contrary to their interests or cause public questioning and demands, which shows the need to pass and implement laws that define procedures and deadlines for the disclosure of information, and responsibilities for non-compliance with this obligation²⁶. In the Health Policy’s context, legislation regulates the right to information since Law 8080/90, and subsequent legislation addresses the need to give State action transparency.

Shared management and the role of councils

One of the means adopted by the Brazilian public health policy to make information available to society is through documents of the Unified Health System (SUS). The laws governing the SUS have incorporated such instruments to guide the allocation of public resources, give visibility to government actions, and inform society of the State’s intentions vis-à-vis the Health Policy.

Currently, SUS management is governed by Ordinance N° 2.135 of September 25, 2013, which defines that the Health Policy is summarized in three primary documents: i) the Health Plan (HP), which is the central instrument of planning for the definition and implementation of all initiatives within the scope of health of each sphere of SUS management for four years and explains the government’s commitments to the health sector and reflects, based on the situational analysis, the health needs of the population and peculiarities of each sphere; ii) the Annual Health Program (AHP), which is the instrument that operationalizes the intentions expressed in the Health Plan and aims to annualize the goals of the Health Plan and provide for the allocation of budgetary resources to be executed; and c) the Annual Management Report (AMR), which is the management instrument with annual preparation that allows the manager to present the results achieved with the implementation of the AHP and guides any redirections that may be necessary in the Health Plan. The Ordinance’s text also provides for the need for transparency and visibility by encouraging popular participation³⁰.

In order to increase the State’s accountability regarding the health policy, Federal Law N° 141 of 2012 establishes that health councils have a more prominent position in the SUS management cycle so that councils have the prerogative of evaluating and issuing a conclusive opinion (even vetoing) the AMR, and the legislation of the SUS and the Councils regulates that the councils appreciate and approve both the HP and the AHP³¹.

Law N°141/2012 further states that the municipalities must widely disseminate the health accounts for consultation and appreciation of the population³¹. GM/MS Ordinance N° 575, of March 29, 2012, establishes that all SUS management instruments (HP, AHP, and AMR) must be made available for public access in the Management Report Support System (SARGSUS), available at <www.saude.gov.br/sargsus>³².

While compulsorily linked to the SARGSUS System, it is understood that all administrative spheres are obliged to promote transparency and visibility by electronic means of easy public access, in order to fulfill the right to information, participation, and control by institutions, users, and citizens³³. Despite these instruments’ importance, studies show that they are sometimes unknown to health counselors, especially users’ representatives^24,25.

While in place for almost 30 years as a locus of social control and claim to health, studies point to an absolute lack of awareness among the population about the Health Council’s role^25,34,35. Others bring the councilors’ perception that the council has no visibility or support from the general population and is sometimes centered on the civil organizations involved^25,34. Demo³⁶ believes that councils’ visibility, materialized by the creation of communication channels with the population, is a decisive factor for democratic practice.

Aiming to increase transparency and ensuring visibility of information, given their capillarity and easy access²⁷, the municipal portals represent the introduction of a new element into the relationship between government and citizen and are an initiative to implement governance, aggregating data and information that condition citizens to take their rightful place in citizenship spaces³⁷.

Based on the understanding of the importance of information for the exercise of citizenship, the perception of the low visibility of health councils and the lack of knowledge of councilors regarding the SUS management instruments, under which councils have a prerogative and objective responsibility³⁸, this study aimed to show how the institutional municipal portals of the Brazilian capitals have disseminated not only their Health Councils but also the SUS management instruments necessary for the exercise of societal participation in the health policy.

Methods

This research aimed to analyze to what extent the portals of the capitals of the 27 Federative Units (UFs) in Brazil have broadcast their Health Councils and comply with the provisions of Law Nº 141/2012 regarding the publication of SUS management instruments (HP, AHP, and AMR). Portals were evaluated in December 2017, and the official electronic addresses of the capitals were considered, as set out in Chart 1.

Chart 1
Official electronic addresses of municipal portals.

