Abstract

Minas Gerais started the development of the Minas Gerais Health Promotion Policy (POEPS-MG) based on the review of the National Health Promotion Policy (PNPS). This is a case report based on the documentary analysis of the material produced in the 38 workshops with a participation of 1.157 members across the State. The first workshop was intrasectoral and took place at the State Health Secretariat (SDH-MG). The second was an intersectoral workshop with the participation of several State Health Secretariats of Minas Gerais. The final workshop counted on the participation of State Regional Technical References. Another 35 workshops were developed in the 28 State Regional Administrations. Results were systematized and consolidated from the Analytical Matrix used in the PNPS, generating the base document of the POEPS-MG. It is important to highlight that, the specific regional requirements identified during the Policy's construction process reinforce the enriching moments of developing in an innovative, democratic and participative way actions that may provide some meanings to Health Promotion in the State of Minas Gerais. The State Policy seeks to bring life to the PNPS, adapting it to the reality of the territory and strengthening it - with the assurance of budgetary resources.

Key words
Health promotion; Public policy; Social participation; Funding

Introduction

The concept of Health Promotion was established 30 years ago at the First International Conference on Health Promotion in Ottawa in 1986 and has been discussed worldwide since¹1. World Health Organization (WHO). The Ottawa Charter for Health Promotion. Ottawa: WHO; 1986.^,22. Buss PM, Carvalho AI. Desenvolvimento da Promoção da Saúde no Brasil nos últimos vinte anos (1988-2008). Cien Saude Colet 2009; 14(6):2305-2316.. In Brazil, in that same year, at the Eighth National Health Conference, the expanded concept of health was adopted, which seeks to overcome the mere lack of diseases and to approach the Health Promotion concepts, prioritizing life care-focused policies²2. Buss PM, Carvalho AI. Desenvolvimento da Promoção da Saúde no Brasil nos últimos vinte anos (1988-2008). Cien Saude Colet 2009; 14(6):2305-2316..

Regarding the historical development of Health Promotion in Brazil, the 1986 National Health Conference defined it as the concept that articulates the mobilization of public and private, technical and scientific and sociocultural institutional and community resources for the social production of health in the daily life of the population and that combines actions, developed jointly by different sectors of government and civil society to improve living and health conditions, promoting equity and the development of citizenship³3. Brasil. Ministério da Saúde (MS). Relatório Final 8ª Conferência Nacional de Saúde. Brasília: MS; 1986.^,44. Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Política Nacional de Promoção da Saúde. Brasília: MS; 2006.. Buss and Carvalho²2. Buss PM, Carvalho AI. Desenvolvimento da Promoção da Saúde no Brasil nos últimos vinte anos (1988-2008). Cien Saude Colet 2009; 14(6):2305-2316. also highlights principles and guidelines of the Unified Health System (SUS), defined in the 1988 Federal Constitution, which are focused on Health Promotion and reinforced in 1992 by the establishment of the Family Health Program (PSF) with its multidisciplinary teams. Until 2006, some isolated programs of healthy eating, traffic violence and physical activity stood out as Health Promotion strategy. The preliminary version of the National Health Promotion Policy was elaborated in 2002, but the actual institutionalization of this approach to health occurred only in 2006, establishing, therefore, more robust initiatives²2. Buss PM, Carvalho AI. Desenvolvimento da Promoção da Saúde no Brasil nos últimos vinte anos (1988-2008). Cien Saude Colet 2009; 14(6):2305-2316.^,44. Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Política Nacional de Promoção da Saúde. Brasília: MS; 2006.

5. Brasil. Ministério da Saúde (MS). Política Nacional de Promoção da Saúde (versão preliminar). Brasília: MS; 2002.

6. Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União 1988; 5 out.^-77. Brasil. Ministério da Saúde (MS). Política Nacional de Práticas Integrativas e Complementares no SUS. Brasília: MS; 2014. aimed at changes in society that directly influence the health situation of the population⁸8. Guerra VA, Rezende R, Rocha DG, Silva KR, Akerman M. Oficina como um exercício de aprendizagem e de escuta colaborativa: o caso da Revisão da Política Nacional de Promoção da Saúde. ABCS Health Sci 2015; 40(3):352-359..

