Abstract

Introduction

This article points to some directions to approach intersectorality. It points to the fact that so far there is a lack of theory to consecrate this topic as a category in research and evaluation. It suggests that one of the possible directions to approach intersectorality would respond to different questions or issues, favoring the creation of a “question database” for research that will be presented in this article.

The article contextualizes the intersectoral debate; with approximations to the topic, indicating that there are open issues, and inspired in the plurality of the word “intersectorialitieS”, signaling the need to build a research agenda to include theoretical contributions, so that intersectoral action will not be an experiment in public action and truly build a government praxis.

Magalhães and Bodstein¹1 Magalhães R, Bodstein R. Avaliação de iniciativas e programas intersetoriais em saúde: desafios e aprendizados. Cien Saude Colet 2009; 14(3):861-868. contribute to this debate upon saying that “the interface and dialogue between research, evaluation and follow-up of decision making processes constitute the main axes for greater social and institutional learning in this field”.

More than a mere academic debate, there are cries about the important insufficiencies in isolated intersectoral action with potential to face the root of the major problems affecting the health of populations, such as the unequal distribution of power, services and resources among countries, within countries and population groups, as well as the current forms of production and consumption, deleterious to health and life²2 Franco S, Nunes ED, Breilh J, Laurell AC. Debates em Medicina Social. Quito: OPAS, Alames; 1991.

3 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Política Nacional de Promoção da Saúde. Brasília: MS; 2006.

4 Barreto ML, Carmo EH. Padrões de adoecimento e de morte da população brasileira: os renovados desafios para o Sistema Único de Saúde. Cien Saude Colet 2007; 12(Supl.):1179-1790.

5 Buss PM, Pellegrini A. A saúde e seus determinantes sociais. Physis 2007; 17(1):70-93.

6 Viana ALD, Elias PEM. Saúde e desenvolvimento. Cien Saude Colet 2007; 12(Supl.):1765-1777.

7 CDSS. Reduzindo as desigualdades sociais em uma geração - Relatório Final. Genebra: OMS; 2008.

8 Bierman AS. Project for an Ontario Women-s Health Evidence-Based Report. Toronto; vol 1. 2009. [acessado em 2013 jan 10]. Disponível em: http://www.powerstudy.ca.
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9 Bierman AS. Project for an Ontario Women's Health Evidence-Based Report. Toronto; vol. 2. 2010. [acessado 2013 jan 10]. Disponível em: http://www.powerstudy.ca
http://www.powerstudy.ca... ^{- 10}10 Akerman M, Gonçalves CM, Bógus CM, Chioro A, Buss P. As novas agendas de saúde a partir de seus determinantes sociais. In: Campos GW, Minayo MCS, Akerman M, Drumond Junior M, Carvalho YM, organizadores. Determinantes Sociais e Ambientais. Washington: OPS, MacGill; 2011. p. 1-16..

These cries find their backing in a recent article in the Lancet, “The political origins of inequity in health: perspectives for change”, published by a coalition of groups and independent authors. They signal that “equity in health cannot be approached in isolated fashion within the health sector, through mere technical measures”, and that it is “necessary to adopt multiple forms of intersectoral governance”¹¹11 Ottersen OP, Dasgupta J, Blouin C, Buss P, Chongsuvivatwong V, Frenk J, Fukuda-Parr S, Gawanas BP, Giacaman R, Gyapong J, Leaning J, Marmot M, McNeill D, Mongella GI, Moyo N, Møgedal S, Ntsaluba A, Ooms G, Bjertness E, Lie AL, Moon S, Roalkvam S, Sandberg KI, Scheel IB. The political origins of health inequity: prospects for change. Lancet 2014; 383 (9917):630-667..

In which context can we understand the intersectoral debate?

The comic strip (Figure 1), by Chris Browne, makes us reflect that even with a multiplicity of interests, it is possible to obtain some sort of common result, in this case peace, but that war is potential in that never-ending clash between the diversity of chants.

