Health promotion practices as resistance and counter-conduct to neoliberal governmentality

This article analyzes the discourses within Health Promotion (HP) practices in Primary Health Care (PHC) that constitute actions of resistance and counter-conduct to the neoliberal governmentality inscribed in these tools. Drawing upon descriptive and exploratory field research, together with a qualitative approach, we interviewed 23 PHC workers in a municipality in southern Brazil. The results point out possibilities to enhance HP in PHC: strengthening training activities within health units; problematizing Social Determinants of Health (SDH); methods to encourage participation; collectivization of health demands; appreciation and reinforcement of achievements and collective actions; recovery of the local community’s culture and habits; and HP advocacy in PHC.


Introduction
Contemporary neoliberal rationale is constructed as something that goes beyond mere economic theory.Its assumptions and mechanisms of operation have spread throughout all realms of life in such a way that the business logic, in which what stands out is the hypervaluation of subjects capable of achieving their maximum performance, through the processes of self-management, as well as in the sphere of work relations, accomplishes personal, sanitation, esthetic, and educational relationships, among others 1 .
The modus operandi of current capitalism, whose bases were developed throughout the twentieth century, and were consolidated in the two first decades of the twenty-first century, use technologies that subjectify subjects through resources that shape their wishes and desires.In this sense, people do not need to be coerced to produce in large scale or to assume determined ways of life that are supposedly more appropriate.The process of subjectivation inscribed in the neoliberal rationale results in subjects that find satisfaction and pleasure in successes achieved by means of high performance rates 1 .
Since the fifteenth century, measures have been developed that have opened the door for capitalism to evolve.As of the eighteenth century, the method applied to map out behaviors ceased to be something individualized -operated through disciplinarian technologies -and began to be constructed through aggressions against the population as a whole, by means of a patchwork of devices, often disciplinarian, which engender subjectivities that are syntonic to the most valuable interests of the capitalist machine, but without the need for violent practices.
This complex trauma, which sought to rationalize the problems and organize the life of the population, is what Michel Foucault termed "biopolitics".And that of the meeting -or the articulated operations -of the techniques of conducting one's behavior (exercised over others) and the techniques themselves, he called governmentality 2 .
The current capitalist system in the Western world and in Brazil, is organized by a neoliberal governmentality, whose operations contemplate mechanisms of subjectivation that praise individual performance and make the subject responsible for his/her own achievement of success in the different realms of life 1 .
The field of health has not remained immune to antagonisms from this type of rationale.Since the creation of the contemporary concept of Health Promotion (HP), different rationales have been in dispute, which can be identified in the technical-legal documents that refer to the theme and to the practices conducted in a variety of scenarios.Thus, HP can at least be characterized by two aspects in the current reality.One emerges from behavioral approaches, geared solely toward the change in habits and the adoption of lifestyles that are considered to be healthy, while the other contemplates intersectoral practices geared toward the transformation of the Social Determinants of Health (SDH) 3 .
Although the principles of HP contemplate actions that seek to resist total prejudice, the literature 4 points out that many HP practices are, for the most part, encompassed within the rationale of the neoliberal governmentality.That is, the approaches seek changes in individual habits and behaviors through the understanding that the subjects are capable of being responsible for their own health conditions and, in this sense, presented good -or the desired "improved" -results linked to their performance and choices.
However, in the same way that we have practices that sustain the status quo, it is possible to identify others that operate in the logic of resistance (characterized by the tensioning and the transformation of governmentalizing practices) and of the counter-conducts (conducts that are different from those inscribed in governmentality) 2 .
In this light, the present study aimed to analyze HP practices, developed in the sphere of Primary Health Care (PHC), capable of taking action as resistance and counter-conduct to the practices inscribed in neoliberal governmentality.

methods
This work conducted a descriptive and exploratory field study, together with a qualitative approach and a genealogical research, in the context of PHC, in Porto Alegre, the capital of the state of Rio Grande do Sul, Brazil, which currently has a population of 1.4 million inhabitants (IBGE, 2020) 5 .The study was developed within the Health Units (HUs) of the Communitarian Health Service (SSC, in Portuguese) of the Conceição Hospital Group (GHC, in Portuguese), one of the largest hospitals in Brazil, whose majority shareholder is the Ministry of Health.
