Abstract

Deliberation in municipal councils of sanitation and health is the object of this study. Deliberation is understood as decision making and argumentative process, from the formulations of Rousseau, Habermas and Cohen. The proposed objective was to evaluate the effectiveness of the deliberative action of the councils of Belo Horizonte (MG) and Belém (PA). The evaluation included the study of variables defining the degree of institutionalization of the councils and revealing the dynamics of the deliberative process developed in them. The internal regulations of each council and the minutes and resolutions produced by them during the 2012-2014 triennium were consulted. The results showed that the four councils, in the period and according to the defined criteria of analysis, are far from the degree of deliberative effectiveness desired, considering the purposes of the social control in sanitation and in health, arranged by the specific legislation of each area. Even with broader experience, considering their years of participatory pedagogical exercise, health councils were no more effective than neophyte sanitation councils.

Key words
Sanitation; Social Participation; Social Control; Deliberation. Health

Introduction

In 2007, Federal Law Nº 11.445 established social control as one of the principles by which sanitation services should be provided throughout the national territory to ensure society’s access to information, technical representations and participation in policymaking, planning and related evaluation methods¹1 Brasil. Lei nº 11.445 de 5 de Janeiro de 2007. Estabelece diretrizes nacionais para o saneamento básico. Diário Oficial da União; 2007..

This Law was regulated by Federal Decree Nº 7.217/2010, which provided for various social control mechanisms, including collegiate bodies²2 Brasil. Decreto nº 7.217 de 21 de Junho de 2010. Regulamente a Lei nº 11.445, de 5 de janeiro de 2007, que estabelece diretrizes nacionais para o saneamento básico, e dá outras providências. Diário Oficial da União; 2010., also existing in other fields of public policy, since the enactment of the 1988 Federal Constitution.

While several of these bodies, in the areas of health, water resources, environment, child and adolescent rights, social assistance and education, for example, were created with a clear assurance of their deliberative nature, this was not the case in the area of sanitation. On the contrary, the referred Decree refers to the possibility of exercising social control through advisory bodies (Article 34, chapter 5)²2 Brasil. Decreto nº 7.217 de 21 de Junho de 2010. Regulamente a Lei nº 11.445, de 5 de janeiro de 2007, que estabelece diretrizes nacionais para o saneamento básico, e dá outras providências. Diário Oficial da União; 2010..

However, some deliberative bodies in the area are found, established from 2007³3 Belém. Lei nº 8.630 de 7 de Fevereiro de 2008. Transforma o Serviço Autônomo de Água e Esgoto de Belém em Agência Reguladora Municipal de Água e Esgoto de Belém. Diário Oficial da União; 2008. and even earlier⁴4 Belo Horizonte. Lei nº 8.260 de 3 de Dezembro de 2001. Institui a Política Municipal de Saneamento e dá outras providências. Diário Oficial da União; 2001., such as, for example, the Higher Council of the Belém Municipal Water and Sewerage Regulatory Agency (CSAMAE), whose attributions are social control, and the Municipal Sanitation Council of Belo Horizonte (COMUSA).

Because of this peculiarity, it is appropriate to understand the deliberative practice in these councils. To this end, and compared to older deliberative collegiate bodies - the Belém Municipal Health Council (CMS/Bel) and the Belo Horizonte Municipal Health Council (CMS/BH) - this paper seeks to answer the question: what is the level of deliberative effectiveness of the four councils under study?

It is not a matter of considering seniority as a variable for evaluating deliberative effectiveness, but only as a factor that provides, in theory, the so-called participatory pedagogical and democratic exercise⁵5 Silva ALN, Souza DE. Deliberação e controle social: um perfil dos conselhos estaduais de políticas públicas no nordeste brasileiro. Rev Eletr de Ciên Pol 2013;4(1-2):80-100., which may be reflected in greater effectiveness. By comparing councils attentive to different social policies, albeit interconnected, we seek to evaluate how the neophyte social control institution can be considered effective in the area of sanitation. To this end, we take as a parameter the experience of nearly three decades of community participation in the management of the Unified Health System (SUS), as regulated by Federal Law Nº 8.142/1990⁶6 Brasil. Lei nº 8.142 de 28 de Dezembro de 1990. Dispõe sobre a participação da comunidade na gestão do SUS e sobre as transferências intergovernamentais de recursos financeiros na área da saúde. Diário Oficial da União; 1990..

Concerning the health area, this may be one of several studies already produced on the theme⁷7 Lavalle AG, Voigt J, Serafim L. O que fazem os conselhos e quando o fazem? Padrões decisórios e o debate dos efeitos das instituições participativas. Rev Ciên Soc 2016;59(3):609-650., but for the sanitation area, it is the more relevant initiative, since studies on councils⁸8 Piterman A. (A falta de) controle social das políticas municipais de saneamento: um estudo em quatro municípios de Minas Gerais. Saude Soc 2013;22(4):1180-1192. are rare and no studies specific to this topic were identified.