Capital (UF)	Electronic address
Manaus (AM)	http://www.manaus.am.gov.br/
Boa Vista (RR)	https://www.boavista.rr.gov.br/
Porto Velho (RO)	https://www.portovelho.ro.gov.br/
Rio Branco (AC)	http://www.pmrb.ac.gov.br/
Belém (PA)	http://www.belem.pa.gov.br/
Macapá (AP)	http://macapa.ap.gov.br/
Palmas (TO)	http://www.palmas.to.gov.br/
Maceió (AL)	http://www.maceio.al.gov.br/
Salvador (BA)	http://www.salvador.ba.gov.br/
Fortaleza (CE)	https://www.fortaleza.ce.gov.br/
São Luis (MA)	www.saoluis.ma.gov.br
João Pessoa (PB)	http://www.joaopessoa.pb.gov.br/
Recife (PE)	http://www2.recife.pe.gov.br/
Teresina (PI)	http://www.teresina.pi.gov.br/
Natal (RN)	https://natal.rn.gov.br/
Aracaju (SE)	http://www.aracaju.se.gov.br/
Goiânia (GO)	https://www.goiania.go.gov.br/
Cuiabá (MT)	http://www.cuiaba.mt.gov.br/
Campo Grande (MS)	http://www.campogrande.ms.gov.br/
Distrito Federal	http://www.df.gov.br/
Vitória (ES)	http://www.vitoria.es.gov.br/
Belo Horizonte (MG)	https://prefeitura.pbh.gov.br/
São Paulo (SP)	http://www.capital.sp.gov.br/
Rio de Janeiro (RJ)	http://www.rio.rj.gov.br/
Curitiba (PR)	http://www.curitiba.pr.gov.br
Florianópolis (SC)	http://www.pmf.sc.gov.br/
Porto Alegre (RS)	http://www2.portoalegre.rs.gov.br/portal_pmpa_novo/

The following aspects were considered: a) whether the page of the Health Secretariat located at the municipal portal had a page for the Municipal Health Council; b) what information did the council page provide; c) whether the management tools were available on the Council’s website; and d) whether the management instruments were on the Health Secretariat’s page if not found on the Council’s page.

The selection of the Health Secretariat’s page as a base locus for directing to the Health Council’s page is because councils are part of the organizational structure of these secretariats responsible for the physical and operational support of the councils^28,31,39.

The portals’ analysis adopted two procedures (Figure 1): the main SUS management instruments (HP, AHP, and AMR) were searched on the Municipal Health Council’s page, available at the Municipal Health Secretariat (Flow 1). If not found, they would then be searched directly on the Municipal Health Secretariat’s page (Flow 2).

Figure 1
Representation of the portals’ analysis flows.

If the SUS management instruments were not available either on the Council’s page (Flow 1) or the Health Secretariat’s (Flow 2), a third search would be carried out using the search engine of the Municipality’s portal using the descriptors “municipal health council”, “municipal health plan”, “annual management report”, and “annual health program”. Concerning the search carried out for the Federal District, the descriptor “municipal” was replaced by “district”.

It is worth noting that when no mention of the Health Council was made on the Health Secretariat’s page, the Google search engine was used to verify whether the Health Council had a page external to the Municipal portal. In this case, the descriptor “municipal health council of <name of the city>” was used, and the first result from this operation was selected, whenever consistent with that indicated in the institutional environment.

The results were tabulated and divided into five categories (I, II, III, IV, and V). In increasing order, they indicate the availability of information within the virtual space reserved for the Municipal Health Councils, the locus established by law for the evaluation and approval of the central instruments of management of the local health policy. The categories indicate that the portal (Health Secretariat’s page): (I) did not provide a page about the Health Council or management tools; (II) provided a page on the Health Council, but not the management tools, verified on the Council’s and the Health Secretariat’s pages; (III) did not provide a page for the Council but the management tools on the Health Secretariat’s website; (IV) provided a page for the Health Council and the management tools on the Health Secretariat’s website; and (V) provided a page for the Health Council and management tools within the Health Council’s page.

The posting of instruments made on portals [which is not mandatory, but allows greater visibility] was also compared with that of the SARGSUS system [which is mandatory by law for the AMR instrument] to assess the extent of transparency sought by local health managers. The 2016 management tools were searched in the SARGSUS system, given the possibility of observing the most recent closed planning cycle of the SUS – the 2013-2017 MHP, the 2015 AMR, and the 2017 AHP.

Results

The analysis of the results showed that more than half of the portals in the capitals (63% of the surveyed universe) had a specific page for the Health Council. Among the portals that provided a page for the Council, only four (14%) showed the management instruments on the Council’s page (category V); in five of them (19%), the instruments were on the Health Secretariat’s page (category IV); and in eight of them (29%), the management instruments were not found in any of them (category II).

Ten capitals did not have a specific page for the Health Council. Of these, nine also did not have the management instruments on the Health Secretariat’s page (category I), leaving only one with management instruments on the Health Secretariat page (category III). Figures 2 and 3 summarize the results.