The choice of the SSC/GHC was due to the fact that it was a privileged space in which to car-ry out HP services, following the guidelines set forth by the National Health Policy (NHP) 6 and the National Health Promotion Policy (PNPS, in Portuguese) 7 .In addition, as it is a reference service in the city, in the state, and in the country, and as it has its own funding, despite the municipal management, it has not greatly suffered the consequences of the dismantling and de-financing stemming from the review of the founding guidelines from the PHC, from 2017, which weakens the principles of inclusion and equality, especially due to the doubts generated in relation to the limits of managers and to the regional healthcare coverage 8 .Another aspect to be considered is that, as it belongs to the same organizational structure (GHC), it has similar characteristics concerning the composition of the teams and the organization of the work process.
The SSC/GHC is the reference for the population of the city's North Zone (around 100,00 inhabitants) and is comprised today of twelve HUs, 39 Family Health Strategy (FHS) teams, four Family Health Support Centers (NASF, in Portuguese), one Street Office team, three Psychosocial Healthcare Centers (CAPS, in Portuguese), including one Child CAPS (CAPSi), one Alcohol and Drugs CAPS III (CAPS AD III),and one CAPS geared toward users, adults, and individuals with severe mental health disorders (CAPS II).
The data from the study were produced by means of semi-structured interviews with workers from twelve HUs, which corresponds to the total number of FHS teams and NASFs.The professional centers of the participants (and the respective number of participants) were: Social Service (6), Nursing (5), Psychology (4), Community Health Agent (ACS) (3), Medicine (2), Dentistry (2), Nutrition (1), totaling 23 participants.
The production of the data occurred by means of recorded and transcribed interviews, from February to May 2020.Participant selection was performed using the "snowball" method, that is, first, the key informers were contacted, called seeds 9 , and, from these, other participants who were directly involved in HP practices at SSC/ GHC were recommended.
The problematization of the data was conducted through techniques inspired in genealogical research, which brings visibility to the tensions, disputes, discourses, practices, and power relations.Genealogy is a study of the forms of power: "[…] in its multiplicity, in its differences, in its specificity, in its reversibility: studying them, therefore, as relations of power that intersect, that remit one to another, converge, or, to the con-trary, oppose one another [...]" 10 (p.71).The task of the genealogist consists of analyzing the possible effect of the discourses and of the practices in order to find the possible conditions from which the discursive formations emerged, as well as the powers that are in play in this process 11 .
Therefore, to reach the intended objective, this study adopted the following analytical steps: reading of the transcribed interviews and of the main technical-legal documents referent to PHC 5,12,13 and to HP in Brazil 6,14 .Through analyses sustained by the theoretical references from Michel Foucault, from contemporary authors who update the theory and from Collective Health references, from HP, and from PHC, we described the actions that articulate the potential for the emergence of resistances and counter-conducts, when faced with neoliberal rationale.
During the entire study, the ethical procedures for studies conducted with human beings in Brazil was observed 15 .To preserve the anonymity of the participants in this study, they were identified with codenames -chosen by them -which refer to artistic expressions.The study was approved by the Research Ethics Committee from the Federal University of Rio Grande do Sul and from GHC, logged under protocol number CAAE 16078319.7.0000.5347and CAAE 16078319.7.3001.5530,respectively.

results
Reports from the participants of this study point to possibilities to be explored as means through which to enhance HP in PHC.These include: 1) the strengthening of educational activities in the realm of health care; 2) the problematization of the SDH and the methods in which to encourage participation; 3) the collectivization of health demands; 4) the appreciation and reinforcement of the achievements and collective actions; 5) the recovery of the local community's culture and habits; and 6) advocacy.
The providing of educational activities, which are the main characteristic of the SSC/ GHC as a "school service", are presented as potential actions for HP, since they deal with a field for Residency in Family and Community Medicine, Interdisciplinary Residency in Family and Community Health, as well as the stages of undergraduate studies and technical courses in health.According to the following reports, the proximity with education in health encourages the creation of new practices and strengthens the continuity of the existing practices: The undertaking of a University extension project was essential for the creation and continuity of the Creative Writing workshop.(Creativity) The Residency in Health, both from the Medical School as well as the Interdisciplinary team, contribute greatly toward the implementation of the practices of Health Promotion.(Pérola) We began to understand the importance of educational practices that favor on-the-job learning, since the students and residents develop skills to work at SUS and the services at the same time.They are qualified through the constant reflective process proposed to the teams in the pedagogical itinerary of the courses within the field of education 16 .