The following sections shows a conceptual discussion of deliberation and deliberative effectiveness; the contextualization of the councils under study; the methodological procedures adopted; the results achieved and their discussion, and the final considerations.

Deliberation and deliberative effectiveness

Considering deliberation as the central theme of this study, two questions whose clarification is fundamental to the understanding of their findings emerge, as follows: 1) what is the meaning of this term? and 2) how is it approached here?

The answer to the first question requires us to resort to a study that, by addressing the formulations of various authors, since Jean-Jacques Rousseau, within contemporary democratic theory, discusses the shift from a decisionistic concept of deliberation, based on the Rousseaunian thought, to an argumentative concept, consolidated by Jurgen Habermas and Joshua Cohen, from the 1970s⁹9 Avritzer L. Teoria democrática e deliberação pública. Lua Nova 2000;49:25-46..

The decisionistic concept favors the moment of decision-making and comes down to it, in which, based on the will of the majority, one proposal is declared the winner. The argumentative concept considers that deliberation is a process in which one or more agents evaluate the reasons that permeate an issue, favoring the debate of ideas⁹9 Avritzer L. Teoria democrática e deliberação pública. Lua Nova 2000;49:25-46..

Regarding the second question, the approach proposed in this study is not linked exclusively to the concepts at hand. On the contrary, deliberation, whose effectiveness one seeks to evaluate, is in line with the idea of a deliberative process that involves both concepts because, in Latin and English, the word deliberation has two etymological meanings: 1) to decide, solve; 2) to ponder, reflect⁹9 Avritzer L. Teoria democrática e deliberação pública. Lua Nova 2000;49:25-46..

A third question also arises: what is deliberative effectiveness? It is the effective capacity of participatory forums to act on public policy in order to influence, control, and define it. Thus, it expresses itself and can be analyzed from elements external and intrinsic to the councils¹⁰10 Cunha ESM. A efetividade deliberativa dos conselhos municipais de saúde e da criança e do adolescente no nordeste. In: Avritzer, L, organizador. A participação social no Nordeste. Belo Horizonte: Editora UFMG; 2007. p. 135-162..

External factors include government coalitions set by political parties, which may or may not support the delegation of power to citizens; the associative experience of the communities; the conjunction of social and political forces interested in participatory experiences¹⁰10 Cunha ESM. A efetividade deliberativa dos conselhos municipais de saúde e da criança e do adolescente no nordeste. In: Avritzer, L, organizador. A participação social no Nordeste. Belo Horizonte: Editora UFMG; 2007. p. 135-162..

Among the internal factors is the institutional design: parity among council members, not only concerning numerical equality, but also access to information and the possibility of training and availability of council members; representativeness of these members, translated as their authority to speak on behalf of the segment they represent rather than themselves¹¹11 Teixeira EC. Efetividade e eficácia dos conselhos. In: Carvalho MCAA, Teixeira ACC, organizadoras. Conselhos gestores de políticas públicas. São Paulo: Pólis; 2000. p. 92-96.; presence of strong groups to influence decisions¹⁰10 Cunha ESM. A efetividade deliberativa dos conselhos municipais de saúde e da criança e do adolescente no nordeste. In: Avritzer, L, organizador. A participação social no Nordeste. Belo Horizonte: Editora UFMG; 2007. p. 135-162.. The existence of committees and technical chambers that act as channels of access to information by the councilors, as well as the choice of the president of the council are also highlighted as competing factors for deliberative effectiveness¹²12 Faria CF. Sobre os determinantes das políticas participativas: a estrutura normativa e o desenho institucional dos conselhos municipais de saúde e de direitos da criança e do adolescente no nordeste. In: Avritzer, L, organizador. A participação social no Nordeste. Belo Horizonte: Editora UFMG; 2007. p. 135-162..

At the national level, reports of investigations conducted in Paraná, Goiás, Mato Grosso do Sul and several northeastern states identified low deliberative capacity in the studied bodies, because of the following: 1) the centrality of the Executive Branch in the definition of relevant issues for discussion in the councils; 2) the absence of debate, including on issues related to public policies, which shows a certain “consensus” or “harmony”, which do not fit the expectations of democratic deliberation, marked by the explicitness of conflicts; 3) the lack of training of councilors, so they may also understand the financial situation of the policy to which they are bound; 4) the low representativeness; 5) the difficulty in dealing with the plurality of interests; 6) the upkeep of clientelist standards between state and society; 7) the state’s refusal to share power; 8) bureaucratization and restriction of direct citizen participation; 9) failure to hold meetings; 10) the lack of parity, among others⁵5 Silva ALN, Souza DE. Deliberação e controle social: um perfil dos conselhos estaduais de políticas públicas no nordeste brasileiro. Rev Eletr de Ciên Pol 2013;4(1-2):80-100.^,1313 Tatagiba L. Conselhos gestores de políticas públicas e democracia participativa: aprofundando o debate. Rev Sociol Polít 2005;25:209-213.^,1414 van Stralen CJ, Lima AMD, Fonseca Sobrinho D, Saraiva LES, van Stralen TBS, Belisário SA. Conselhos de saúde: efetividade do controle social em municípios de Goiás e Mato Grosso do Sul. Ciên Saude Colet 2006;11(3):621-632..