And in this music festival, there is no way to do without a jury that will include, mediate and decide how the different voices will participate in the contest”. The opportunity then appears to discuss herein the role of the State that not always has played a constant and stable action faced with the flavor of ideological, political and economic waves of the times, allowing it to become a problem at times, and at others, a solution.

Evans¹²12 Evans P. O Estado como problema e solução. Lua Nova 1993; 28,29:107-156. carries out this analysis and characterizes three waves, the coming and going of an intervener model for the conception of a minimal state, quasi absent, to the recovery or redemption of a reconstructive role for the State:

• While a problem, the intervener state arose in part due to the failure of carrying out the tasks set forth by a prior agenda (1^st wave).

• The new agenda, neo-utilitarian, preaches minimalist theories for the State,... and, advocates a structural adjustment for the State (2^nd wave).

• Doubts regarding if the structural adjustment would suffice to guarantee future growth,... The response did not lie in dismantling the State, but instead in its reconstruction (3^rd wave).

This debate also had its repercussions in Brazil, and Bresser Pereira¹³13 Bresser-Pereira LC. Reforma do Estado para a cidadania: a reforma gerencial brasileira na perspectiva internacional. São Paulo-Brasília: Ed. 34-Enap; 1998. (apud Franzece¹⁴14 Franzese C. Administração Pública em contexto de mudança: desafios para o gestor de políticas públicas. In: Ibañez N, Elias PEM, Seixas PHA, organizadores. Política e Gestão Publica em Saúde. São Paulo: Hucitec, CEALAG; 2011.), in the context of a state reform, claimed for the expansion of non-state forms of participation and social control as a key dimension for the 20^th century, indicating perhaps that intersectorality would come as a response to these non-state forms of management. Abrucio and Gaetani¹⁵15 Abrucio FL, Gaetani F. Avanços e perspectivas da gestão pública nos estados: agenda, aprendizado e coalizão. Brasília: Consad; 2006.conversed about these proposals and noted that the reform focused more on planning and budgeting than on the articulation of different sectors, under the form of priority programs, but that the organization of the Brazilian federation forced us to seek articulated and cooperative work among the three government spheres.

However, beyond a merely technical conversation that supports intersectorality or not as a device to enhance efficiency, effectiveness and efficacy of public management, there is an issue that has to be faced and can be seen in the next comic strip (Figure 2). In the dialogue between characters Frank and Ernest created by Bob Thaves, they judge if the role adopted by the State or through a management device, in this case intersectorailty, has the ability to increase the buy-in of those who are outside the game (or the music festival).

In other words, the simplicity and delicateness of a comic strip that questions us if this should not be the ethical-political objective for any State reform or management device, to increase opportunities for those that are out of the game, using the lens of equity¹⁶16 Shankardass K, Solar O, Murphy K, Greaves L. A scoping review of intersectoral action for health equity involving governments. Int J Public Health 2012; 57(1):25-33..

We do not have the intention nor the naiveté of presenting intersectorality as the “weapon” in this confrontation, but as a device to allow for meetings, listening and otherness, besides helping explain the diverging interests, tensions and to seek (or reaffirm the impossibility) of potential convergences¹⁷17 Akerman M, Mendes R. Intersetorialidade e sustentabilidade nas políticas de saúde: meros vocábulos? In: Gaspar R, Akerman M, Graib R, organizadores. Espaço Urbano e Inclusão Social: a gestão pública na cidade de São Paulo 2001-2004. São Paulo: Editora Fundação Perseu Abramo; 2006. p. 59-80.. One that can also avoid duplicity of actions and seek budgetary integrations for priority projects, articulate resources, ideas and talents¹⁸18 Junqueira LAP. Novas formas de gestão na Saúde: descentralização e intersetorialidade. Saude e Soc 1997; 6(2):31-46.

