Problems and Purpose

Summoned by the Executive branch through its ministries and secretariats, the Brazilian Conferences on Health consist of spheres of representation, deliberation, and participation which are designed to provide guidelines for the formulation of the Health public policy. The national conferences are, as a rule, preceded by rounds at the municipal, state, or regional levels. In all the rounds, the brainstorming, deliberation, and decision-making processes are held in workgroups and plenaries. The aggregate results of the deliberations are the object of deliberation in the following conference, attended by the delegates from the previous rounds. Those delegates represent all the segments related to the health policy: 50% are policy users, 25% represent health workers, and the remaining 25% are public managers and health service providers. At the national conference, they deliberate over a final document containing the guidelines for the design of the Health policy, as the result of a long process of deliberation and consensus formation between government and civil society.

Background History and Context

The First Seven Conferences on Health:

The first Conference on Health was held in 1941, summoned by former President Getulio Vargas.[1] Created by Act 378 of January 13, 1937, the meeting aimed to provide information about the health and education-related activities for the Federal Government and guide them in the performance of local health and education services.[1] The Act established that the meetings would be convened by the President every two years and would be constituted of representatives of the government of the three levels of the Federation and representatives of social groups related to the policy area.

Notwithstanding the legal guidelines, other Conferences on Health were only held from 1946 to 1964, along with the establishment of democracy.[1] During this democratic period, the government held the second and third Conference on Health in 1950 and 1963 respectively. The first one was accompanied by sanitary campaigns to combat serious health epidemics and claims for sanitation policies. Those protests led to the creation of the National Department of Health in 1953, through Act 1920, which became responsible for regulating the area. In turn, by the third Conference on Health, the decentralization of health services was established and set a National Health Care Policy under the responsibility of the new National Department.

Over the following political period of Military Dictatorship (1964-85), four other Conferences on Health were held.[1] In 1967, the fourth Conference aimed to offer suggestions for the formulation of a national policy on human resources. The development of health activities in the country was scarce so far. Almost a decade later, in 1975, the fifth Conference was summoned to consolidate and disseminate the National Health System, which had been created in the same year, on July 17, 1975. Two years later, the sixth Conference on Health was held to evaluate the implementation of the National Health System, among other things. Misjudged, this system was put aside and a new nationwide program, called Basic Health Care Services Program (PREV-HEALTH), was drawn up to be discussed at the seventh Conference held in 1980. The meeting deliberated about the implementation and development of that program over the following years. [2]

The Watershed: the 8th Conference on Health

Despite popular participation having been guaranteed by Act 378 of 1937, the first seven Conferences on Health did not have significant involvement of social actors. The striking Conference on popular participation was the eighth, held in 1986, under the context of political democratization and of intense and conflicting dispute over the Health Care System reform under discussion in the Constituent Assembly.

The eighth Conference was marked by the radical defense of popular participation on Health policies. It took place one year after democratization and benefited from the moment mobilization cycle. Popular participation was advocated as one of the conditions to ensure the right to health, being understood as "the control of the formulation, management and evaluation of social and economic policies by the population". [3] The right to health would constitute a "social achievement," whose full exercise would enable, among other things, "public participation in the organization, management and control of healthcare services and actions". [4] From this perspective, the population would be the main protagonist of the social construction of the right to health, so that this right would be guaranteed to "every single Brazilian" (universal right to health) by the participation of the organized population in the decision-making processes. [5]

Implications of the 8th Conference on Health:

The role of civil society in building the right to health fostered a broad popular mobilization in order to ensure, in the new Federal Constitution under discussion, the universal right to healthcare and a National Public Health Care System (SUS). The strong advocacy of those claims resulted in the constitutional definition of health as a right of all and a duty of the State and in the creation of SUS, a decentralized and participatory public healthcare system targeted to comprehensive care of citizens. [6]

Moreover, the intense lobbying by social groups for a universal and participatory healthcare system led to the enactment of Act 8142 of 1990. The Act ensured community participation in the management of the National Public Health Care System by two participatory institutions: the Health Councils and the Conferences on Health. The Health Councils would be permanent and deliberative bodies constituted by representatives of the government, service providers, health professionals and users, engaged in the formulation of strategies and in the implementation of health policy at local, state and national level. The Conferences on Health, in turn, would be held every four years to assess the health situation and propose guidelines for healthcare policy by representatives of government and social groups. [7]

Once popular participation in the construction, implementation, and evaluation of Health Care Policy was legally ensured, the six Conferences on Health that followed the eighth Conference in 1986 (1992, 1996, 2000, 2003, 2007 and 2011)[1] were characterized by broad participation of users, health professionals, and health service providers at the municipal, state, and national level. Year after year, the breadth, range, and inclusivity of the Conferences on Health have increased. In December of this year, the 15th Conference on Health will be held to discuss the quality of Health Care to take good care of the people.