A survey conducted in the city of Guarulhos (SP), which analyzed administrative acts of various local councils, reveals that deliberative activity is higher in those who receive high federal induction (especially the conditional transfer of resources), which are widespread in the country and well-integrated with their respective sectors or policy areas⁷7 Lavalle AG, Voigt J, Serafim L. O que fazem os conselhos e quando o fazem? Padrões decisórios e o debate dos efeitos das instituições participativas. Rev Ciên Soc 2016;59(3):609-650.. Even in the case of a deliberative council for self-regulatory purposes and only advisory for other purposes, such as the Council of Cities (ConCidades), this level of effectiveness was also experienced from 2003 to 2005, in which, regardless of the limitations imposed by this institutional design, due to the will and political commitment in force, the council influenced the decision-making processes of the Ministry of Cities and other bodies to which it forwarded resolutions, among which the National Congress¹⁵15 Brasil FPD, Carneiro R, Barbosa TP, Almeida ME. Participação, desenho institucional e alcances democráticos: uma análise do Conselho das Cidades (Concidades). Rev Sociol Polí 2013;21(48):5-18..

At the international level, there are also references to the low influence of participatory bodies on the public policy, which is the case, for example, in the United Kingdom, where community health councils were active¹⁶16 Serapioni M, Romaní O. Potencialidades e desafios da participação em instâncias colegiadas dos sistemas de saúde: os casos de Itália, Inglaterra e Brasil. Cad Saude Pub 2006;22(11):2411-2421.. The role of these forums in influencing decisions and setting priorities has been reported to be less effective than suggested by the official rhetoric that supported them¹⁷17 Milewa T, Valentine J, Calnan N. Managerialism and active citizenship in britain's reformed health service: power and community in an era of decentralization. Soc Scien Medic 1998;47(4):507-517.^,1818 Rhodes P, Nocon A. User involvement and the NHS reforms. Health Expectations 1998;1(2):73-81.. Similarly, in Spain and Portugal, as well as in Italy and Greece, political discourse has not resulted in practical experiences capable of making the participation of service users effective¹⁹19 Matos AR, Serapioni M. O desafio da participação cidadã nos sistemas de saúde do Sul da Europa: uma revisão da literatura. Cad Saude Pub 2017;33(1):1-11.^,2020 Serapioni M, Duxbury N. Citizens participation in the italian health-care system: the experience of the Mixed Advisory Committees. Health Expectations 2012;17(4):488-499..

On the other hand, research conducted in Mexico indicates that the so-called aval ciudadano (institutional strategy for health service quality surveillance) has great potential to represent users and influence service delivery²¹21 Nigenda-Lopez GH, Juárez-Ramiréz C. Ruíz-Larios JA, Herrera CM. Participación social y calidad de salud: la experiência del aval ciudadano em los servicios en México. Rev Saude Pub 2013;47(1):44-51.. In Colombia, where a Community Participation Committee and user associations operate, a study argues that, although their findings point to the satisfaction of their respondents regarding their ability to influence the conduct of health services, institutional effective spaces and answers²²22 Delgado-Gallego ME, Vazquez ML. Percepciones de usuarios y líderes comunitarios sobre su capacidad para influenciar em la calidad de los servicios de salud: un estudio de casos de Colombia y Brasil. Cad Saude Pub 2009;25(1):169-178. are not always the case.

Contextualization of councils under study

COMUSA was created and started its activities before the enactment of Law Nº 11.445/2007, unlike CSAMAE, which was created one year after this legislation, and it was another seven years until the onset of its operations.

The CMS/Bel was created a few months before the regulatory infra-constitutional laws of the SUS (the CMS/Bel did not inform the year in which the council came into operation), while the establishment and start of CMS/BH activities occurred after these laws.

The four councils are deliberative, which should be underscored, considering that COMUSA was created already assuming that nature six years before the legislation established the creation of advisory sanitation councils.

A single study was found on COMUSA²³23 Mello MCC, Rezende S. O Conselho Municipal de Saneamento de Belo Horizonte: desafios e possibilidades. Eng Sanit Ambient 2014;19(4):479-488., and its conclusion highlights that, although with merits (brought and may bring even more positive changes to the sanitation scenario in Belo Horizonte), between 2004 and 2008, the council could not guarantee social control. There were limitations on the generation of own proposals and action on public policy, and there was a feeling that the approved definitions were just “done deal” proposals that the Municipality of Belo Horizonte (PBH) would carry out even if the council did not exist.