19 Junqueira LAP. Intersetorialidade, transetorialidade e redes sociais na saúde. Rev Adm Publica 2000; 34(6):35-45.

20 Calame P. Repensar a gestão de nossas sociedades - 10 princípios para a governança, do local ao global. São Paulo: Pólis - Instituto de Estudos, Formação e Assessoria em Políticas Sociais; 2004.

21 Andrade GRB, Vaitsman J. A participação da sociedade civil nos conselhos de saúde e de políticas sociais no município de Piraí, RJ (2006). Cien Saude Colet 2013; 18(7):2059-2068. ^{- 22}22 Moretti AC, Teixeira FF, Suss FMB, Lawder JAC, Lima LSM, Bueno RE, Moysés SJ, Moysés ST. Intersetorialidade nas ações de promoção de saúde realizadas pelas equipes de saúde bucal de Curitiba (PR). Cien Saude Colet 2010; 15(Supl. 1):1827-1834..

Furthermore, it is worthwhile mentioning that we are attentive to the warnings made by some authors that “totality, integrality, holism, interdisciplinarity are notions that pretend to represent the whole. As a result, and very frequently, theoretical schemes that use these tend to disqualify any approach or any snippet that dares to speak about only a piece or part of things.”²³23 Campos GV. Efeito torre de babel: entre o núcleo e o campo de conhecimento e de gestão das práticas: entre a identidade cristalizada e a mega-fusão pós-moderna. Cien Saude Colet 2007; 12(3):570-573., or that “we cannot fall into the error that intersectoraility is an antagonist or a substitute for sectorality”²⁴24 Sposati A. Gestão pública intersetorial: sim ou não? Comentário de experiência. Serv Social Soc 2006; 85:133-141..

Theory, research and evaluation: in the quest for a real intersectoral praxis

Intersectorality is one of the most commented themes in public management. However, so far there is no theory developed upon which a framework of analysis can be based for research and evaluation²⁵25 Cunnil Grau N. La Intersectorialidad en el Gobierno y Gestión de la Política Social. Washington: BID; 2005. (Trabajo elaborado por encargo del Diálogo Regional de Política del Banco Interamericano de Desarrollo) ^{, 26}26 Potvin L. Intersectoral action for health: more research is needed! Int J Public Health 2012; 57(1):5-26.. The artificial character of fragmentation of arising from the Cartesian paradigm of the production of knowledge and action and the approximation to theories of a more complex and deeper and interconnected thought can prove to be the foundation for a less empirical intersectoral praxis, one that is more anchored on evaluation research²⁷27 Japiassu H. Interdisciplinaridade e Patologia do Saber. Rio de Janeiro: Imago Editora Ltda.; 1976.

28 Santos M. O retorno do território. In: Santos M, Souza MAA, Silveira ML, organizadores. Território: Globalização e fragmentação. São Paulo: Hucitec; 1994. p. 15-20.

29 Almeida Filho N. Intersetorialidade, transdisciplinaridade e saúde coletiva: atualizando um debate em aberto. Rev Admin Publica 2000; 34(6):11-34. ^{- 30}30 Monnerat GL, Souza RG. Da seguridade social à intersetorialidade: reflexões sobre a integração das políticas sociais no Brasil. Revista Katálysis 2011; 14(1):41-49..

And while seeking this direction, we dare to suggest an exploratory script that will indicate a “what” – for the architectures; a “how” – the methodologies; a “with whom” (“for whom and” and “by whom”) – of the players; a “for what” –the intentions; and a “why” – of the paradigms³¹31 Mendes R, Akerman M. Intersetorialidade: reflexões e práticas. In: Fernandez JCA, Mendes RB, organizadores. Promoção da Saúde e Gestão Loca. São Paulo: Hucitec, Cepedoc; 2007. p. 85-110.. This direction or path could result in a possible operational concept in which intersectorality would be defined as a form of management (what) developed by means of a systematic process of (how) articulation, planning and cooperation between the different (with whom) sectors of society and among diverse public policies to act on (for what) social determinants.