The policy review process attended by the various sectors of society⁹9. Rocha DG, Alexandre VP, Marcelo VC, Rezende R, Nogueira JD, Sá RF. Processo de revisão da Política Nacional de Promoção da Saúde: múltiplos movimentos simultâneos. Cien Saude Colet 2014; 19(11):4313-4322. brought broader conceptual and strategic approaches, transcending individual co-responsibility for individual and collective health towards citizenship. With regard to SUS purposes, Health Promotion actions seek to reduce regional gaps and open the possibility of access to these services in a more equitable way¹⁰10. Brasil. Ministério da Saúde (MS). Gabinete do Ministro. Portaria n° 2446, de 11 de novembro de 2014. Redefine a Política Nacional de Promoção da Saúde (PNPS). Diário Oficial da União 2014; 13 nov..

In order to operationalize the Health Promotion actions, it is necessary to consolidate practices aimed at the individual and the collective, from a multidisciplinary, comprehensive and networked perspective, considering all the needs of the population, under the perspective of public policies¹⁰10. Brasil. Ministério da Saúde (MS). Gabinete do Ministro. Portaria n° 2446, de 11 de novembro de 2014. Redefine a Política Nacional de Promoção da Saúde (PNPS). Diário Oficial da União 2014; 13 nov..

In the national setting, Health Promotion strategies gained strength in 2014 with the PNPS review, through a participatory and democratic process with the purpose of attuning it to the new health demands and, above all, strengthening Health Promotion as a strategy to promote care, with broad participation of managers, health workers, counselors, representatives of social movements and researchers linked to educational institutions¹⁰10. Brasil. Ministério da Saúde (MS). Gabinete do Ministro. Portaria n° 2446, de 11 de novembro de 2014. Redefine a Política Nacional de Promoção da Saúde (PNPS). Diário Oficial da União 2014; 13 nov..

In the State of Minas Gerais, Health Promotion has been in place since 2007, when the Health Promotion Management was created through State Decree N° 44.479, of March 9, 2007. In 2009, Decree N° 45.038, of February 6, 2009, established the Health Promotion Advisory Office under the Sub-Secretariat of Health Surveillance.

In 2011, through Decree N° 45.812, of December 14, 2011, it was renamed as the Health Promotion and Non-Communicable Diseases Board and allocated to the Superintendency of Epidemiological, Environmental and Occupational Health Surveillance. In 2015, in order to increase and strengthen State Health Promotion actions, the sector was reassigned to the Superintendency of Primary Health Care with a proposed elaboration and implementation of the State Health Promotion Policy.

The construction of the State Health Promotion Policy of Minas Gerais (POEPS-MG) was motivated by the implementation of reviewed PNPS actions, aiming at accelerating the introduction of Health Promotion actions into the daily routine of PHC services in Minas Gerais municipalities. In addition to the inductive effect inherent to Public Policies, it provides these professionals continued education practices through dissemination/discussion in the instances of the Unified Health System (SUS). This construction built on internal discussions of the Health Promotion Board when PNPS actions were implemented and with a diagnosis of ongoing health promotion actions, which signaled the need to add state specificities to PNPS, which culminated then with the interest and political decision of strengthening Health Promotion in the SUS-MG.

This work aims to describe this construction process, highlighting the values and principles, the foundations, the operational and cross-sectional strategies and the proposed financing model to support the implementation of the POEPS-MG.