Several works are cited about CMS/BH²⁴24 Takamatsu SL. Gestão pública participativa: a experiência do Conselho Municipal de Saúde de Belo Horizonte [dissertação]. Rio de Janeiro: Fundação Getúlio Vargas/EBAP; 1996. [acessado 2017 Mar 08]. Disponível em: http://bibliotecadigital.fgv.br/dspace/bitstream/handle/10438/8857/000076675.pdf?sequence=1&isAllowed=y
http://bibliotecadigital.fgv.br/dspace/b...

25 Bicalho MS. Conselheiros de saúde construindo o controle social do SUS. Psicol Rev 2003;10(14):149-154.

26 Santos SF, Vargas AMD, Lucas SD. Conselheiros Usuários do Conselho Municipal de Saúde de Belo Horizonte: características sociais e representatividade. Saúde e Soc 2011; 20:483-495.

27 Oliveira AMC, Ianni AMZ, Dallari SG. Controle social no SUS: discurso, ação e reação. Ciên Saude Colet 2013;18(8):2329-2338.^-2828 Machado JA, Lucas SD. Análise das resoluções do Conselho Municipal de Saúde de Belo Horizonte no período de 1991 a 2010. Ciên Saude Colet 2013;18(8):2401-2411.. One of them highlights two possibilities²⁸28 Machado JA, Lucas SD. Análise das resoluções do Conselho Municipal de Saúde de Belo Horizonte no período de 1991 a 2010. Ciên Saude Colet 2013;18(8):2401-2411.: 1) Mayors (between 1997 and 2008) were not publicly assuming their vetoes, because by not approving resolutions approved by the Council, which were not in line with their interests, they would be seeking to avoid the political burden that would mean vetoing them; 2) In the period mentioned above, by not triggering the Public Prosecutor’s Office against the PBH for not ratifying the approved resolutions, the CMS/BH would still be experiencing limitations regarding the exercise of its power, due to historical aspects of Brazilian society or political-partisan links with the Executive.

No studies were found on CSAMAE, and only one study on CMS/Bel was identified²⁹29 Cristo SCA. Controle social em saúde: o caso do Pará. Serv Soc e Socie 2012;(109):93-111.. In this study, the author points out characteristics that marked the council between 2010 and 2011, such as the insecurity of council members in the face of their power and consequent responsibility.

Methodological procedures

This is a descriptive study³⁰30 Apolinario F. Dicionário de metodologia científica: um guia para a produção do conhecimento científico. São Paulo: Atlas; 2007., based on document analysis³¹31 Gil AC. Como elaborar projetos de pesquisa. São Paulo: Atlas; 2002., which adopted with adaptations variables of analysis proposed in other studies³²32 Avritzer L, organizador. A participação social no Nordeste. Belo Horizonte: Editora UFMG; 2007.. Observations were also made during the plenary sessions of the councils and, in specific cases, informal dialogue with the health council president was identified.

Two groups of variables were defined: 1) defining the degree of institutionalization of the councils; 2) revealing the dynamics of the deliberative process developed in these instances.

The variables of the first group (internal organs; frequency and place of ordinary meetings as per bylaws (RI); number of members and parity; choice of members; choice of presidency; mandate and reelection; formality for publishing decisions) allow to evaluate the organizational structure of the councils, their composition and the procedures adopted for their operation, considering that their format or institutional design influences their deliberative effectiveness¹²12 Faria CF. Sobre os determinantes das políticas participativas: a estrutura normativa e o desenho institucional dos conselhos municipais de saúde e de direitos da criança e do adolescente no nordeste. In: Avritzer, L, organizador. A participação social no Nordeste. Belo Horizonte: Editora UFMG; 2007. p. 135-162..

These variables were studied through document analysis. The object of this analysis was the RI of the councils (in force during the period of interest of the research) because it is a document that reveals the normative conditions that may or may not favor a democratic and inclusive process in these bodies.

Regarding the period of interest of the research, we sought to analyze a recent time interval that would allow the study in two consecutive municipal administrations, with and without the change of mayors. Thus, the triennium was defined from 2012 to 2014, since in the case of Belém, 2012 corresponded to the end of one management and 2013 and 2014 to the first two years of the management of a new mayor. In Belo Horizonte, as the mayor was reelected in 2012, there are two administrations of the same mayor. Also, considering that CSAMAE started operating in 2015, this year was defined as the year of interest for this council.

Thus, the following were consulted: RI COMUSA approved by Decree Nº 11.730/2004 and amended by Law Nº 10.433/2012; RI CMS/BH approved in 2007 and replaced under Resolution Nº 366/2014; RI CSAMAE approved by Resolution Nº 002/2015; RI CMS/Bel approved in 2001.

The second group includes the following variables: deliberative equality; prevalent decisions; prevalent functions; number of published and unpublished resolutions. The variable deliberative equality is based on the idea of equal possibility for all the subjects of the process to present topics to the agenda and reasons for debate¹⁰10 Cunha ESM. A efetividade deliberativa dos conselhos municipais de saúde e da criança e do adolescente no nordeste. In: Avritzer, L, organizador. A participação social no Nordeste. Belo Horizonte: Editora UFMG; 2007. p. 135-162.. It aims to assess the ability to verbalize and influence each of the segments that underpin the council in the decisions taken. It is expressed by the number of vocalizations, that is, of manifestations that occurred during the meetings and the occurrence of the proposition of topics for debate during the sessions, to be included or not in the agenda by its definer/organizer.