Despite this theoretical vacuum, the theme of necessary intersectoral action has been present in the collective health field in various technical-political movements. For example, in the Alma-Ata Declaration (1978), in the 8^th CNS (Brazilian Health Conference) (1986), the Ottawa Charter (1986), in the Rio Political Declaration on Social Determinants of Health - SDH (2011), in the World Conference on Health Promotion in Helsinki, Health in all Policies (2013) appearing in expressions such as:

In the documents for the construction and foundation of the ideal of the Unified Health System – SUS - an intersectoral articulation is recommended to make the health-disease process ever more visible. This is composed of multiple aspects; the need to convene other sectors to consider evaluation and sanitary parameters regarding the enhancement of quality of life and of the population when they set forth their own specific policies.

There is therefore intersectoral activism that is still based on a praxis that has sufficient creative power to influence new governance architectures for public policies.

Let us explore the issues that are pending or still open. Shankardass et al.¹⁶16 Shankardass K, Solar O, Murphy K, Greaves L. A scoping review of intersectoral action for health equity involving governments. Int J Public Health 2012; 57(1):25-33. carried out a review on the topic and although they identified 5342 articles for intersectoral action undertaken by governments in the last 60 years, they noticed that only 194 has the explicit purpose of fostering equity in their arrangements, and that only 16% went deeper into mechanisms for the integration of objectives, administrative and funding processes. The other 84% set up some sort of information sharing, cooperation and coordination, but were unable to set forth processes for innovative management that would be better integrated, the raison d´etre of intersectoral undertakings.

Shankardass et al.16 and Solar et al.34 see the need to pose questions that can understand or comprehend this “scarcity of integration” to overcome it, indicating a possible and more encompassing research agenda.

• Which players take the initiative in triggering intersectoral undertakings?

• Which political context favor the carrying out of these intersectoral undertakings?

• Which has been the role of the health sector?

• Which incentives have attracted players to intersectoral undertakings?

• Which reasons lead players to move away from this participation?

• Have intersectoral undertakings facilitated or impeded social participation?

• Are there competencies that need to be developed to trigger or unleash these intersectoral undertakings?

• What type of negotiation is undertaken among the different players involved: in terms of funding, loss of autonomy, decisions and responsibilities?

To sum up, these are the questions that deep down could guide us in that challenge of questioning if there truly does exist an intersectoral culture that needs to be modified or could take us in the direction of presenting analytic tools to develop the ability to look, listen and evaluate which undertaking is more appropriate for each situation.

And, as literature points to the fact that this information is scarce, descriptive and under isolated perspectives, either from the health sector or that of academy²⁶26 Potvin L. Intersectoral action for health: more research is needed! Int J Public Health 2012; 57(1):5-26., we suggest we follow “questions for research” with the aim of broadening analytic frontiers on the topic of intersectorality.

Possible analytical paths: presenting a question database for research

There is no frozen “intersectorality” bank. Each situation-problem or territory will demand a different response for articulation, acquiring its own DNA³¹31 Mendes R, Akerman M. Intersetorialidade: reflexões e práticas. In: Fernandez JCA, Mendes RB, organizadores. Promoção da Saúde e Gestão Loca. São Paulo: Hucitec, Cepedoc; 2007. p. 85-110..

In the research work on the topic that we carried out to be able to draft this article, it was possible to identify six analytical paths, not necessary excluding among themselves, that point to different research questions permeated by diverse analytical categories.

The first analytic path suggested is “Integrated Public Policies and Intersectoral Strategies: why and what for?”