Methodology

In order to substantiate the proposal for the formulation of POEPS-MG, the Theory of Communicative Action, elaborated by Jurgen Habermas, specifically the concept of democracy that it engenders, whose pillar is the praxis of autonomy of those involved was adopted¹¹11. Habermas J. Between facts and norms, contributions to a discourse theory of law and democracy. Cambridge: The MIT Press; 1996.. A brief description of the theory to introduce its main elements starts from the basic concept of communicative action, understood as language-mediated interaction that develops in the context of daily life in which stakeholders agree with each other to coordinate their actions¹¹11. Habermas J. Between facts and norms, contributions to a discourse theory of law and democracy. Cambridge: The MIT Press; 1996.^,1212. Habermas J. Teoria de la ación comunicativa. Madrid: Taurus; 1987..

This communicative practice carries in itself argumentation and unfolds in its reflective form the discourse¹²12. Habermas J. Teoria de la ación comunicativa. Madrid: Taurus; 1987.^,1313. Habermas J. Teoria de la accíon comunicativa: complementos y estudios previos. Madrid: Cátedra; 2011., so that it begins here and now, in the daily context, but can proceed, overcome boundaries, embrace all involved and achieve universality¹⁴14. Habermas J. Consciência moral e agir comunicativo. Rio de Janeiro: Tempo Brasileiro; 1989.

15. McCarthy T. The critical theory of Jurgen Habermas. 7th ed. London: The MIT Press; 1989.^-1616. Habermas J. Escritos sobre moralidad y eticidad. Barcelona: Paidós; 1991.. In its dialectical relationship with communicative action, discourse is the only place of rational will, since it brings autonomy and universalization¹⁶16. Habermas J. Escritos sobre moralidad y eticidad. Barcelona: Paidós; 1991.; it transforms social stakeholders into authors¹¹11. Habermas J. Between facts and norms, contributions to a discourse theory of law and democracy. Cambridge: The MIT Press; 1996.; it articulates micro and macro-space and decompresses life's world: in the words of Habermas “[…] life's world opens up whenever at least two subjects meet and are willing to act cooperatively”¹¹11. Habermas J. Between facts and norms, contributions to a discourse theory of law and democracy. Cambridge: The MIT Press; 1996.. That is exactly why health promotion was thought in an articulated way to the praxis of autonomy¹⁷17. Tavares R, Catalan VDB, Romano PMM, Melo EM. Homicídio e Vulnerabilidade Social. Cien Saude Colet 2016; 21(3):923-934.^,1818. Melo EM, Silva JM, Akerman M, Besilário SA. Promoção de Saúde: Autonomia e Mudança. Belo Horizonte: Folium; 2016., and the entire formulation process of the POEPS-MG built through workshops, with broad participation of various social stakeholders and decision-making levels.

The methodology used by this study is case report built from the documentary analysis of the products developed during the elaboration of the State Policy of Minas Gerais.

Thirty-eight workshops were held and organized by the Health Promotion Board of the State Health Secretariat (SES-MG). In all the workshops, themes were selected by participants through the prioritization procedure called Taking Stock, proposed by Fetterman⁸8. Guerra VA, Rezende R, Rocha DG, Silva KR, Akerman M. Oficina como um exercício de aprendizagem e de escuta colaborativa: o caso da Revisão da Política Nacional de Promoção da Saúde. ABCS Health Sci 2015; 40(3):352-359.. The methodology used in the workshops proposed the broad participation of individuals and, thus, contributed to a democratic and participatory policy construction movement⁸8. Guerra VA, Rezende R, Rocha DG, Silva KR, Akerman M. Oficina como um exercício de aprendizagem e de escuta colaborativa: o caso da Revisão da Política Nacional de Promoção da Saúde. ABCS Health Sci 2015; 40(3):352-359..

Of these workshops, three were held at the central level, the first was intrasectoral, with professionals from the State Health Secretariat of Minas Gerais (SES-MG). The second was intersectoral, with the participation of Minas Gerais State Secretariats and with the participation of professionals who are Health Promotion technical references at the State Regional Administrations. Health managers and workers, representatives of the Municipal Health Secretariats Council of Minas Gerais (COSEMS-MG), the School of Public Health of the State of Minas Gerais (ESP-MG), the Federal University of Minas Gerais (UFMG), as well as professionals from other State Secretariats and institutions with an interface with Health Promotion, as per Chart 1.