The prevalent decisions variable reveals the content of decisions taken by the councils, which indicates the prevalent functions performed, categorized as follows: proposed policy; policy control; other functions. The first of these is linked to the most central aspects of the policy to which the council is attached, including, for example, the proposed budget and action plans, and the consideration of management reports.

The control function includes the monitoring and evaluation of State actions, expressed through complaints, intervention proposals, and evaluation of the services provided. The other functions performed by the councils, categorized as others, are internal organization, reports, problems unrelated to the policy itself.

The number of resolutions published and not published in the Official Gazette of the Municipality (DOM) is a variable that shows a possible tension between the council and the Executive, considering the formality for publishing the deliberations variable, belonging to the first group of variables under study, and what is signaled by the literature²⁸28 Machado JA, Lucas SD. Análise das resoluções do Conselho Municipal de Saúde de Belo Horizonte no período de 1991 a 2010. Ciên Saude Colet 2013;18(8):2401-2411..

The minutes and resolutions approved by the councils in the years of interest of the research were analyzed to study these variables, highlighting that the CMS/Bel did not provide us with the 2012 and 2013 minutes.

After studying these variables, the level of effectiveness was evaluated for each council, adopting four evaluative realms, three different degrees of effectiveness were defined for each, as shown in Chart 1.

Results and discussion

Level of institutionalization of councils

Regarding internal bodies, it appears that, in general, the design of health councils, among themselves, is similar, as well as that of sanitation.

The sanitation councils have fewer bodies, no commissions, and technical chambers, which could compromise their actions since these bodies contribute to the clarification of the councilors about specific issues that they are often unaware of¹²12 Faria CF. Sobre os determinantes das políticas participativas: a estrutura normativa e o desenho institucional dos conselhos municipais de saúde e de direitos da criança e do adolescente no nordeste. In: Avritzer, L, organizador. A participação social no Nordeste. Belo Horizonte: Editora UFMG; 2007. p. 135-162.. However, these pieces of advice are mostly technical. Even with different academic backgrounds, councilors are “self-sufficient”, which would not be the case if the profile of councils were expanded to include popular representation, as in the case of health councils.

Although not having designated in its RI the existence of a Secretariat, COMUSA has such a body, as much as the CSAMAE, since the minutes of the meetings are prepared by it. Similarly, although it did not make explicit the existence of advisors, such as the CMS/Bel, which has a Technical Advisory Service, the CMS/BH has one of an accounting nature. Moreover, even under different names, CMS/BH chambers, and CMS/Bel specific committees and chambers perform similar functions.

Besides the similarities pointed out, there are differences. The CMS/Bel did not create, as the CMS/BH did, sectoral plenary sessions (plenary sessions of women’s movements, retirees, communities, productive sector unions, people with chronic pathologies, health workers, managers, and service providers).

Unlike CSAMAE, in order to promote (and not to include) popular participation, COMUSA has a committee of 32 representatives of social movements, created in 2009, at the Second Municipal Sanitation Conference, to monitor council meetings. Its members do not hold voting rights, only voice.

The difference in the frequency of ordinary meetings between CSAMAE (twice a semester) and the other councils (monthly) is significant. Despite the larger interval defined between them, there are no records that they did not occur, unlike CMS/Bel, where this situation occurred more than once, which is pointed by the literature as a compromising factor of deliberative capacity⁵5 Silva ALN, Souza DE. Deliberação e controle social: um perfil dos conselhos estaduais de políticas públicas no nordeste brasileiro. Rev Eletr de Ciên Pol 2013;4(1-2):80-100..

On the other hand, none of them defines, in their RI, their place of performance. Taking as reference the 95 minutes consulted, while the others use other spaces provided by the City Hall, the CMS/Bel informs that meetings are held in its room. However, as observed on a site visit, it is a small and stuffy place. Therefore, the council usually limits the number of visitors who want to attend the meetings, and have already canceled some of them, as already mentioned, due to breakdowns in the refrigeration equipment installed there.

It is also noted that COMUSA, CSAMAE, and CMS/Bel have a close number of councilors, but below the number set for CMS/BH. In the health councils, as per their RI, the user segment includes entities of the women’s movement, people with disabilities and pathologies, residents, the trade union movement of the productive and service sectors, and, in the case of CMS/BH, the regional health offices of the municipality. Popular participation is more restricted in sanitation councils.

In these councils, the civil society segment includes only one representative of the district or residents’ association (the COMUSA popular commission is not part of the council itself). The others come from employer, labor union, and engineering and legal professions oversight entities, as well as non-governmental organizations working in the area of sanitation and environment. Specifically, in the COMUSA, this segment also includes representatives from universities, health councils, a scientist, technologist, researcher, or individual reputed for their knowledge dedicated to related activities.