Burlandy´s³⁵35 Burlandy L. A construção da política de segurança alimentar e nutricional no Brasil: estratégias e desafios para a promoção da intersetorialidade no âmbito federal de governo. Cien Saude Colet 2009; 14(3):851-860. study on “The National Policy on Food and Nutritional Safety” inspired the suggestion of this first path. It highlights that it is possible to find political fundamentals – the political decision for integration and articulation – and technical ones – intersectoral strategies per se – as base categories for the analysis of an integrated policy, conditions pointed out by Cunnil Grau²⁵25 Cunnil Grau N. La Intersectorialidad en el Gobierno y Gestión de la Política Social. Washington: BID; 2005. (Trabajo elaborado por encargo del Diálogo Regional de Política del Banco Interamericano de Desarrollo) as being sine qua non to elaborate a theory on intersectorality.

In this sense, in Chart 1 we suggest the first block of research questions connected to this initial path.

Some authors suggest that when proposing an intersectoral undertaking, the latter should explain an ethical-political purpose, so as not to become a mere utilitarian artifact for the search of efficiency in management¹⁶16 Shankardass K, Solar O, Murphy K, Greaves L. A scoping review of intersectoral action for health equity involving governments. Int J Public Health 2012; 57(1):25-33. ^{, 34}34 Solar O, Valentine N, Rice M, Albretch D. What kind of intersectoral action is needed. An approach to an intersectoral typology. Nairobi: OMS; 2009. (Documento preparado para a 7ª Conferência Mundial de Promoção da Saúde) ^{, 36}36 World Health Organization (WHO), Public Health Agency of Canada. Health equity through intersectoral action: an analysis of 18 country case studies. Ottawa: Public Health Agency of Canada; 2008..

Shankardass et al.¹⁶16 Shankardass K, Solar O, Murphy K, Greaves L. A scoping review of intersectoral action for health equity involving governments. Int J Public Health 2012; 57(1):25-33. considered the equity promotion and acting on social determinants of health as criteria for inclusion in its review of government experiences on intersectorality. They found a scant 194 studies with these characteristics, in 43 countries, among the 5343 identified with intersectoral proposals.

Nevertheless, not all principles or ideas translate into the complete fulfillment of desires and it would be naive to imagine that an intersectorl arrangement would have sufficient power to invert the logic of political responses that oftentimes reflect the power structure of the society they are part of³⁷37 Feuerwerker LM, Costa H. Intersetorialidade na Rede Unida. Divulgação Saude Debate 2000; 37(22):25-35.

38 Moysés SJ, Moysés ST, Krempel MC. Avaliando o processo de construção de políticas públicas de promoção de saúde: a experiência de Curitiba. Cien Saude Colet 2004; 9(3):627-638.

39 Andrade LOM. A saúde e o dilema da intersetorialidade. São Paulo: Hucitec; 2006. ^{- 40}40 Silva EC, Pelicioni MCF. Participação social e promoção da saúde: estudo de caso na região de Paranapiacaba e Parque Andreense. Cien Saude Colet 2013; 18(2):563-572..

For example, even in the SUS, that vigorously raises the flag of equity when analyzing the data referring to transplantations, they observe that of every 10 transplantations done, seven refer to white males, not necessarily reflecting the epidemiologic structure of health needs⁴¹41 Instituto de Pesquisa Econômica Aplicada (Ipea). Homens brancos são maioria dos transplantados. Negros e mulheres têm menos acesso a cirurgias, 2011. [acessado 2013 abril 15]. Disponível em: http://agenciabrasil.ebc.com.br/noticia/2011-07-08/homens-brancos-sao-maioria-dostransplantados-negros-e-mulheres-temmenos-acesso-cirurgias-segundo-ip
http://agenciabrasil.ebc.com.br/noticia/... . On the other hand, there should be an attempt to intervene in the distribution logic of resources in public management, as those with the greatest power resources will receive the greatest piece of the pie of available resources, whilst the weaker ones will compete for the leftovers, deepening inequities⁴²42 Akerman M. A construção de indicadores compostos para os projetos de cidades saudáveis: um convite ao pacto transetorial. In: Mendes EV, organizador. A Organização da saúde em Nível Local. São Paulo: Hucitec; 1998. p. 319-336..