Considering the projects related to on-the-job learning, it can be understood that the creation of pedagogical strategies in practical scenarios brings the faculty members, students, users, and workers closer together.Therefore, what takes place are educational movements and moments of reflection regarding professional practices that are aligned with public health policies 17 .
Another strength refers to the construction of spaces for the problematization of the conditions that interfere in people's health, the SDHs, through the use of language and methods that are accessible to the participants, in turn recovering characteristics that have been lost over time: Making the Health Council a space in which to broaden people´s awareness, for people to understand that a Constitutional Amendment, which freezes investments in Health and Education, will appear in the their loss of rights, of tangible things in their lives.This could worsen their health services even further.

[…] One critical hurdle is the question of how we communicate, translate [the information] to the community, to the people who are hungry and out of work. (Capoeira)
The use of methodologies capable of subverting individualizing processes, which are predominant in today's society, seems to be one of the greatest challenges for HP.One way to bring the community into the debate, which it powerful in encouraging reflective processes, is pointed out below: Art may be a strong resource to mobilize people to participate.It is a way to translate the questions to the people, using their language.(Capoeira) Hence, encouraging creative and reflective processes, together with the communities, using dynamics capable of involving and stimulated participation can be a transforming practice.The criticism invites people to problematize their conditions, as well as their conducts in relation to the questions concerning HP.Such postures oppose the neoliberal giving impetus to counter-conduct against the production of behavioral patterns that are determined by means of rules, norms, and parameters pre-defined by governments and technical health teams.
Nevertheless, it is important to highlight that the reflective exercise of criticism, in Foucault's point of view 18 , does not foresee a process capably generating transcendence or a definitive emancipation of the subjects.To the contrary, it means maintaining a constant reflective and critical attitude, referent to the individual and collective processes of life 18 .The problematizations can be defined as "the set of discursive or non-discursive practices that make something enter the game of true or false and is constituted as the object for thought 19 (p.236).
From this point of view, the act of problematizing should not be seen as a methodology, but rather as a way of acting when faced with an object that is put in question in order to promote a work of thought.It also means understanding that truths are constructions and only exist through the creation of discourses that establish a relationship with what is considered to be true (or false) in a given historical moment 20 .Thus, problematization, in the sense treated here, presupposes the maintenance of reflective attitudes and of a constant criticism referent to the individual and collective processes 18,21 .
The permanent character of problematization proposed by Foucault 18 can be a more effective attitude in combatting the practices contrary to the collective context.Insofar as the reflective process is maintained, there are more chances for aggressions from the hegemonic power to be observed and chances to adopt stances of resistance and counter-conduct when faced with this predicament, that is, to construct forces capable of resisting prescribed conducts by means of a practice of governmentality, or even adopt a conduct different from that expected (counter-conduct) through the practice of governmentality 5 .
Another aspect that points to HP practices as a possibility of a collective struggle and the transformation of the subject was pointed out by a participant: Whenever you can promote a meeting between people, the activity impacts their lives, because some kind of experience they take with them.Even if a doubt of an experience is manifested individually, when it is collectivized, something different can be produced, since the problem is no longer individual.The meeting enables the production of affection as well as identities.Bringing neighbors together, the recognition of common fragilities, and the possibility of seeking collective solutions.(Vibração) The collectivization of the individual demands, through meeting spaces and problematization, seems to be the effect nearest to an HP approach geared toward SDH within PHC.The contemporary neoliberal rationale has a reach that surpasses the limits of the economic operations of the capitalistic system.The logic of individual responsibility, of the subjects as entrepreneurs of themselves, capable of managing their own lives and competing at all levels of social life has spread throughout all dimensions and permeates the relationships established in all realms 1,22 .
In the technical-political field, the neoliberal rationale occupies spaces in such a way that, under the influence of international financial agencies, it incorporated health practices geared toward the accountability and blame of individuals, reinforcing the idea of the individual management of risks and weakening actions geared toward SDH.
