Participation in the Health System: renewed theories and practices in the papers of Sergio Arouca's Prize for Participatory Management in Health



Alcindo Antônio FerlaI; Izabella Barison MatosII

IMedical doctor, PhD in education and assistant teacher at the Collective Health graduation course at the University of Rio Grande do Sul (UFRGS). E-mail: alcindoferla@uol.com.br
IISocial worker, PhD in Sicences - Public Health, and assistant teacher at the Collective Health graduation course at the University of Rio Grande do Sul (UFRGS).They are Invited editors for this special number of Health and Society Journal



The papers presented at this number of Health and Society were selected from the group of finalist papers of the third edition of Sergio Arouca's Prize for Participatory Management in Health, which was promoted by the Strategic and Participatory Management Secretariat of the Health Ministry in 2008. Besides their relationship with the Prize, the articles have the merit of highlighting participatory management as a field of knowledge and practices in a variety of creative perspectives; they celebrate the advances and conquests obtained in the last years, and propose the forthcoming challenges for management in Brazilian's sanitary context. The papers check disciplinary approaches of knowledge production, even in the field of Collective Health, interdisciplinary by its own nature but with a tendency of relegating to the background the contribution of its disciplines in terms of empirical, theoretical and methodological approaches (Luz, 2011). The set has great potential for debating with the varied and complex daily routine of the SUS - Brazil's National Health System. It is a chock to the logic of "wasting experience" (Santos, 2000) that often plagues knowledge production actors: sitting in a safe and comfortable position over their own theories and reflexive experiences, they tend to produce "pure" epistemological solos and theories meant for theoreticians.

Lived experiences, intense and visceral, are presented hereafter, in which routine confabulates with theories and concepts, and practice is analyzed in order to draw the maps of initiatives, strengths and potentialities of the theme of participatory management in health. It is a potentiality close to what Deleuze has named theory as a "tool box" - a theory that has to serve, to function, and that explodes when colliding to the impossibility of having practical consequences (Foucault and Deleuze, 1992). It is also close to the "practical becoming" proposed by Ayres (2009) for technologies that, mediating between models of care and their routine works, open the models and the theories that support them to productive debates that renew them both. For Ayres, tensions between instrumental and strategic orientations of theories and models are signs of vitality, and must be understood as "indicative of the need of flexibility of concepts and techniques, of the search for productive ways of handling conflicts that are born from these tensions", particularly the need of finding "shared horizons towards a productive dialogue" (Ayres, 2009, p. 13). The same can be said of the diversity of routinely operation.

Naming the prize after the sanitarian Sérgio Arouca gives the cue to understanding the diversity of approaches and the theme of participatory management. In his opening speech at the 8th National Conference on Health, Arouca challenged social participation when he informed that the fundamental problem of the Conference, and of the process of Sanitary Reform that surrounded the meeting, was not restrict to the creation of a "health system adequate to our Brazilian culture"; according to him, the main question was

"to search for a health system with an experience that has been nurtured in the experiences of community work at the neighborhoods, in the practices of unions, churches, health authorities, that have faced so much trying to transform the system, based even in the knowledge of people who, by assuming the life with this perverse system, have moved to another place in the country and started a concrete experience trying to change it" (Arouca, 1987, p. 39).

The slogan "Health is democracy", hallmark of Brazilian Sanitary Reform during that period, acquires an extended meaning when seen in this context. It is a participation that does not wears out at the formal spaces, and is not seeking solely the "administrative modernization of institutions, or even simply to change their performance (although this is of utmost importance)"; neither "simply to end up with corruption (although this is central), nor only to recover the dignity of a public service". It is a participation rooted in the idea that supports the project of Reform - that of improving living conditions of the population; a participation ethically committed to it (Arouca, 1987, p. 42). It is the translation of culture into the social and historical context in which it is expressed, and also a device to produce new cultures, more sensitive to diversity, to the collective and to the very idea of democracy; not only a new arrangement, but a dynamics that can express what is lived, the wrath towards injustice and avoidable illnesses. A sensitive listening, a permanent negotiation, networks of local knowledge, an ethical commitment with life, with the right - and the moral obligation - of sharing ideas and democratically taking part indecision processes: participation is all that, in the basis of health system reform, acting as an indicator of directionality. The challenge, as Sergio Arouca used to say, is to transform routine into act:"It is as if we were in a steam locomotive that pants, slowly releasing clouds of smoke, almost breaking down, and we, without stopping it, transformed it into a great locomotive to take us to the future" (Arouca, 1987, p. 42). More than basis and directionality, participation is the ultimate goal of the health system and of its idea of democracy.