Organizing, Supporting, and Funding Entities 

Act 8142 of 1990 established the guidelines for community participation in the management of Health Policy. The Act required that Conferences on Health must be convened by the Executive Branch or by the Health Council and must have their organization and methodology defined by internal rules, as well as the requirement to ensure equal representation. The meetings have been convened by the President every four years and the Conference’s internal rules have ensured 50% representation of users and 50% of health professionals, managers and service providers.

Participant Recruitment and Selection 

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The Conferences ensured parity of representation of users (50%) and the other three groups: health workers (25%), and public managers and health service providers (25%). Another requirement was gender parity with equally represented men and women.

Methods and Tools Used 

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What Went On: Process, Interaction, and Participation

The legal guidelines to convene the health conferences and ensure equal representation have been followed by the Executive branch since the enactment of Act 8142. In addition to the legal guidelines, internal rules have determined the objectives of the meeting, themes to be discussed, stages and dates for holding the debates, dynamics of deliberation of proposals, and the guidelines for the referral of proposals approved in each meeting to the organizing committee of the next conference.

Objectives and Phases:

Regarding the objectives and themes discussed, each conference has peculiarities according to the priority and the government political project for the area at the time of the summons. Despite those distinctions, the primary purpose of the conference, established by Act 8142 of 90, must be fulfilled, namely to assess the health situation and propose guidelines for the formulation of the healthcare policy.

Concerning the phases and dates, the internal rules ensure Conferences on Health at local and state levels, before the national meeting. The period of completion of each stage is defined by those rules and applies likewise to all municipalities and states. Although the national conferences usually last three or four days, the entire process takes almost a year to be completed. In all meetings, the objectives and themes of discussion are the same as well as the basis-document that guides the deliberation in these forums.

On the local stage, community participation is wide open to all, and all participants have the right to speak and vote in all deliberative spaces. By the end of the meeting, the delegates that will participate in next stage Conference are chosen by majority vote. At the state level, a similar voting process takes place to elect delegates to participate in the national conference in Brasilia. Regardless of the stage, the selection of delegates must ensure equal representation of women and men and 50% of users, 25% of Health workers, and the remaining 25% of public managers and health service providers.

The Deliberative Process:

Moreover, at every stage, the deliberative process takes place in working groups and plenaries. The working groups discuss and vote on the proposals in the basis-document of the conference. Amended or new proposals approved by majority vote of the delegates in the group are brought to the plenary for final examination. All modified and added guidelines approved at the plenary are included in the final report of the conference by the corresponding organizing committee. Therefore, the deliberative process begins in the first stage and is applied to all meeting until the last one, at the national level. All the guidelines approved along this process are included in the final report of the conference, which will serve to guide the government projects and programs on health at the municipal, state and federal level.

Influence, Outcomes, and Effects

Empowering social actors and participatory institutions

The enactment of Act 8142 of 1990 democratized the management of health policy in Brazil by constituting participatory designs as part of that policy decision-making process. The Conferences on Health have been decisive to increase community participation in the formulation and implementation of local and national policies by the corresponding Executive branches. Unlike what occurred until the eighties, Conferences on Health have no longer been the main arenas of negotiation and mediation for stakeholders since 1990, but have taken two other primary institutional roles. [8]

The first role is as the articulator of social forces in favor of deepening the system reform process. The institutionalization of participation by Act 8412 enabled the strengthening and integration of social movements on Health and, therefore, the organization of integrated and participatory management systems in that area.

Secondly, the Conferences on Health have approached users and managers of health policy, especially at the municipal level. As the process of policy management decentralization advanced, the conferences became the locus where representatives of users — mainly the residents of the poorest parts of municipalities — started to bring forward their demands to policy managers.