Considering this scenario, HP practices are capable of recovering the collective character of health needs, as well as the need for co-accountability in combatting the factors that cause health problems.In addition, it can stress the role of the State as the provider of public policies, representing points of resistance in a field in which discourses are used to subjectify in order to make one believe that the responsibility for health care is individual.
Therefore, the collectivization of demands has the potential to construct other means through which to produce healthcare in the context of PHC, in an all-encompassing manner, in which the subject begins to understand healthcare as a product of the SDH and to realize that the responsibility for change in these conditions of life is not individual, since it involves the protagonism of the State and of society as interconnected dimensions.
Faced with the individualization of the responsibilities for one's health, the appreciation and reinforcement of the public achievements, fruit of the collective actions, can also be constructed as a path to join the HP of strategies that achieve change in the indices related to the SDHs.The communities whose HUs participated in this study have a history of collective struggle to guarantee local resources: All of the resources that exist in the community were achieved by the communitarian organization, The health clinic, the recycling center, the children´s school.So, I think that it is powerful to recover this history to work on this sense of the community's struggle together with the people.(Capoeira) Emphasizing the power of the collective organization, reactivating the memory of transformations that were considered positive in the context of the community, can be an alternative path toward individualizing practices.In addition, what appears as the HP strategy is the recovery of local habits and culture.Considering the homogenization proposed by the neoliberal government, which seeks to shape ways of living 1,23 and which also occupies the hegemonic position in HP practices, the strengthening of local habits can represent an action of resistance and counter-conduct to combat medicalizing, individualizing, and consumer practices: The recovery of the culture of a community, of its roots, can be powerful for Health Promotion.The community in which I work was resettled.They were removed from a place in which there was ample space, where there were gardens, they planted trees, they had patios.In the resettlement, they don´t have this space.There is a lot of concrete; it´s very arid.So we tried to create these collective initiatives of planting trees to try to recover this characteristic of the community and to leave the space less arid.(Capoeira) The act of privileging the local culture and guaranteeing space for popular knowledge is set forth in the National Policy for Population Education in Health when proposing political-pedagogical practices to guide actions geared toward the "[…] promotion, protection, and recovery of health through dialogue within the diversity of knowledge, the appreciation of popular knowledge, the ancestry, the incentive for individual and collective production of knowledge […]" 24 (p.16).
The recovery of ancestral and traditional practices can be seen as resistance to the homogenization of the ways of living proposed by neoliberal governmentality.One study on the educational practices within the PHC defends this argument, demonstrating that health practices, capable of recovering the ancestral culture of the community, reinforce the collective protagonism 25 .
In the end, the notion of health advocacy 3 can be adapted to HP advocacy in the context of PHC: I think that what prevents the social control activities from stopping in our country is the profile of the team.Many professionals are engaged in the process and encourage the population to participate.They talk about the importance of partici-pating.The PHCs, which have a direct relationship with the community, are very involved with this in the country.There will be a break, a very great difficulty in this sense without them.(Teatro) Much like the health advocacy, which seeks to defend the structuring of intersectoral public policies capable of creating favorable environments for health 3 , HP advocacy is something that, if protagonized by the workers and users, can expand the community movements in the defense of health practices that are less individualized and biomedical and can be created as a collective practice: The workers would need to have more knowledge about the possibilities in the collective sphere.Most think that all collective activities are simply peer groups and that only individual care can bring results in a therapeutic process.(Mosaico)  For this, it is necessary for the teams to be persistent in the initial processes in order to implement legitimate spaces for debate and reflection together with the communities, providing the space for recognition in that which refers to the potential of their results along with the health managers: The group needs persistence.The workers have to maintain the group, even if with only a few participants.It needs to happen in order to be put in place and more people begin to participate.(Brincar) Considering that mentioned above, it is possible to identify that the possibilities for the expansion of the scope of the HP practices within PHC fit within a heterogeneous field of endeavors.In this context, certain established knowledge (or rationale) can push the existing (or commonly used) practices to strengthen HP practices aligned with neoliberal rationale, which often individualizes and blames the people while, at the same time, removing the responsibility of the State to guarantee access to health services in a free, universal, equal, and participative format, as defined in the principles of SUS.