The other 35 workshops took place in the 27 Regional Health Administrations and counted on the representation of 508 municipalities (61.80% of the total of the municipalities of the State) and the participation of 966 professionals. These workshops were distributed across the State and regionalization was set forth in the Regionalization Master Plan (PDR) as a guiding process¹⁹19. Malachias I, Leles FAG, Pinto MAS. Plano Diretor de Regionalização da Saúde de Minas Gerais (PDR - MG). Belo Horizonte: Secretaria do Estado de Minas Gerais; 2011., as per Chart 1.

Products obtained in the 38 workshops were systemized as shown in Chart 1 using the matrix developed in the 2014 PNPS review and adapted to the state reality, entitled “Matrix of connection between the components of the National Health Promotion Policy, Brazil, 2014”, described in a 2014 study by Rocha et al.⁹9. Rocha DG, Alexandre VP, Marcelo VC, Rezende R, Nogueira JD, Sá RF. Processo de revisão da Política Nacional de Promoção da Saúde: múltiplos movimentos simultâneos. Cien Saude Colet 2014; 19(11):4313-4322.. After the systematization, the POEPS-MG Minutes were jointly drafted by the POEPS-MG Working Group (GT-POEPS-MG) in face-to-face meetings on January 27-28 and February 03-04, 2016.

Results

The products obtained after systematization of all the workshops through the elaboration of an analytical matrix assisted in the construction of the Minutes of the POEPS-MG, which were later submitted to deliberative bodies such as the State Health Council and the Bipartite Interagency Committee (CIB).

The first workshop was intrasectoral and held with representatives of other areas of the Minas Gerais State Health Secretariat (SES-MG), which had an interface with Health Promotion, on November 03-04, 2015, and was attended by the following areas: Policy Directorate for Primary Health Care Policies; Superintendency of Pharmaceutical Care; Coordination of Noncommunicable Diseases and Problems; Coordination of Chronic Diseases Care Networks; Directorate of Occupational Health; Directorate of Oral Health; Food Surveillance / Health Surveillance Directorate; Social Media Advisory Office; Coordination of Specialized Care; Coordination of Women's Health Care / “Rede Cegonha”; Coordination of Integrative and Complementary Practice and Superintendency of Regional Management.

The second workshop aimed to implement the methodology of construction of the POEPS-MG with the representatives of the Regional Health Administrations and training them for the replication of the methodology at the regional level for the municipalities within their jurisdiction. This workshop was attended by the technical references of the Health Promotion Board (Central Level) and representatives (Health Promotion technical references and coordinators of PHC facilities – NAPRIS) of the 28 State Health Administrations.

The third workshop was intersectoral and took place on November 26-27, 2015, between the Health Promotion Board and other Secretariats and institutions related to the theme of Health Promotion and that are essential in the planning of intersectoral actions for the implantation and implementation of the State Health Promotion Policy in the State. The following areas attended the event: State Sports Secretariat; State Agriculture, Livestock and Supply Secretariat; Intersectoral Governmental Chamber for Sustainable Food and Nutritional Safety of Minas Gerais; State Human Rights, Social Participation and Citizenship Secretariat; Sustainable Food and Nutrition Safety Council; Military Police of the State of Minas Gerais; State Education Secretariat; State Social Defense Secretariat; State Culture Secretariat; Military Fire Brigade of Minas Gerais; Caio Martins Educational Foundation; State Labor and Social Development Secretariat; Council of Municipal Health Secretariats of Minas Gerais; School of Public Health of Minas Gerais; Federal University of Minas Gerais. The organization of the intersectoral workshop was prompted by Health Promotion based on a socio-environmental approach, where health is considered as a daily production, with influences on the social, economic and cultural conditions (Social Determinants of Health) in which individuals are inserted. Therefore, the responsibility for promoting health is not limited to the health sector; intersectoriality triggers increased health gradient, with suprasectoral decisions materialized through programs with a real impact on the health and quality of life of the population. Intersectoriality provides for the articulation of knowledge and experiences in the planning and implementation of Health Promotion actions, with a view to achieving integrated results in complex situations¹1. World Health Organization (WHO). The Ottawa Charter for Health Promotion. Ottawa: WHO; 1986.^,22. Buss PM, Carvalho AI. Desenvolvimento da Promoção da Saúde no Brasil nos últimos vinte anos (1988-2008). Cien Saude Colet 2009; 14(6):2305-2316.^,2020. Silva KL, Sena RR, Akerman M, Belga SMM, Rodrigues AT. Intersetorialidade, Determinantes Socioambientais e Promoção da Saúde. Cien Saude Colet 2014; 19(11):4361-4370.^,2121. Carvalho MF, Barbosa MI, Silva ET, Rocha DG. Intersetorialidade: diálogo da Política Nacional de Promoção da Saúde com a visão dos trabalhadores da atenção básica em Goiânia. Tempus – Actas de Saúde Coletiva 2009; 3(3):44-55..