Building Health Policy

Moreover, the Conferences on Health have impacted the decisions taken by the Executive and the Legislature. It was through the deliberation of the eighth Conference held in 1986 that the right of every citizen to public health and the creation of the Unified Health System (SUS) became enshrined in the 1988 Federal Constitution. In turn, the 10th Conference boosted the Basic Operational Rule 96 (NOB 96), which encouraged municipalities to take over the management of the local health services network and, in the same year of the 11th Conference on Health, Constitutional Amendment 29 was enacted, which set a threshold for the use of public funds in the financing of health actions and services by municipalities, states and the federal government. [9]

The impact of the guidelines approved in Conferences on Health on the Executive's decisions can be also observed at the sub-national level. The five Conferences on Health held by Parana state government from 1991 to 2002 performed a diagnosis of the health policy and health services situation which influenced the decisions made by the state managers later. [10] Similarly, the Conferences on Health held in 16 municipalities of Mato Grosso state played an important role on pointing out local priorities and demands on Health for the corresponding Executive branch. [11]

Lastly, the Conferences on Health have influenced the bills proposed and acts enacted by the Legislature. The final report containing policy guidelines approved by the conferences have activated and impelled the legal activity of the Congress, and its effect on lawmaking can be measured by the number of bills proposed and statutes enacted, as well as by the content addressed in them. From 1988 to 2009, about 12% of the bills proposed in Congress were substantively convergent with the national conferences policy guidelines. As for the approved legislation, 13.3% of all statutes and constitutional amendments enacted by the Parliament can be said to deal with specific issues deliberated on by the Conferences on Health. [12]

Hence, Conferences on Health have been a public forum within which the interests of ordinary people are represented and in which the representatives of Health sectors have participated in deliberative processes undergone in them.

Analysis and Lessons Learned

Conferences on Health have become one of the main 'labs' for analyzing community participation in the management of public policy. A rich and varied body of research has assessed the role Conferences on Health have taken, the networks of relations and structures of social relations within them, the impact of approved guidelines on decisions made by the Executive and the Legislature, and the institutional and political limits faced by these forums.

Regarding the role Conferences on Health have played in the context of health policy, most studies focus the analysis on their institutional design. [13] [14] [15] [16] The eventual character of the process implies, to some extent, changes in the role those forums take over time. Since 1990, the role each Conference took depended, somehow, on its central theme and working dynamic as previously defined by the National Health Council. [17]

Power relations in Health Councils, mainly at the national level, have also impacted, to some extent, the configuration of network relations and social relations structures in the Conferences on Health. How and to what extent social and political actors participate is somehow determined by the resolutions enacted by the Councils, which define the rules of each meeting and, as a result, shape the relation between community and government representatives in those forums. In this sense, the enactment of rules that ensure representation of all groups of the area does not mean they will participate. As shown by Faria et. al. (2012), [18] health service providers didn’t participate in any local conference held in Belo Horizonte city before the 14th National Conference on Health in 2011.

Furthermore, the presence of a higher number of community representatives does not guarantee that these actors will either have a greater influence on the guidelines approved or lead the decision making processes by occupying higher-ranking positions in the network of social relations that constitute the conferences. [19] [20] How and to what extent community and state actors participate in the meetings depend on the local and national situation of Health Care policy and, more specifically, on the set of social relations in the area at each Federative Unit and the relative positions of the actors within it. [21]

Regarding the impact of approved guidelines in Conferences on Health on Executive decisions, those forums have notably faced political barriers. Policy managers have not followed, to a significant degree, the priorities suggested and the guidelines for health financing policies approved by conferences' participants. It is clear that the impact of Conferences on Health decisions on the policy-making process within the Executive branches is still limited. [22]

Similarly, the degree of the impact of the guidelines approved in the conferences on future legislative activities in the National Congress is limited and affected by the political coalition in power. The effect of the guidelines approved in the Conferences held from 1988 and 2009 on the bills proposed and the laws enacted only became higher and more significant after the first mandate of former President Fernando Henrique Cardoso (1998-2002) and, even more prominent, during Luís Inácio Lula da Silva governments (2003-2009), when there was an explosion in legislative bills related to guidelines approved in Conferences on Health. Lula’s governments not only made the conferences more effective and remarkable in the political scene, but made representative and participatory designs more solid and deeply rooted. [23]

Despite the democratic achievements of the Conferences on Health, those forums face political and institutional boundaries which shape the role they take, the networks of relations and structures of social relations within them, and the degree of impact of their approved guidelines on the decisions made by the Executive and the Legislature.