By contrast, other knowledge can also be strengthened and explored so that resistance and counter-conduct actions are promoted.Here, we seek to give visibility to the elements that enhance practices that broaden the scope of HP in PHC, reported by the workers themselves and that can be strategic when faced with a scenario that is ever-increasingly exclusionary and precarious, which today is imposed by neoliberalism (and their practices of fiscal austerity).

Discussion
As described in the introduction, the contemporary neoliberal rationale is sustained by a conservative character 1,22 , whose characteristics oppose the principles of citizenship, "wellbeing", or "common good", present in the context of democratic societies based on the rule of law 1 : "it is what is seen especially through the practical questioning of rights that were, up to that moment, linked to citizenship, beginning with the right to social protection, which was historically established as the logical consequence of political democracy" 1 (p.374).The managerial reform of public action directly affects the possibility of the population to access social resources concerning employment, health, and education, thereby highlighting inequality, reinforcing the logic of exclusion and the production of "sub-citizens" and "non-citizens" 1 (p.375).
The aggressions, used to push for change in the care model adopted in the context of the Brazilian PHC, through the PNAB 6 and the weakening of the public health policies, align with the logic that sees SUS users as entrepreneurs of their own lives.Hence, the neoliberal rationale considers and educates in such a way that the users of the public health system see themselves as the sole providers of the conditions of life that converge with the production of good health indices.According to this model, it is hoped that the people will receive information about the conditions of health and be responsible for managing their own HP, obtaining the "best" possible results, even using mechanisms of self-monitoring 26 .
It is important to highlight, however, that the expansion of this type of relationship between the user and health services tends to produce outcomes that are often disastrous (to say the least): the self-management of one's health, through self-monitoring, many times by means of technologies with a high financial cost (electronic devices).In this sense, rather than generating desired "improvements", the self-management tends to imprint the logic of competitiveness (with others, but especially with themselves), in the sense that life begins to demand the control and the meeting of goals in ordinary everyday activities: counting calories, steps, heartbeat, among other possible measures 26 .
The race to meet goals -imposed by the subjects themselves, under the influence of health parameters that have been widely established and disclosed within the health services and the digital media -generates processes of self-competitiveness which can translate into frustration and anxiety.In the end, we live in a time of maximum personal demands, even in relation to the production and control of one's own health 27 .
This equation, however, cannot be balanced if the SDHs are not included in the health building process.It is well-known that the approach that considers personal behaviors as the sole factor related to health conditions is not capable of producing complete care, which would reach different dimensions of life, as defined in the broader concept of health 3 .
The idea of balanced health requires conditions of dignity, housing, income, public transport, good environmental conditions, and guarantees of work, which are only a few of the elements necessary for a healthy life.In the neoliberal rationale, however, the responsibility to provide such conditions is also entirely delegated to the individuals themselves 1,22 .Following advice relative to the adoption of healthy habits for those who do not have the most basic conditions of life incurs cynical practices of HP, in which the health services give advice as to what should be done, without considering the real conditions for the adoption of such behavior 27 .
Two possible outcomes can be pointed out as results of the use of this rationale in the context of health services.In social classes with better income levels, what seems to prevail is the suffering that results from a life based on the competition with oneself in all spheres of life (work, health, social and affective relationships, among others) and their corresponding frustrations when the maximum performance is not achieved.As an answer to these types of illnesses, a vast market of psychotropic drugs acts in an intense process of medicating people 1,28 .
As regards the economically poorer populations, the effects are even worse.Besides living in precarious conditions, being deprived of the basic conditions of life, the people are also subjected to the logic the entrepreneurship of one's own self.Hence, they must deal with the suffering coming from the conditions of misery, at the same time that they are led to believe that such conditions are caused by their own behavior and, therefore, understand that the act of rising out of a situation of misery, "sub-citizenhip" 1 or "non-citizenship" 1 is only a question of one's own will or personal merit 29 .
In the current Brazilian scenario, in which 23.3 million people (11.2% of the population) 30 live below the poverty line, and 41.9% of all the entire income of the country is concentrated in 10% of the population 30 , in addition to all of the illnesses related to the social inequalities, the population that lives in a situation of poverty will also suffer from the psychological illnesses generated by the frustration and anxiety of not being able to achieve better conditions of life 28 .