In the State Health Promotion Policy of Minas Gerais (POEPS-MG), values, principles, guidelines, cross-sectional themes, operational axes and competencies that portray recommendations, suggestions, perceptions and visions of the social stakeholders that participated in the POEPS-MG are covered. All PNPS principles and values were also included in the workshops and new ones that emerged in the policy-making workshops were validated in the Working Group (WG) to define which ones would be included in the Policy as show in Chart 2. The values and principles incorporated were creativity, respect, perseverance, belonging, amorousness, horizontality and environmental justice.

The “Guidelines” outlined in the PNPS were renamed “Foundations” in the POEPS-MG, but the concept remains the same and is understood as the basis for the action and is related to its purpose, understood as a draft, general project line or plan¹⁰10. Brasil. Ministério da Saúde (MS). Gabinete do Ministro. Portaria n° 2446, de 11 de novembro de 2014. Redefine a Política Nacional de Promoção da Saúde (PNPS). Diário Oficial da União 2014; 13 nov.. The foundation that was added to include Minas Gerais demands was Popular Education in Health, through the political-pedagogical and participatory construction of knowledge oriented to Health Promotion, stimulating the empowerment and self-care of the population.

The Cross-Sectional Strategies are conceptualized in the POEPS-MG as those that should be used as reference for the establishment of Health Promotion agendas and the adoption of strategies. Operating in line with the principles and values of the SUS and traversing all Health Promotion actions, within the scope of the State of Minas Gerais, they are found in the PNPS, under the title of “Cross-Sectional Themes”, with a new reference to the Promotion of Equity in Health (Chart 3).

The “Operational Axes” of the PNPS are called Operational Strategies in the POEPS-MG and they aim to achieve the development of Health Promotion practices, respecting values, principles, guidelines and objectives that are the same as those of the National Policy. There was only one change in the PNPS, namely, “Social Communication and Media” to “Mobilization and Social Communication”, where social mobilization is an action that aims at establishing subjects and groups in favor of more solidary societal arrangements, considering participation as an act of freedom, as per Table 1. Mobilization and popular roles collaborate to raise awareness about the importance of the relationship between health and living conditions and the possible actions to reduce inequities and advocate the right to health. They value the diversity of knowledge and cultures, integrating popular knowledge into the daily life of health services.

The “Priority Themes” of the PNPS were called Themes in the POEPS-MG and are described in Chart 3. The process to define them was similar to the PNPS review⁹9. Rocha DG, Alexandre VP, Marcelo VC, Rezende R, Nogueira JD, Sá RF. Processo de revisão da Política Nacional de Promoção da Saúde: múltiplos movimentos simultâneos. Cien Saude Colet 2014; 19(11):4313-4322.. Themes were ranked according to the number of votes of the participants of the 38 workshops (managers, technical references, leaderships and other participants) and in how many workshops each topic was recurrent, as described in Table 4. Finally, products were systematized by the Working Group (GT-POEPS-MG) during the preparation of the minute. Themes will bear references for the establishment of health promotion agendas and the prioritization of strategies in Minas Gerais, and should be in line with SUS principles and values. After the publication of the POEPS-MG, there was a return movement to the regions to show the policy and provide support to implement it.