See Also 

First National Conference on Public Security in Brazil 

National Public Policy Conferences 

References

[1] Comitê Executivo da 14ª Conferência Nacional de Saúde. (n.d.). Histórias das Conferências de Saúde. http://conselho.saude.gov.br/14cns/historias.html

[2] Sayd, Jane Dutra; Vieira Junior, Luiz; Velandia, Israel Cruz (1998). Recursos Humanos nas Conferências Nacionais de Saúde (1941 a 1992). Rio de Janeiro: Revista Saúde Coletiva, 14.

[3] Brasil, Ministério da Saúde (1986). CONFERÊNCIA NACIONAL DE SAÚDE, 8., Relatório final. Brasília: Ministério da Saúde, p. 4.

[4] Brasil, Ministério da Saúde (1986). CONFERÊNCIA NACIONAL DE SAÚDE, 8., Relatório final. Brasília: Ministério da Saúde, p. 5

[5] Brasil, Ministério da Saúde (1986). p. 8

[6] Brasil, República Federativa do (1988). Constituição da República Federativa do Brasil de 1988. Disponível em: <http://www.planalto.gov.br/ccivil_03/constituicao/constituicao.htm>. Accessed October 1, 2015.

[7] Brasil, República Federativa do (1990). Lei no 8.142, de 28 de dezembro de 1990. Dispõe sobre a participação da comunidade na gestão do Sistema Único de Saúde (SUS} e sobre as transferências intergovernamentais de recursos financeiros na área da saúde e dá outras providências. Disponível em: <http://www.planalto.gov.br/ccivil_03/LEIS/L8142.htm>. Accessed October 1, 2015.

[8] Cortes, Soraya Maria Vargas (2009). Conselhos e conferências de saúde: papel institucional e mudança nas relações entre Estado e sociedade. In: Fleury, Sonia, Lobato, Lenaura de Vasconcelos Costa Lobato (organizadoras) (2009). Participação, Democracia e Saúde. Rio de Janeiro: Cebes.

[9] Pinheiro, Marcelo Cardoso, Westphal, Márcia Faria, Akerman, Marco (2005). Eqüidade em saúde nos relatórios das conferências nacionais de saúde pós-Constituição Federal brasileira de 1988. Cad. Saúde Pública, Rio de Janeiro, 21(2):449-458, mar-abr.

[10] Carvalho, M (2004). O impacto das conferências de saúde na definição do financiamento do SUS no Paraná. Dissertação (Mestrado em Saúde Coletiva) – Centro de Ciência da Saúde, UEL, Londrina.

[11] Müller Neto, J.S.; Schader, F.T.; Pereira, M.J.V.S.; Nascimento, I.F.; Tavares, L.B.; Motta, A.P. (2006). Conferências de saúde e formulação de políticas em 16 municípios de Mato Grosso, 2003-2005. Saúde em Debate, v. 30, n. 73/74, p. 205-218.

[12] Pogrebinschi, Thamy and Santos, Fabiano (2010). Participation as Representation: The Impact of National Public Policy Conferences on the Brazilian Congress (2010). APSA 2010 Annual Meeting Paper. Available at SSRN: http://ssrn.com/abstract=1643679.

[13] Avritzer, Leonardo (2009). Participatory Institutions in Democratic Brazil. Baltimore: John Hopkins University Press.

[14] Guizardi, F.L.; Pinheiro, R.; Mattos, R.A.; Santana, A.D.; Matta, G.; Gomes, M.C.P.A. (2004). Participação da comunidade em espaços públicos de saúde: uma análise das conferências nacionais de saúde. Physis: Revista de Saúde Coletiva v. 1, n. 14, p. 15-39.

[15] Escorel, S.; Bloch, R.A. (2005). As Conferências Nacionais de Saúde na construção do SUS. In: Lima, N.T.; Gerschmhman, S.; Edldler, F.C.; Suárez, J.M. (Org.). Saúde e Democracia: história e perspectivas do SUS. Rio de Janeiro: Fiocruz, p. 193-233.

[16] Kruger, T.R. (2005). Os fundamentos ideo-políticos das conferências nacionais de saúde. Tese (Doutorado) – Centro de Ciências Sociais Aplicadas, UFPE, Recife.