Upon assuming the attributes of the neoliberal rationale, HP is characterized as a biopolitical strategy to control bodies, through the modulation of behaviors.However, the present discourses in HP practices, described in the results presented herein, can be understood as expressions of resistance and counter-conduct to the practices inscribed in the aspects of the neoliberal governmentality.In a field of knowledge-power, in which practices that lead to individualism, blame, and meritocracy prevail, one can find reports that break away from this aspect, which incite resistance and, primarily, which propose conducts that are different from those dictated by the rationale prevalent in Western societies.
Strengthening the educational character (school service) of the health services, problematizing the SDH and the methods through which to encourage participation, collectivizing health needs, appreciating and reinforcing the achievements and collective actions, recovering the local community's culture and habits, and promoting HP advocacy within PHC are practices that strengthen the principles of citizenship and participation.Although under a major influence of the subjectivities present in the Brazilian Sanitation Movement, whose bases sustain themselves in a democratic society based on the rule of law, such affirmations can represent more than a call for the return to an old model of social operations.
We agree with those 1,31 who defend that we live in times of the failure of liberal democracies, in such a way that, in addition to biopolitical strategies, which seek to maintain life in societies such as the Brazilian society, the processes of exclusion and inequality also promote the death of populational groups that have been deprived of any social protection 32 .In this case, there arises the notion of necropolitics 33 , that is, a policy that kills a part of the population that is not desirable or that is considered to be useless to the economic system.
In this scenario, potential change can be seen in the manifestations presented in this text, especially in the sense of the construction of processes of subjectivization, which do not fit within the neoliberal rationale.Through the power of the joining forces of SUS users, workers, and students, who favor the strengthening of spaces for debate and problematization, we believe that it is possible to formulate the co-production of subjectivities that promote actions of resistance and counter-conduct.
This perspective aligns with the proposal of the creation of a governmentality of the "common good", in which the subjects are co-produced in horizontal, dialogic, respectful, harmonious, and loving relationships.The purpose is not performance, nor is it competitiveness, but rather the production of supportive, cooperative, interested subjects in providing care to themselves and to others.The intention, with the recovery of the "common good", is to respond to a general longing for new forms of life in which all people act as human beings in a sustainable and ecologically preserved world 34 .
At the local level, the construction of this new governmentality, geared toward the "common good", presupposes that the practices carried out in the communities are capable of favoring the collective, rather than the individual, character.In addition, they must be able to recover the power found in combatting disease and in the search for collective and co-responsible solutions.The strengthening of such practices, in educational scenarios for future SUS workers, tends to optimize the construction of collective and supportive values, which can be multiplied in their new work spaces.
We therefore recognize that the HP practices can be capable of goading on resistances and counter-conducts when faced with the logic of neoliberal governmentality.Only the effect of diminishing the individual accountability and blame, even of the more disadvantaged and excluded populations, can provoke changes in the current scenario.The maintenance of this exercise of the joining together and production of subjectivities as HP practices within PHC, which seek a more just, cooperative, harmonious, and sustainable society, seems to be the most relevant, possible, and desirable solution that we can strive to achieve.

final considerations
The possibility of the emergence of a governmentality that is not inscribed within the neoliberal rationale seems to be a great instigator of the current discourses in the HP practices, which position themselves as activators of resistance and counter-conduct to one of the aspects of HP, which has the intention to shape behaviors, render people accountable, and blame them for their conditions of health.
Running in contrast to the current history, this study points out HP actions that can be capable of producing subjectivities, as well as promote the collective and harmonious character of health actions: the strengthening of educational activities in health services; the problematization of the SDHs and the methods of encouraging participation; the collectivization of health demands; the appreciation and reinforcement of achievements and the collective actions; the recovery of the local community's culture and habits; and advocacy.
Even if this study was conducted in a very private scenario -a public health service, fully financed by the Ministry of Health, which is relatively well-organized, and has been historically and collectively constructed as a reference to the PHC strategies in Brazil (and this can represent the biggest limitation of this study) -the intention, upon disclosing and problematizing this study's results, is to show existing and possible alternatives in favor of life, in the face of a scenario of exclusions and death present in our country today.

Collaborations
FC Mattioni and CMF Rocha worked on study design, preparation, elaboration and review of the manuscript.CD Souza and RP Silveira worked on review of the manuscript.