Figure 2
Health councils and management instruments dissemination.

Figure 3
UFs’ map with the classification proposed in the research.

It is worth mentioning that Curitiba’s municipality was classified in category V since the 2016 and 2017 AHP were found on the page of the Municipal Health Council’s Minutes and made available through an easy-to-view link. On the other hand, the municipality of Florianópolis was allocated to category IV, as it was not possible to access the AHP on the Council’s page in the same way, but on the Health Secretariat’s page.

Five of the 17 municipalities with a specific page for Health Councils on their portals used the page to provide general information such as location, opening hours, and legislation on social control. Eight of them also presented the minutes and agendas of meetings and their resolutions. Only four had management tools on their Health Council’s pages, besides general information, minutes, meeting agendas, and resolutions.

Seven Municipal Councils (25%) had pages outside the Municipal Health Secretariat’s page, and for two of them, this was their only address, as they did not have a page linked to the Municipal Health Secretariat. The Google search engine revealed that 22 municipal health councils (81%) had a profile on Facebook, of which nine (33%) did not have a council page linked to that of their municipalities’ Health Secretariats, and seven had blogs external to the institutional portal. For example, the Manaus blog had full and updated information with management tools, but not on its portal.

Given the proposed search protocol for investigation, three municipalities [(Palmas (TO), Vitória (ES), and Campo Grande (MS)] were classified as “I” because they linked their Council’s page to other tabs of the Municipality’s portal instead of the Health Secretariats’ page.

Overall, 38% of the portals provided SUS management tools. In the SARGSUS system, in the analyzed period, fifteen capitals showed all three instruments, twelve failed to present at least one, and four did not mention any.

The results found in the portals and the SARGSUS system are detailed in Chart 2. Eight capitals classified as I or II (without the instruments in their portals) had complete and updated publications in the SARGSUS. On the other hand, nine capitals classified as I or II evidenced gaps in the publications. At the other extreme, four of the nine capitals classified as IV or V showed gaps in publications in the SARGSUS.

Table 2
Health Councils and management instruments visibility in municipal portals and SARGSUS system.

Capital - UF	Portal's Classification 2017	SARGSUS System 2016
		AMR	MHP (2013-2017)	AHP 2017
Aracaju - SE	II	Yes	Yes	Yes
Belém - PA	I	Yes	No	No
Belo Horizonte - MG	V	Yes	Yes	No
Boa Vista - RR	I	Yes	Yes	Yes
Campo Grande - MS	II	Yes	Yes	Yes
Cuiabá - MT	II	Yes	Yes	Yes
Curitiba - PR	V	Yes	Yes	Yes
Brasília - DF	II	Yes	Yes	No
Florianópolis - SC	IV	Yes	Yes	No
Fortaleza - CE	I	Yes	Yes	Yes
Goiânia - GO	IV	Yes	Yes	Yes
João Pessoa - PB	II	No	Yes	Yes
Macapá - AP	I	No	No	No
Maceió - AL	I	Yes	Yes	Yes
Manaus - AM	IV	Yes	Yes	Yes
Natal - RN	III	Yes	Yes	Yes
Palmas - TO	I	Yes	Yes	Yes
Porto Alegre- RS	V	No	No	No
Porto Velho - RO	I	No	No	No
Recife - PE	II	Yes	Yes	No
Rio Branco - AC	I	No	No	No
Rio de Janeiro - RJ	V	Yes	Yes	Yes
Salvador - BA	II	Yes	Yes	Yes
São Luís - MA	II	Yes	Yes	No
São Paulo - SP	IV	No	Yes	Yes
Teresina - PI	I	Yes	Yes	No
Vitória - ES	IV	Yes	Yes	Yes

Discussion

One of the postulates of democracy is the right to access information, a sine qua non of political participation under conditions of equality²⁷. Only a society informed about politically relevant public interest matters can act accordingly to use political participation mechanisms⁴⁰.

The State can provide information and services to citizens through institutional portals, whether they are available or not in remote and difficult access locations⁴¹, allowing them to expand their political participation in the decision-making process⁴².

This research shows difficulties in publicizing both Health Councils and documents that guide the planning, implementation, and monitoring of the health policy. As the government owns portals, the results give weight to the counselors’ perceptions that the Health Council is still linked to management actions⁴³ and, in part, that they have little visibility for society^24,25,44. As seen, 37% of the capitals’ portals did not bring pages referring to the Health Council, and 29% of those that made them available only brought generic information about telephone, location, and what social control is.