The model proposed in the Brazilian public health system is successful in theory, however, the financing model is unable to ensure the necessary resources to maintain the system. That is why it is so important to support the funding of public policies, so that it accompanies the expansion of services, ensuring the comprehensive services to citizens. Equity in financing ensures reduced regional disparities and resources for PHC²²22. Teixeira MG. O imperativo do financiamento e da gestão: desafios ao Sistema Único de Saúde. Rev. Direito Sanitário 2003; 4(1):85-96.. One of the great challenges of public health is funding health actions and services, not only due to budget constraints, but also the increasing prevalence of the burden of chronic diseases²³23. Abegunde DO, Mathers CD, Adam T, Ortegon M, Strong K. The burden and costs of chronic diseases in low-income and middle-income countries. Lancet 2007; 370(9603):1929-1938.^,2424. Bahia L, Coutinho ES, Barufaldi LA, Abreu GA, Malhão TA, Souza CP, Araujo DV. The costs of overweight and obesity-related diseases in the Brazilian public health system: cross-sectional study. BMC Public Health 2012; 12:440..

Thus, the POEPS shows the specific budget assurance for Health Promotion as an innovative aspect, which is a great advance, since this happens for the first time since Health Promotion was established in the SES-MG. In order to receive the mentioned financial incentive, the municipality signed the Term of Commitment in the Indicators, Commitments and Goals Management System (GEICOM).

This financial incentive transfers financial resources to the municipalities by means of a fixed amount and a variable amount corresponding to 50% of the total amount of the financial incentive for each party. The variable amount is accounted for proportionally to compliance with five selected indicators that will guide the monitoring and evaluation of Health Promotion actions carried out by the municipalities, as well as the implantation and implementation of the State Health Promotion Policy in the State²⁵25. Minas Gerais. Secretaria Estadual de Saúde (SES). Política Estadual de Promoção da Saúde. Belo Horizonte: SES; 2016..

Conclusion

The State Health Promotion Policy is a way to strengthen and expand the PNPS and, instead of reviewing it, provides its detailed study and incorporation into the work routine. It complements and strengthens and reaffirms its purposes, adds specific characteristics of the territory and ensures its legitimacy with the linkage of budgetary resources and the introduction of health promotion actions in PHC through continuous monitoring and education activities.

The POEPS-MG was built in decentralized and participatory fashion, with a work methodology that ensured the effective involvement of stakeholders. The elaboration process stood out because it considered the specific regional demands identified during its construction and reinforces the enriching elements of its development built in an innovative, democratic and participatory way, enabling planning of actions, the proposal of indicators and use of the financial incentive as reliably as possible with the realities found in the municipalities of Minas Gerais. In addition, it provided greater ownership of the POEPS-MG by all the people involved in its construction process and who participate in the movements that implant and implement the Policy in the territories.

The actions that will be developed are based on the Themes and Guidelines defined in the POEPS-MG and aim to cover all the municipalities of Minas Gerais, generating increased health of individuals, improving the way of living, increasing the empowerment of individuals and communities in the search for reduced inequalities, vulnerabilities and health risks by acting on the social, economic, political, cultural and environmental determinants, for which purpose it has budgetary and financial allocation from the State for the implementation and implementation of the POEPS- MG, which was a great advance, since this is unprecedented.

Acknowledgements

We wish to thank the Regional References for Health Promotion of the 27 Regional Health Administrations, the Working Group set up by SESMG for the preparation of the POEPS-MG, the Executive Secretariat of CONSEA-MG and CAISAN-MG, Prof. Dr. Kênia Lara Silva/UFMG, Ms. Stephanie Marques M. F. Belga, Daniela Santos Serpa Siqueira and Raquel Randow, students of the Health Services Management Course/UFMG.

References

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