The idea of generating new institutions and cultures in the health system - and in society as a whole - using as a starting point the daily experience is not trivial; Arouca translated into his opening speech for the 8th National Conference on Health a collective belief that was central in helping to define social participation as one of SUS' constitutional guidelines. This idea is present also in more recently adopted policies, such as Continuing Education in Health. This one, by the way, uses its analysis of existing situations as a tool for producing useful knowledge, and also for an adapted management of the work, in accordance with different contexts and needs. Education, understood as permanent learning from daily work, stimulates cognition and decision-making in a collective way of thinking, of acting. It is not walking towards an ideal model, but searching and overcoming daily difficulties: concepts, theories and strategic plans are the tools for this search. Continuing education in health "means to produce knowledge at the daily routine of health services, from reality experienced by the social actors; the problems that come up at work, the experiences of these actors, are the basis for questioning and changing" (Ceccim and Ferla, 2009, p. 162). Continuing education is focused on the work done at the health system, but is close conceptually to popular education, focused on citizenship. From the association between them we will be able understand the high frequency with which popular education concepts and methodological approaches appear in the texts of this number of Health and Society.

The first group of papers makes us think about the interface between management and participation per sectors, more specifically discussing day-to-day management and the problems that arise from it. The theme of continuing education pervades these papers as a policy at the basis of the SUS, and also as the practice of teaching and learning within the services, amalgamating initiatives of management, workers and social movements. Papers were often written by social actors coming from universities. Different theoretical-methodological approaches, different theoretical constructs make this group of articles heterogeneous.

The creation of a management collegiate, its organization and operation in a municipal context is the theme of Aparecida Linhares Pimenta's article, which mobilizes workers and founds management collectives through continuing education and its circles. This is also the motto of the work of Vera Dantas and colls but, in this one, the tool is the Circle of Life; the participants are social movements in search of a channel for expressing their popular perspectives and to participate in the formulation, installation and management of health policies and services. At Ivana Barreto and colls's article, participation comes up as integration between education and health systems for the launching of Family Health Leagues: services' and university's participants united through continuing education with a popular education approach. Ivana Macedo Cardoso analyzes the implantation of Family Health Strategy in a municipal context, in which the "continuing education circles" were the tool for professional training and for expression of these actors in management, in organizing care and in modeling services. Still on the theme of professional training, Roseni Pagani and Luiz Odorico de Andrade analyze territory preceptorship during Multiprofessional Residency in Family Health; there, continuing education has a double insertion - as a pedagogical practice and as a professional skill for residents and preceptors. In this set of articles, participation shows itself as a possibility of expressing ideas and interests for conducting the health sector, and also as a process of enhancing professional subjectivity.

A second group of papers presents the organization, operation and scope of participation forums, those common in the health sector, such as councils and conferences, as well as more uncommon ones regarding their participatory mechanisms - managerial councils, collegiate, ombudsmen. In them, theoretical-methodological diversity and singularity of empirical approaches can also be found.

Lisiane Possa and Soraya Côrtes analyze participation mechanisms and social actors in hospitals through a case study in a big institution; they discuss specifically the role and impact of these mechanisms over existing relationships amongst social actors, and over employee engagement. Social sciences contribute hugely towards the understanding of institutional practices in health. Penha Cunha and Flávio Magajewski chose to write an essay about recent public policies, evaluating their institutional effects in terms of adding up new actors and strengthening workers' action in technology and care modeling. In the same perspective, but focusing on Health Councils, the articles of Lucilane da Silva and colls, and of Elisfábio Duarte and Maria de Fátima Machado take the organization and operation of these forums as research object; so does the paper by Juliana Coelho. Besides broadening existing knowledge over social participation forums in health, the articles contribute with new methodologies and analysis' technologies.