Resolution N° 453/2012 of the National Health Council determines that the three spheres of government guarantee administrative autonomy for the Health Council’s full functioning with budgetary allocation, financial autonomy, and organization of the Executive Secretariat, which includes infrastructure and technical support, and the means to enable channels of information with the represented citizens. If participatory institutions are going to affect decisions, then their functioning must be open to scrutiny not only to participants but also to the general public⁴⁵.

The survey results indicate that the councils seek to establish an information channel, and this was portrayed when 81% of the councils maintain profiles on social networks such as Facebook and seven others feed blogs external to the portal. Castells⁴⁶ argues that new technologies are integrating the world into global networks, and this network structure allows greater mobility and versatility in the flow of information. Communication becomes more fluid and streamlines information exchange, “breaking with the traditional hierarchical model of corporate or state bureaucracy”⁴⁷. The need to overcome the state bureaucracy was sought by nine councils that did not have “institutional” websites but did have Facebook pages. These manifestations in social networks, blogs, and other environments (including offline), allow democratizing and decentralizing the control, production, and circulation of information⁴⁸.

Looking more closely at the content of the Council’s pages, 12 included on their pages the information relevant to their actions, decisions, and structure, which, can expand opportunities to inform citizens and ensure the public nature of debates and decisions⁴⁹. These results were as per Ordinance MS/GM 1802/2009, which guides the councils in its article 6 § 5 on what to inform the population: I - forms of participation; II - composition of the Health Council; III - internal regulations of the Councils; IV - Health Conferences; V - date, place, and agenda of the meetings; and VI - deliberations and actions initiated.

Democracy theorists argue that a well-informed citizen is better equipped to decide and evaluate government activities. Transparent decision-makers’ actions and intentions allow the citizen to ascertain the fulfillment of democratic principles and the rules that establish the social contract (right of control of civil society in the political regime)^42,50.

The results show that 62% of Brazilian capitals, where, in principle, more resources are available, lack SUS management instruments (HP, AHP, and AMR) in their portals. Even in the SARGSUS system, established by the Ministry of Health as a place of mandatory publication of the instruments, 44% of the municipalities did not present the three instruments surveyed.

Realizing public management’s democratization requires the incorporation of councils as effective channels of participation, establishing new relationships between the State and society. Therefore, changes must be sought in the state structure’s functioning that should be willing to share the power of decision, control, and implementation of the health policy⁵¹. However, there is still a breakdown of the State to make its information, procedures, decisions accessible and, therefore, to “establish a partnership relationship with society”⁵². The lack of specific information hinders the negotiation and shared management of the policy by the councilors, which can reduce this deliberative public sphere to a claiming space^52,53 or even a crossing point of the policy when it should be a stop [node]¹⁴.

Conclusion

This research sought to analyze to what extent the portals of the capitals of the Brazilian UFs comply with the provisions of resolution N° 453/2012 of the National Health Council and Law N°141/2012, regarding the dissemination of the Health Council and its management instruments. To this end, the existence of the Municipal Health Council’s page and the HP, AHP, and AMR instruments were verified on the portals of the capitals.

While recommended by law, publicizing occurs differently in the capitals. Although the best scenario was for each capital to disclose the Council’s page and, within it, the instruments that condition citizens to exercise social control, this is a reality for only 14% of those surveyed. The largest contingent (33%) refers to portals that did not disclose information about the Health Council or management tools.

Although publicizing is mandatory only for the SARGSUS, we should understand why the management tools were not published on the portals, given the institutional nature and scope in reaching different audiences. In a system that includes citizen participation, giving them access to intelligible information is an elementary issue to reduce asymmetries in the decision-making process.

The gaps found in this study in a repertoire of informational content central to health policy’s functioning signal a difficulty to be addressed in the SUS for greater citizen participation. Failure to do so can lead to the weakening of the Council’s institutionality and, thus, of participatory democracy itself. Research limitations relate to the methods chosen for searching the Council’s page and management tools, the search engine’s descriptors via the portal mechanism, and the search engine itself.

Acknowledgments

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES). The authors would like to thank the Universidade Federal de Santa Catarina (UFSC), the Post-Graduated Program in Knowledge Engineering and Management (PPGEGC) and CAPES.

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Publication Dates

• Publication in this collection
  06 Nov 2020
• Date of issue
  Nov 2020

History

• Received
  03 July 2018
• Accepted
  15 Apr 2019
• Published
  17 Apr 2019