Integrative practice policy in Recife , Northeastern Brazil : an analysis of stakeholder involvement

OBJECTIVE: To examine the involvement of stakeholders in the implementation of a local policy of integrative practices. METHODOLOGICAL PROCEDURES: Qualitative study conducted in the city of Recife, Northeastern Brazil. Data was collected from local health board records between 2004 and 2009, interviews with managers and key informants and focus groups with providers and users. The analysis was performed using the condensation of meaning model. The results were grouped into four categories of stakeholders according to their infl uence and interest, namely: subjects; population; leaders; and players. ANALYSIS OF RESULTS: Five years after the policy was implemented in Recife, only a single service offered integrative practices. The population, or users, did not have any effective involvement and did not make any contributions to the policy, and health providers, despite their willingness to participate in the process, were not involved. The leaders included the local health board, managers and medical organizations; the latter two were also players as they were effectively involved in the formulation of the policy. CONCLUSIONS: The involvement of few stakeholders in the formulation of an integrative practice policy makes it diffi cult its implementation and widens the gap between formulation and implementation, hindering the achievement of expected results. DESCRIPTORS: Health Policy, Health Public Policy. Consumer Participation. Health Councils. Health Knowledge, Attitudes, Practice. Qualitative Research.


INTRODUCTION
Policy analysis is a multidisciplinary fi eld that seeks to identify the network of relationships between leaders, the state, and its citizens.This form of analysis attempts to explain the interactions between institutions and their interests and ideas that are related to the political process, and this method has both retrospective and prospective applications.Policy analysis explains policy failures and successes, and it lays the foundation for future policies. 22,23Policy making must be understood as a dynamic process in which the outcome of a decision refl ects potential feasibility, advancement, and failure.
In some instances, policies can be developed by including the contributions of different actors in a pluralistic manner.Alternatively, policies can be formulated by a small group of individuals that usually includes leaders or managers, and this type of policy formation is generally considered elitist. 2 a Ministério da Saúde.Relatório do 1º seminário internacional de práticas integrativas e complementares em saúde.2008 maio 13-15; Brasília; 2009[cited 2010 Jun 19].Available from: http://189.28.128.100/dab/docs/geral/relatorio_1o_sem_pnpic.pdf The contribution of actors is not static; in the course of policy development, some actors may be favorable at the outset, although the same individuals may subsequently hinder the policy's progression or alter it in some way. 20Thus, the behavior of participants in policy making may be analyzed by understanding the participants' interests and power. 7 Brazil, the implementation of the National Policy for Integrative and Complementary Practices (PNPIC) is an example of a policy that has involved heavy participation by stakeholders and has been infl uenced by power and mobility.The numbers of health care professionals 19 and health care system users who are interested in integrative and complementary medicine are currently increasing in several counties.3,8 Despite this recent surge in interest, the establishment of the PNPIC in the health system is the result of the historical persistence of several actors who, beginning in the 1980s, devoted their efforts to include this policy in the national health system (Sistema Único de Saúde -SUS).17 After several attempts, the PNPIC was instituted in 2006.18 This policy seeks to include and increase the presence of homeopathy, acupuncture, hydrotherapy, herbal medicine, anthroposophic medicine, and body practices (yoga and tai chi chuan) in the SUS, thus making them more widely accessible to the Brazilian population and particularly at the primary health care level.
Prior to the implementation of the PNPIC, the city of Recife (Northeastern Brazil) developed and implemented a policy that incorporated "alternative medical approaches" into the prevailing SUS biomedical structure.In 2004, Recife established a policy that sought to improve patients' quality of life, increase assistance to patients, and offer a range of integrative medical approaches.For this reason, a Health Integral Care Unit (HICU) was established.This unit was incorporated into the city health care network as a centrally located reference center and focused primarily on patients referred by the Family Health Strategy program.The HICU made therapeutic modalities such as homeopathy, herbal medicine, and acupuncture available.Subsequently, these modalities acquired formal status in the PNPIC.The HICU also offered additional activities, including a healthy nutrition program with counseling as well as workshops targeting the elderly, adolescents, individuals with high blood pressure and/or diabetes, and health care professionals.a Despite the more than fi ve years that have elapsed since PNPIC was implanted in Recife, there have been no studies to assess its development and the participation of the relevant actors.Therefore, this study sought to analyze the participation of the actors involved in this policy making process as well as their infl uence on the development of the policy for integrative medicine.