[17] Escorel, S.; Bloch, R.A. (2005). As Conferências Nacionais de Saúde na construção do SUS. In: Lima, N.T.; Gerschmhman, S.; Edldler, F.C.; Suárez, J.M. (Org.). Saúde e Democracia: história e perspectivas do SUS. Rio de Janeiro: Fiocruz, p. 193-233.

[18] Faria, Claúdia Feres; LINS, Isabella L.; LOBÃO, Evelyn R.; CARDOSO, João Antônio P.; PETINELLI, Viviane (2012). Conferências Locais, Distritais e Municipais de Saúde: Mudança de Escala e formação de um Sistema Participativo, Representativo e Deliberativo de Políticas Públicas. IPEA, Texto para discussão 171x, Rio de Janeiro, Março.

[19] Escorel, S.; Bloch, R.A. (2005). As Conferências Nacionais de Saúde na construção do SUS. In: Lima, N.T.; Gerschmhman, S.; Edldler, F.C.; Suárez, J.M. (Org.). Saúde e Democracia: história e perspectivas do SUS.

[20] Müller Neto, J.S.; Schader, F.T.; Pereira, M.J.V.S.; Nascimento, I.F.; Tavares, L.B.; Motta, A.P. (2006). Conferências de saúde e formulação de políticas em 16 municípios de Mato Grosso, 2003-2005. Saúde em Debate, v. 30, n. 73/74, p. 205-218.

[21] Cortes, Soraya Maria Vargas (2009). Conselhos e conferências de saúde: papel institucional e mudança nas relações entre Estado e sociedade. In: Fleury, Sonia, Lobato, Lenaura de Vasconcelos Costa Lobato (organizadoras) (2009). Participação, Democracia e Saúde. Rio de Janeiro: Cebes.

[22] Carvalho, M (2004). O impacto das conferências de saúde na definição do financiamento do SUS no Paraná. Dissertação (Mestrado em Saúde Coletiva) – Centro de Ciência da Saúde, UEL, Londrina.

[23] Pogrebinschi, Thamy and Santos, Fabiano (2010). Participation as Representation: The Impact of National Public Policy Conferences on the Brazilian Congress (2010). APSA 2010 Annual Meeting Paper. Available at SSRN: http://ssrn.com/abstract=1643679.

Avritzer, Leonardo e Sousa, Clovis (2013). Conferencias nacionais: atores dinâmicas participativas e efetividade. Brasília: IPEA.

Cortes, Soraya Maria Vargas (2002). Construindo a possibilidade da participação dos usuários: conselhos e conferências no Sistema Único de Saúde. Sociologias 7 (2002): 18-48.

Faria, Claudia Feres; Lins, Isabella Lourenço (2013). Participação e deliberação nas conferências de saúde: do local ao nacional. In: Avritzer, L.; Souza, C. H. L. Conferências Nacionais: atores, dinâmicas e efetividade. Brasília: IPEA.

Guizardi, Francini Lube, Pinheiro, Roseni, Mattos, Ruben Araujo, Santana, Ana Débora, Matta, Gustavo da, Gomes, Márcia Constância Pinto Aderne (2004). Participação da Comunidade em Espaços Públicos de Saúde: uma Análise das Conferências Nacionais de Saúde. PHYSIS: Rev. Saúde Coletiva, Rio de Janeiro, 14(1):15- 39.

Fleury, Sonia, Lobato, Lenaura de Vasconcelos Costa Lobato (organizadoras) (2009). Participação, Democracia e Saúde. Rio de Janeiro: Cebes.

Menicucci, Telma Maria Gonçalves (2007). Público e privado na política de assistência à saúde no Brasil: atores, processos e trajetória. Fiocruz.

Petinelli, Viviane (2011). As Conferências Públicas Nacionais e a formação da agenda de políticas públicas do Governo Federal (2003-2010). Opinião Pública, Campinas, vol. 17, no 1, Junho, p.228-250.

__________, Viviane (2013). Contexto Político, Natureza da Política, Organização da Sociedade Civil e Desenho Institucional: Alguns Condicionantes Da Efetividade Das Conferências Nacionais. Rio de Janeiro: IPEA.

External Links

Website of the National Department of Health

Website of Health Councils: http://conselho.saude.gov.br/

Website of the Conferences on Health

Notes