A third group of articles approaches participation from the perspective of different groups of social actors. Maria Verônica Silva and colls present a research about the operation of a regional appointments' scheduling center, evaluating its capacity of efficiently channel the demands of the population towards specialty reference services. Here, the attentive listening is a form of reception for society's participation in the management of health services. Maria Gabriela Godoy and colls assess the creation and operation of a Psychossocial Care Center, in an empirical research that tries to identify social participation through community organizations, and its effects on producing integral care to the users. Télia Negrão develops an essay on reproductive rights from a trigger-case: a program for distributing hormonal contraceptive implants to teenagers living in the outskirts of a southern capital in Brazil. In this case, participation is expressed at the creation of a defense network fighting for ethical standards of public policies, coordinated by the Municipal Health Council, which has stopped the program. The article seeks the support of Political Science and Feminism to discuss the strategies, alliances and pleas of women's movement to revert the program, and the lessons that can be learned from them. Denise Severo and Marco Da Ros focus their attention over social participation at the SUS in a different group - the Movement of Landless Rural Workers (MST). Katiane Cruz and Elizabeth Coelho do it from the point of view of Indian population. Both articles bring relevant contributions to the understanding of the perspective of particular groups in relation to social participation. This is also the contribution of the articles of Amanda Martins and Gabriela Lotta, which approach the perspectives of participation and social control of nurses and community health agents.

The group of articles that ends this special number of Health and Society is formed by six papers that present the experiences of participation and social control in different situations. Heloisa Alencar reports an experience of continuing education in health developed by a Municipal Health Council and its effects in terms of strengthening social control and the protagonism of the Council's performance in health and other public policies. Hermínia da Ponte and colls report the reactivation of local health councils in a Northeast town, also by using a system of continuing education focused on political training of social leaders. Luis Tofani and Maria do Carmo Carpintéro tell us about the making of a municipal health conference with intense social participation that has used political negotiation devices to allow intersectoral engagement and mobilization of electoral agendas. Rosiane Palheta and Roberta da Costa describe the experience, in a public hospital of Brazilian North region, of circles of humanization operating as continuing education tools, and its effects in terms of management and care practices. Luciane Ferreira describes the experience of participative organization of strategies for articulating two different medical services -Indian medicine and the official health care service - with good results in terms of integrality of care and combination of knowledge. This set of articles also nurtures the theme of social participation due to their analysis of concrete situations: they offer technologies and methodologies to strengthen social control in health.

We would like to highlight that the whole of the articles goes beyond diagnosing or denouncing limit situations regarding participation. The question here is not the macro analytical theory or the capacity of bringing up claims and slogans that will mobilize society, but to produce and disseminate technologies for action over the daily routine. This finding can be enlightened by Madel Luz's reflection, made to present a selection of part of the many texts she wrote in a very productive academic career. She evaluates that there's been a theoretical growth by the combination of analysis tools of the beginning of her career, when macro analytical approach and a certain Marxist structural objectivity predominated, with other analytical operators and authors which were brought in later in her professional development. This combination allowed a theoretical mediation between the analytical macro level and institutional dimension, "strategic for the understanding of agents' routine, at the micro analytical level, in its relation with the political power of the Estate" (Luz, 2007, p.16). The perspective of the texts presented here is, in a certain way, a path in the inverse sense: at the front of the stage are the actors that perform the daily routines of care; theory and analysis stream from micro to macro level. The relational perspective of social actors, institutions and policies, which Merhy (2002) named micro political dimension, also has analytical power: in this case, micro politics of work, in particular the work of participating of the management of health systems, networks and care. It is in this micro political dimension, related to relationships among actors and situated at the institutional and normative sphere, that are constituted the phenomena that bring to light certain technologies used for establishing work organization that are invisible if one looks from the macro analytical point of view. Merhy sees in these phenomena the very nature of the work in health care. In the case of the papers presented in this journal's special number, the understanding of particular perspectives of such heterogeneous subjects in search of taking a leading role in the health system gives us the dimension of the analytical gains; it will also help the conduction of policies brought in by this approach. They are not isolated experiences, but part of a network of interconnected local experiences; they show that participatory management is more than an administrative-institutional title: it is a field of booming knowledge and practices, mobilized by administrative and institutional devices, public policies and support initiatives, such as the Prize Sérgio Arouca.

We feel that the papers presented in this number of Health and Society have the same spirit of Sérgio Arouca's speech at the opening of the 8th National Health Conference. This is not a trivial contribution, because SUS has, from the beginning, the challenge of assuming a configuration originated from local experiences and daily knowledge, in intense dialogue with formal knowledge; this is a contemporary challenge. These contributions, more than proposing new theories about social participation in health, have the power to bespeak the effects of "local truths networks" (Santos, 2000) on the making of health policies, on new health cultures, on democracy. After all, as Sérgio Arouca used to say, what we want for the health system, we want for Brazilian society!



The authors wish to thank Dr. Ana Maria Costa for her help during the first period of organization of this number.



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Faculdade de Saúde Pública, Universidade de São Paulo. Associação Paulista de Saúde Pública. SP - Brazil
E-mail: saudesoc@usp.br