From this perspective, and in that tension between finding solutions and facing problems that will be dealt with through intersectoral undertakings steadily anchored on the purpose of fostering equity, appears the second path set forth, “Intersectorality as a problem and a solution in the path towards the promotion of equity?”.

Chart 2 includes the block of research questions aligned to the second path.

De Salazar⁴³43 De Salazar L. Abordaje de a equidade en intervenciones en promoción de la salud en los países de la UNASUR. Tipo, alcance y impacto de intervenciones sobre os determinantes sociales de la salud (DSS) y equidade en salud. Cali: CEDETS, Ministerio de la Salud y Protección Social República de Colombia; 2012. identified in a study on the equity approach in interventions for health promotion in the UNASUS countries, based on a review of literature in the period of 2007 to 2012, that the topics related to the components: reorientation of services, inequities in health, intersectorality and social determinants represented 82% of the production in that period. Brazil presented the largest volume of publications (24.5%), followed by Chile (12.3%) and Argentina (12%). Notwithstanding this, “the emphasis in the articles is still not on the conceptualization, and very little on the operationalizing of these concepts”⁴³43 De Salazar L. Abordaje de a equidade en intervenciones en promoción de la salud en los países de la UNASUR. Tipo, alcance y impacto de intervenciones sobre os determinantes sociales de la salud (DSS) y equidade en salud. Cali: CEDETS, Ministerio de la Salud y Protección Social República de Colombia; 2012.. Several recommendations from the abovementioned study ratify the need to investigate the issues pointed out in this second path.

Our third path to be tread is based on a communication hypothesis, and borrows the biblical passage of the Tower of Babel when God launched divine punishment upon condemning mankind to have several languages, making communication among them more difficult: “Intersectorality: Babel among public policies?”.

It is far from our intention to cause a dispute with God and revert His punishment. There are authors that preach “imperfect communication” precisely as a gap through which the possibilities of emergence of something novel can infiltrate themselves ^29,44 .

This communication hypothesis could also be translated as an “intersectoral dilemma”³⁹39 Andrade LOM. A saúde e o dilema da intersetorialidade. São Paulo: Hucitec; 2006. ^{, 45}45 De Faria MSR. A Intersetorialidade e os dilemas de sua prática no trabalho em saúde [dissertação]. Belo Horizonte: PUCMG; 2013. in which there is a consensus of discourse on the need for tensioned intersectoral management, nevertheless, through practical political and incessant dissention on the “how” to do this⁴⁶46 Nobre LCC. Trabalho de crianças e adolescentes: os desafios da intersetorialidade e o papel do Sistema Único de Saúde. Cien Saude Colet 2003; 8(4):963-971..

This apparent paradox, many a times permeated by power conflicts and interests that make difficult “communication among men” led us to drafting another block of questions that appear in Chart 3, and could be used to give greater thrust to more research regarding this topic.

We identified that if there is “imperfect communication” among policies/players, this perhaps exists, also in the interface between the responses formulated by governments, and the needs felt/perceived by citizens are their lives unfold in the day-to-day⁴⁷47 Guareshi P. Relações Comunitárias, relações de dominação. In: Campos RHF, organizador. Psicologia Social Comunitária: da solidariedade à autonomia. Petrópolis: Vozes; 1996. p. 81-99.

48 Fonseca TMG. A cidade Subjetiva. In: Fonseca TMG, Kirst P, organizadores. Cartografias e Devires: a construção do presente. Porto Alegre: Editora da UFRGS; 2003. p. 62-68.

49 Wimmer GF, Figueiredo GO. Ação coletiva para qualidade de vida: autonomia, transdisciplinaridade e intersetorialidade. Cien Saude Colet 2006; 11(1):145-154. ^{- 50}50 Viana ALD. Novos riscos, a cidade e a intersetorialidade das políticas públicas. Rev. adm. Pública 1998; 32(2):23-33..