Regarding parity, this feature is found in health councils, in tripartite format, ensuring greater representation of users compared to other segments. In sanitation councils, numerical parity is found between representatives of the Government and civil society, but, as in this last segment, the representation of the simple user of sanitation services is limited, somehow, parity - a relevant factor for deliberative effectiveness⁵5 Silva ALN, Souza DE. Deliberação e controle social: um perfil dos conselhos estaduais de políticas públicas no nordeste brasileiro. Rev Eletr de Ciên Pol 2013;4(1-2):80-100. - is harmed.

In all the studied councils, members are chosen and indicated within the segment they represent, without external interference, within what is considered to be a typical pattern of representation’s choice, although there some exceptions are also found in the health area¹²12 Faria CF. Sobre os determinantes das políticas participativas: a estrutura normativa e o desenho institucional dos conselhos municipais de saúde e de direitos da criança e do adolescente no nordeste. In: Avritzer, L, organizador. A participação social no Nordeste. Belo Horizonte: Editora UFMG; 2007. p. 135-162..

Despite their democratic traditions, the sector’s secretary of some health councils is the born president¹⁴14 van Stralen CJ, Lima AMD, Fonseca Sobrinho D, Saraiva LES, van Stralen TBS, Belisário SA. Conselhos de saúde: efetividade do controle social em municípios de Goiás e Mato Grosso do Sul. Ciên Saude Colet 2006;11(3):621-632.. This is not the case of the CMS/Bel and CMS/BH, which have already advanced to a process that, in theory, requires some distribution of power and the non-preponderance of the Executive over other segments. However, that is what happens in the sanitation councils, only replacing the figure of the secretary with the representative of the Mayor, in the case of COMUSA, and that of the managing director of the Belém Municipal Water and Sewerage Regulatory Agency (AMAE), in the case of CSAMAE. Facts such as these, however accessible and democratic the president’s stance, do not detract from the monopoly of office by the Executive’s representative¹²12 Faria CF. Sobre os determinantes das políticas participativas: a estrutura normativa e o desenho institucional dos conselhos municipais de saúde e de direitos da criança e do adolescente no nordeste. In: Avritzer, L, organizador. A participação social no Nordeste. Belo Horizonte: Editora UFMG; 2007. p. 135-162..

The terms of office are set at two years for all councilors, including the president of the councils. Only in the case of CSAMAE, the term of office is four years, as the president is the agency’s CEO.

Unlike the others, the CMS/Bel RI does not mention the possibility of reelecting users’ representatives, private providers, and workers, nor of the representatives of the Public Power. However, references to both were noted in the text of the resolutions and confirmed through informal dialogue with its current president.

The low renewal of a council with the non-assumption of new councilors and presidents is considered both advantageous (acquisition of familiarity with the topics discussed) and disadvantageous (professionalization and removal of councilors from their base)²⁶26 Santos SF, Vargas AMD, Lucas SD. Conselheiros Usuários do Conselho Municipal de Saúde de Belo Horizonte: características sociais e representatividade. Saúde e Soc 2011; 20:483-495.. In this current case, a relative renewal is noted in the health councils and the COMUSA.

The councils adopt different procedures to define their agendas. COMUSA and CSAMAE exclude the plenary from this function, keeping it as the exclusive prerogative of the Executive, approaching what the literature describes in referring to the centrality of this Power in the definition of matters to be analyzed by the Council¹³13 Tatagiba L. Conselhos gestores de políticas públicas e democracia participativa: aprofundando o debate. Rev Sociol Polít 2005;25:209-213.. The CMS/Bel favors the plenary. However, no reports were identified while reading the minutes.

None of the RIs consulted report whether the ordinary deliberations will be by an open or secret vote, but, on account of the in loco observation during plenary meetings of the COMUSA, CMS/BH, and CSAMAE, the votes were cast openly. However, the RI of the latter has a special provision for secret balloting when a counselor is dismissed. Concerning the CMS/Bel, it was not possible to observe due to the cancellation of meetings, as already mentioned.

In all cases, decisions are taken by simple majority vote, requiring a qualified majority only to amend the RI. It is noteworthy that the sanitation councils assure their president the casting vote. This, in itself, already hurts democratic principles, but, considering that the position of president in these councils is regimentally exercised by a representative of the Executive, there is an even more significant compromise of the quality of the intended democratic exercise²³23 Mello MCC, Rezende S. O Conselho Municipal de Saneamento de Belo Horizonte: desafios e possibilidades. Eng Sanit Ambient 2014;19(4):479-488..