METHODOLOGICAL PROCEDURES
This qualitative study analyzed the participation of several PNPIC actors in Recife.The study methodology included the analysis of documents, interviews with the actors playing relevant roles in the implementation of the policy (key informants and managers), and focus group discussions with health care professionals and users.
Offi cial documents regarding policy implementation and the proceedings of the Recife Municipal Health Council (MHC) between 2004 and 2009 were analyzed.The year that PNPIC was established in the city was defi ned as the starting point.All 126 digitized records of the regular and special sessions were analyzed.The following components of the documents were analyzed: the health practices, alternative health practices, complementary health practices, integrative health practices, complementary medicine, alternative medicine, integral health care units, acupuncture, and homeopathy.Key informants were selected for interviews, which were performed between August 2009 and January 2010, based on their participation in the policy formation.The information reached saturation level at the end of the fi fth interview.
Two focus groups, which were each comprised of ten participants, were carried out between December 2009 and January 2010.One group included HICU health care professionals and the other group included HICU users.The participants for both groups were randomly selected.
The analysis was performed using two methods: 1) Kvale's 9 (1966) meaning condensation analysis was employed to analyze the content of the interviews; and 2) Eden's 7 (1996) adapted model was used as a reference to categorize results that correlated the interests and the power of actors who may have exerted infl uence on the policy-making process (Figure 1).The actors were distributed among the following four categories: • the "population" or the "users" were those who had no interest or power regarding participation in the PNPIC; • the "subjects" included institutions or individuals who had interest regarding participation in the PNPIC but did not have power to infl uence the process; • the "leaders" were comprised of institutions, groups, or individuals who had the power to act as a function of the institutions they represented; • the "players" were those who actively participated in the defi nition of the policy directions because they had the interest and power to do so.
This study was approved by the Aggeu Magalhães Research Center Ethics Committee, protocol 30/2009.All participants signed an informed consent form.

ANALYSIS OF RESULTS AND DISCUSSION
Growing interest in the study of the role of policy actors derives from an explicit acknowledgment of how the characteristics and interests of different groups of actors infl uence participating organizations. 21Actors are infl uenced (individually, as interested groups, or as professional associations) by their work environments both at the macro-governmental and micro-institutional level.Policy context is affected by several factors, including the instability or uncertainty caused by changes in the political regime, neoliberal or socialist ideology, historical experiences, and culture.The process (i.e., how issues enter the political agenda) in turn is affected by the actors, their position within the structure of power, their values, and their expectations. 24In Recife, the proposal to include integrative health practices in the health care network was made during a time of political change when new actors appeared on the stage of health care management.The city government upheld the principle of democratic and popular participation.However, an analysis of the actors' participation demonstrated that there was an elitist model of policy building, which was evidenced by the types of actors involved.complementary practices and did not participate in policy discussion.According to Agyepong & Adjei (2008), 1 the citizens' lack of involvement in policy decision making can defi ne management stability.However, according to these authors, this lack of involvement also hinders the legitimization needed for the continuity of policies and programs.This legitimization problem may explain the fact that the window of opportunity that was created 15 by the interest of the managers for the integrative practices did not suffi ce to increase the number of health care facilities offering this type of assistance during the investigated period.

Subjects
An analysis of the actors' interest and power established that the policy subjects were the health care professionals.Despite their interest in the investigated practices, the health care professionals had no power and only marginal participation in the policy development: "(...) in 2004, I can remember that…we saw there was an initiative to create a reference unit.But we had no participation in its development or organization.We only knew that it would be implemented (...)very little was discussed with the group of health care professionals."(health care professional) According to Mannheimer et al, 10 this is a serious fl aw because the formulation of public policy cannot be estranged from those in charge of its application and development.However, this is also what happened in the case of the PNPIC in Recife.Another factor that infl uenced the fi nal outcome was the lack of participation of the health care professionals and users in defining the policy path.According to Minogue 12 (2010), this is one factor that infl uences the success of social policies.

Leaders
Three leaders were identifi ed and classifi ed as those with the power to infl uence the health care policies.
The fi rst group was the MHC, which is a social agency that controls, surveys, and discusses the city's health care policies.The MHC was rated a relevant and empowered actor due to its importance in political decision making.However, only one investigated proceeding, nº 181 from 2007, alluded to the integrative and complementary health practices policy in Recife: "The councilman (…) reports that the council received an invitation for the third anniversary of the Guilherme Abath Health Care Unit.He suggests that the council must not only visit but also carefully observe this unit, which is currently a distinguishing element in the city of Recife and one that surprised him."(Proceeding) The second group, which is comprised of medical associations, has traditionally displayed effective power over various aspects of public health in the city.These medical associations have exerted direct infl uence on the policy for integrative health practices, as described in the following report: "These health practices had to have proven effi cacy and effectiveness (…) and could only be performed by doctors.These were acknowledged health practices that were restricted to this professional category, but these other practices included a long list of practices ranging from dance to meditation as well as other health practices performed by non-medical professionals."(Key actor) The third group, which was identifi ed as having power in the process, effectively acted as the leader and included members of the city health care administration: "I believe that it was a favorable time (…) for people occupying these positions and areas.It was an administration where the mayor was sensitive, the secretary was sensitive, and the district director was sensitive."(Key actor)