To further explore this hypothesis, we set forth a fourth analytical path: “Intersectorality: the Babel among public policies and daily life!”, the following block of questions exhibited in Chart 4.

In this path or direction, several studies have attempted to point to the applicability of Intersectorality and its translation in the day-to-day of public policies⁵¹51 Santos CRB, Magalhães R. Pobreza e Política Social: a implementação de programas complementares do Programa Bolsa Família. Cien Saude Colet 2012; 17(5): 1215-1224. ^{, 52}52 Os 10 problemas que atrapalham a vida do paulistano. Folha de São Paulo 2013; 25 jan. Caderno SP p. 459.and based on the SUS in Brazil⁵³53 Akerman M, Mendes R. Avaliação participativa de municípios, comunidades e ambientes saudáveis: a trajetória brasileira - memória, reflexões e experiências. Santo André: Mídia Alternativa Comunicação e Editora Ltda.; 2006.

54 Rocha DG, Marcelo VC, Souza MR. SMS/Goiânia: gestão integrada das políticas públicas no âmbito municipal - a experiência da intersetorialidade em Goiânia. In: Akerman M, Mendes R, organizadores. Avaliação participativa de municípios, comunidades e ambientes saudáveis: a trajetória brasileira - memória, reflexões e experiências. Santo André: Mídia Alternativa Comunicação e Editora Ltda.; 2006. p. 92-100.

55 Costa AM, Pontes ACR, Rocha DG. Intersetorialidade na produção e promoção da saúde. In: Castro A, Malo M, organizadores. SUS: ressignificando a promoção da saúde. São Paulo: Hucitec, Opas; 2006. p. 96-115. ^{- 56}56 Sousa MF, Parreira CMSF. Ambientes verdes e saudáveis: formação dos agentescomunitários de saúde na cidade de São Paulo-Brasil. Rev Panam Salud Publica 2010; 28(5):399-404., being that the majority of these conclude that this has been implemented predominantly and in a timely way, fragmented and without mechanisms to sustain it⁴³43 De Salazar L. Abordaje de a equidade en intervenciones en promoción de la salud en los países de la UNASUR. Tipo, alcance y impacto de intervenciones sobre os determinantes sociales de la salud (DSS) y equidade en salud. Cali: CEDETS, Ministerio de la Salud y Protección Social República de Colombia; 2012. ^{, 57}57 Escorel S, Giovanella L, Magalhães de Mendonça MH, Senna MCM. O PSF e a construção de um novo modelo para a atenção básica no Brasil. Rev Panam Salud Publica 2007; 21(2):164-176.. Furthermore, when looking at it from the viewpoint of networking⁵⁸58 Inojosa RM. Redes de compromisso social. Rev Adm Publica 1999; 33(5):115-141., and its potential in promoting social participation, it points to a necessary debate: is social/community empowerment a process or a result of intersectorality?⁵⁹59 Laverack G, Wallerstein N. Measuring community empowerment: a fresh look at organizational domains. Health promot Internation 2001; 16(2):179-185.

The fifth analytical path opens the perspective of intersectorality, not as a management arrangement, but as a device for qualified listening and for the exercise of respect towards the differences and diversities, in the search for possible common interests, albeit temporary ones²⁰20 Calame P. Repensar a gestão de nossas sociedades - 10 princípios para a governança, do local ao global. São Paulo: Pólis - Instituto de Estudos, Formação e Assessoria em Políticas Sociais; 2004..

Chart 5 brings two questions to explore this research path of “Intersectorality as a device for otherness and negotiation!”.