The sanitation councils have the prerogative of forwarding their deliberations for publication in the DOM without the obligation of prior approval by the Executive, unlike the health councils. Concerning this fact to the variable choice of the president, some “compensation” promoted by the Executive to ensure its control over the councils is observed. As a natural representative of the Executive chairs the sanitation councils, they have the autonomy to publicize their deliberations. The health councils, whose president may be a representative of other segments, must submit their deliberations to the sector secretary or the mayor himself before they can be published later. In both cases, this can undoubtedly represent a restriction on the deliberative capacity of these councils²⁸28 Machado JA, Lucas SD. Análise das resoluções do Conselho Municipal de Saúde de Belo Horizonte no período de 1991 a 2010. Ciên Saude Colet 2013;18(8):2401-2411..

Dynamics of the deliberative procedure in the councils

The evaluation of the deliberative equality variable, which includes the vocalization in the debates and the proposition of themes, was impaired concerning COMUSA due to the laconism of this council’s minutes. These almost entirely only mention debates on the points of the agenda and rarely quote the names of the councilors who spoke and the content of their statements. Thus, it became impossible to analyze this council regarding this variable. This undermines the proposed study but reinforces the analysis made in another study²³23 Mello MCC, Rezende S. O Conselho Municipal de Saneamento de Belo Horizonte: desafios e possibilidades. Eng Sanit Ambient 2014;19(4):479-488., which also highlighted this limitation of the referred council. It also suggests the possibility that the minutes are being taken as a mere obligation to be met in compliance with legal requirements¹⁰10 Cunha ESM. A efetividade deliberativa dos conselhos municipais de saúde e da criança e do adolescente no nordeste. In: Avritzer, L, organizador. A participação social no Nordeste. Belo Horizonte: Editora UFMG; 2007. p. 135-162..

In the CMS/BH, in each year, the number of vocalizations of the managers/providers/trainers segment was the lowest compared to the other segments. In total, the workers produced the most significant number of vocalizations and the same number of theme propositions as the users, revealing that, during this period, although their purposeful participation was intense, they were the ones who remained with the highest power of influence in the council. This finding is interesting because it reveals the strength of this segment and differs from others that indicate the preponderance of the Executive¹⁰10 Cunha ESM. A efetividade deliberativa dos conselhos municipais de saúde e da criança e do adolescente no nordeste. In: Avritzer, L, organizador. A participação social no Nordeste. Belo Horizonte: Editora UFMG; 2007. p. 135-162..

At the CSAMAE, civil society and the public authorities equaled the number of vocalizations, and no theme proposed during the meetings took place in the year under study. However, given that the agenda is organized by the Council Secretariat, which is linked to the Executive, and that civil society representation includes only one entity from the popular movement, absent from the two meetings held in the period, we can consider that the most significant power of influence over the council is not in the hands of the sanitation service users attached to the council.

In the CMS/Bel, we can observe that the influence of the user segment prevailed over the others, both in the number of vocalizations and propositions of topics for discussion, also differing from the literature cited¹⁰10 Cunha ESM. A efetividade deliberativa dos conselhos municipais de saúde e da criança e do adolescente no nordeste. In: Avritzer, L, organizador. A participação social no Nordeste. Belo Horizonte: Editora UFMG; 2007. p. 135-162.. This finding, however, and all the others resulting from the analysis of the minutes of this Council, is compromised since the 2012/2013 minutes were not made available. If this harms the analysis of the deliberative equality variable, it favors the investigation of the level of institutionalization of the council, testifying against its ability to organize and allow citizens free access to their records¹⁰10 Cunha ESM. A efetividade deliberativa dos conselhos municipais de saúde e da criança e do adolescente no nordeste. In: Avritzer, L, organizador. A participação social no Nordeste. Belo Horizonte: Editora UFMG; 2007. p. 135-162..

As for the prevailing decisions, topics range from the approval of the municipal policy, the management of financial resources and the definition of tariffs, to the approval of minutes, names of councilors to represent the council, calendars of meetings and public calls.

Noteworthy is the production of the CMS/BH, which during the three years of interest of the research, made 150 decisions, while COMUSA, only 12. However, it is relevant to observe, in this comparison, the typical type of decision. Of the total CMS/BH decisions, 56% (n=85) are related to council internal affairs. In the case of COMUSA, 66% (n=8) of them directly interfere with public policy. However, as it was not possible to assess the vocalizations of the debates in more detail in this Council, one question remains open, which can be posed with reports of decisions taken in the absence of debates, conducted exclusively by the Executive with direct incidence on public policy¹³13 Tatagiba L. Conselhos gestores de políticas públicas e democracia participativa: aprofundando o debate. Rev Sociol Polít 2005;25:209-213.: how much influence does the Executive have on these COMUSA decisions?

In order of prevalence, COMUSA exercised, during the three years considered, what can be called the “listening function”, linked to the receipt of the information provided by PBH and other agencies on actions and projects (15 occurrences). Secondly, the propositional function concerning the public policy emerged, which corresponds to the more exceptional ability to influence state actions¹⁰10 Cunha ESM. A efetividade deliberativa dos conselhos municipais de saúde e da criança e do adolescente no nordeste. In: Avritzer, L, organizador. A participação social no Nordeste. Belo Horizonte: Editora UFMG; 2007. p. 135-162..