Players
Among the policy actors, two types of groups were distinguished as major players, and these were both categorized as leaders.
The medical associations were found to have a strong infl uence on the specifi c policy, as illustrated by the following expression:

"(…) The acupuncture society is fully closed and does not allow other people to practice this treatment (…)
The homeopathic society is not as closed…we did not start using Bach´s fl owers immediately, which we could have done, but there was and there still is much resistance among the society, mostly from the Medical Council."(Key actor) The managers not only showed interest but also participated in the policy development.The following statement shows that the city health care manager developed initiatives related to integrative medical practices: "(…) it was created upon requirement by the health secretary at the time; a group met and developed a project and decided what it would be called... a health promotion operation that would incorporate some individual activities and some group sessions that focused on practices to rejuvenate the body and mind." (Key-actor) The behavior of the main actors, regarding the policy for integrative and complementary medicine, is summarized in Figure 2. Managers (arrow 1) and medical associations (arrow 2) both acted as players because they infl uenced the development and the content of the policy for integrative medical practices.
The policy for integrative medical practices in Recife collides with one of the primary characteristics of health systems in developing countries: the weak legal structure.Funding is often not assured, and results are not surveyed or monitored. 23The low rates of institutionalization for the integrative practices are not exclusive to Recife or to Brazil.A study that was performed in nine Latin American and Caribbean countries demonstrated that the majority had no legislation supporting these practices, although they were quite widespread and accepted by the societies in such countries. 13is study showed that a chosen group of actors acted as the main players in the investigated policy and thus concludes that policy formation and enactment in this instance had an elitist nature because the policies were carried out by fi rst-rank politicians (Figure 2).According to Thomas & Gilson, 20 when a diverse set of actors contribute to the process, including health care professionals, important changes can be made to the health system.
According to Costa, 5 leaders are the holders of political judgment and can only make decisions in these instances, such as the appointment of experts.Decisions are made by experts who are indirectly chosen by the population through voting, and this can be seen in the formation of the PNPIC in Recife.In this case, managers decided to establish a study group comprised of experts in this area to develop the policy for the city.
The formation of "restricted" groups of actors as players for the discussion of integrative health practices may have been the force that kept individuals away who could have participated in a discussion of alternative health practices in Recife.According to Oliveira et al  (2005), 14 the gap between central actors and the local reality may be the cause of the fl aws in policy enactment.According to Minogue, 12 this phenomenon may be a characteristic of poor management.The smaller the distance between those formulating the policies and those applying the policies, the higher the impact exerted and the more likely that the goals will be  fulfi lled by the policies, as planning is often simpler than implementation. 6,11 Recife, the policy was developed by high-ranked managers, and there was little participation from the citizens and little discussion with the health council and the health care professionals.This model of policy formulation and implantation is referred to as "top down". 16This is highlighted by the fact that the city's main institution that represents the interests of the users (MHC) did not deem integrative health practices a relevant subject, and this is often a determining factor for the failure of social policies. 24The lack of involvement in political decision making by the public and those working in public services, as seen in Recife, was also observed for another study, where the scant participation of the public did aid in management stability, but it also made it diffi cult to achieve the legitimization necessary for the continuity of the policies and programs implemented. 1

CONCLUSION
The development of this policy for integrative and complementary medical practices in Recife involved the participation of very few actors.This may be related to the diffi culties thus far in the policy's institutional strengthening.Consequently, the policy's continuity may be threatened due to the increasing gap between formulation and implementation, as it becomes more diffi cult to achieve the expected results.
The study of actors and their interests and power contributes to an understanding of the political process.Methods, such as those proposed by Eden (1996) 7 and those adapted to this study, allow for the visualization of the dynamics of an individual or those of collective subjects who may participate in the political scene.Such methods point to the relevance of including several actors in political processes, as these favor legitimization and assist in understanding the potential fl aws that could be avoided in terms of policy (re)defi nition.
Even at the SUS and in the public health arena, elitist policies prevail.These give rise to a vicious circle, whereby organized society experiences little or no political participation and thus becomes easily manipulable, and the power of elitist and privatizing traditions remains unaffected.Even when managers are committed to integrative practices and policies, their initiatives remain isolated and have little power to grow and consolidate.

Users (the cityFigure 1 .
Figure 1.Organization of the categories of individuals that serve to analyze actors according to their interests and power.Adapted from Eden 7 (1996).

1 2 UsersFigure 2 .
Figure 2. Mobilization of actors in the integrative health practices in Recife according to their interests and power.