A possibility to address this agenda was signaled out by Rocha and Akerman⁶⁰60 Rocha DG, Akerman, M. Determinação social da saúde e promoção da saúde: isto faz algum sentido para a Estratégia de Saúde da Família? Em que sentido podemos seguir? In: Sousa MF, Franco MS, Mendonça AVM, organizadores. Saúde da Família nos municípios brasileiros: Os reflexos dos 20 anos no espelho do futuro. Campinas, São Paulo: Saberes Editora; 2014. p. 720-754., when indicating “entry doors” or “windows of opportunities” to act more effectively and, consequently, respond to the queries above. In this context, a starting point could be analyzing the “intersectoral undertakings” according to management and production levels of care at macro, meso and micro levels.

The sixth analytical path coincides with a movement that the WHO carried out at the 8^th World Conference for Health Promotion, held in Helsinki, in June 2013, in which it advocated for an integral approach for the entire government to evaluate the impact of different public policies for the population´s health: “Health in all Policies?”³³33 Organização Mundial da Saúde (OMS). Health in all Policies, 2013. [acessado 2013 abr 15] Disponível em: http://www.euro.who.int/en/what-we-do/health-topics/health-determinants/socialdeterminants/policy/entry-points-for-addressing-socially-determined-health-inequities/health-in-all-policies-hiap
http://www.euro.who.int/en/what-we-do/he... ^{, 61}61 Koivusalo M. Health in all policies - framework for country action. 2nd draft. Mimeo; 2013..

This WHO proposition also inaugurated a new research current that perhaps can be based on the three questions that are part of Chart 6.

These 23 questions open up the possibility of delineating a research agenda on the topic of intersectorality, and broaden its theoretical and evaluation foundation, which will still have to be developed. However, there are hints for a theoretical and evaluation formulation that can already be observed: (1) some growth in cooperation and coordination movements among sectors; (2) the upsurge of some intersectoral undertakings with the ability to foster equity; (3) undertakings which deliberately set up mechanisms to face the discrepancy between discourse and practice; (4) international movements for the expansion of health accountability¹⁶16 Shankardass K, Solar O, Murphy K, Greaves L. A scoping review of intersectoral action for health equity involving governments. Int J Public Health 2012; 57(1):25-33. ^{, 26}26 Potvin L. Intersectoral action for health: more research is needed! Int J Public Health 2012; 57(1):5-26. ^{, 34}34 Solar O, Valentine N, Rice M, Albretch D. What kind of intersectoral action is needed. An approach to an intersectoral typology. Nairobi: OMS; 2009. (Documento preparado para a 7ª Conferência Mundial de Promoção da Saúde) ^{, 62}62 Nascimento S. Reflexões sobre a intersetorialidade entre as políticas públicas. Serviço Social Soc 2010; 101:95-120. ^{, 63}63 Giovanella L, Mendonça MHM, Almeida PF, Escorel S, Senna MCM, Fausto MCR, Delgado MM, Andrade CLT, Cunha MS, Martins MIC, Teixeira CP. Saúde da família: limites e possibilidades para uma abordagem integral de atenção primária à saúde no Brasil. Cien Saude Colet 2009; 14(3):783-794..

IntersectoralitieS!

There have been several starting points and one point of arrival! Questioning and exclamations appearing on the path of our reflections, dialogues and discoveries or breakthroughs

Through this process, we took six paths that are not parallel straight lines and that only meet in the infinite, but that are interwoven the entire time. They are almost the subtitles for the point of arrival: polysemy of the word intersectorality and multiplicity of research questions or issues = IntersectoralitieS.

Much like waves, intersectoralitieS reveal themselves and alternate according to the flavors of time, the prevailing situation and players: the 1^st wave – Utilitarian, reinforces the minimal state and tutelage by the market “pass the hat” and shares responsibilities; the 2^nd wave – Rationalizing, detects there is fragmentation in policies and in actions that compromise the effectiveness of the State and the search for efficiencycy; the 3^rd wave, about to come – generous Interdependence in which intersectorality is not only the setting up of multisectoral arrangements, but a deliberate ethical-political decision that the State and its management and policies will serve the common interest.

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