In CMS/BH, from 2012 to 2014, and in CSAMAE, in 2015, the function linked to the internal organization prevailed, followed by, respectively, the public action control function and the propositional function. The CMS/BH still exercised, in the third level of prevalence, the propositional function. In 2014, the CMS/Bel, predominantly held a control role, followed by the propositional role and the internal organization role, which indicates attenuated bureaucracy, obstacles and lack of structure that characterized it in previous years²⁹29 Cristo SCA. Controle social em saúde: o caso do Pará. Serv Soc e Socie 2012;(109):93-111..

The sanitation councils published all the resolutions that they approved in the period. However, the same was not the case with health councils, which may be related to the intentional curtailment of the council’s deliberative capacity by the Executive and its difficulty to share power¹³13 Tatagiba L. Conselhos gestores de políticas públicas e democracia participativa: aprofundando o debate. Rev Sociol Polít 2005;25:209-213.^,2828 Machado JA, Lucas SD. Análise das resoluções do Conselho Municipal de Saúde de Belo Horizonte no período de 1991 a 2010. Ciên Saude Colet 2013;18(8):2401-2411..

Of a total of 64 CMS/BH resolutions, 28% (n=18) were not approved by the Executive for publication. At the CMS/Bel, two resolutions approved by the plenary were not published, and seven, which had been approved by the ad referendum council, were not published either and were revoked shortly after that. Also, 17 other resolutions were not published, and their existence is doubtful since as the Council has not delivered its hard copies, we suspect that a numbering failure may have occurred and they may never have existed. Thus, taking into account these circumstances, we can consider that only two adopted resolutions have not been published, which amounts to just over 1% of the total of 171 resolutions. The topics they addressed were the installation of the Medical and Dental Specialties Center, the repeal of one of the resolutions approved ad referendum and the referral of the Municipal Health Plan to the Scientific Committee of the Council.

These facts, which in themselves are already serious, become even more relevant considering that the councils did not resort to the Public Prosecution Service seeking the approvals, as reported by other studies²⁸28 Machado JA, Lucas SD. Análise das resoluções do Conselho Municipal de Saúde de Belo Horizonte no período de 1991 a 2010. Ciên Saude Colet 2013;18(8):2401-2411..

Level of deliberative effectiveness

For the four councils, Chart 2 shows the level of deliberative effectiveness. We were unable to determine it for COMUSA concerning the deliberative equality realm since the defining variables were contradictory: civil society prevails in vocalization, while the Public Power prevails in proposing themes.

In fact, the set of realms, the case of COMUSA reveals a paradox, because, although it has high effectiveness as to the type of decision made (focus on policy), it does not achieve the same performance as the function performed (“listening” function) and the publication of decisions (deliberations published without approval of the Executive because they are approved by its representative, who chairs the council).

In the CMS/BH, the level of effectiveness is low in the type of decision made (linked to internal council issues), the function performed (linked to internal council issues) and the publication of decisions (published only after approval by the Executive, with some unpublished, and the president is not from the Executive). Effectiveness regarding deliberative equality was evaluated as medium (workers’ vocalizations prevail, and numerically tied are theme propositions by users and workers).

In all realms, the deliberative effectiveness of CSAMAE was assessed as low. Regarding deliberative equality, the vocalizations of civil society and the public power prevail with the same number of occurrences, without proposing themes. The type of decision made and the function performed concern the internal organization of the Council, and, concerning the publication of decisions, all were published without approval by the Executive, since they are approved by its representative, who chairs the council.

The CMS/Bel was the council with the highest variability in effectiveness. Deliberative equality was deemed high (with prevailing vocalizations and proposition of themes by users), the type of decision made (linked to the control of public actions) and the function performed (control function), medium, and the publication of decisions (published only after approval by the Executive, with some unpublished, and the President is not from the Executive), low.

Final considerations

The four councils studied, in the period and as per the defined analysis criteria, are far from the desired level of deliberative effectiveness, given the purposes of sanitation and health social control, provided by the specific legislation of each area. Even with broader experience, considering their years of pedagogical and democratic exercise of participation, health councils were no more effective than neophyte sanitation councils.

This is something that, however, should not be interpreted as discouraging or indicative that social control is a utopia, even when the nature of the council is deliberative, not merely advisory. Admitting and recognizing the advancement that is the existence of sanitation councils is something that cannot be missed. Also, the limits identified here can be overcome in that there is a predominance of users/civil society in the vocalization and proposition of themes; interference of the council in the elaboration of public policy; prevalence of propositional functions; resolutions that do not require Executive approval for publication; choice of the president from among the councilors of all segments.

If the quest for effectiveness in councils imposes itself in a general context, it is all the more necessary in such a critical historical moment as this one, in which the actions of the central government turn to the freezing of public investments and the privatization of services, which includes sanitation and health. Therefore, a strong position must be established in the advocacy of sanitation and health with effective social control over state policy, which should be directed towards securing such human rights and not trivializing or turning them into commodities.

References

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