Abstract

The creation of consensus and agreement among managers of the Unified Health System (SUS) was analyzed in Regional Interagency Commissions of two metropolitan scenarios, by means of a multiple case study for comparative analysis between the Metropolitan Region of Fortaleza-Ceará and the Metropolitan Region of Salvador-Bahia. The theoretical reference used was based on Mario Testa’s work and on Habermas’ Theory of Communicative Action. The data production merged documental analysis, interviews with managers of state, municipal and federal levels with direct observation of meetings of the Regional Interagency Commission, the State Health Council, the Bipartite Interagency Commission, meetings between central and regional levels, in addition to extended meetings of the Health Municipal Offices Council, in both states. The problems related to Agreed and Integrated Programming and to the underfunding of SUS were common points in the scenarios studied. Such problems are interlinked and interfere in an important way in the interinstitutional relations between the municipalities, highlighting the dispute for resources as an obstacle for the creation of consensus and agreement, based on the dialogue and understanding between actors.

Key words
Regionalization; Covenants; Health policy; Intergovernmental relations; Metropolitan regions

Introduction

The regionalization of the Brazilian Unified Health System (SUS) was expected in the discursive plan, since the Health Pact, as a structuring and guiding axis of the decentralization and the agreement processes between managers. Faced with the concepts of solidarity and cooperation, there are dilemmas that extrapolate the technical dimension, implying transformations in the political domain, as it depends on federative relations guided by complex decision-making processes involving several actors and federated entities. A paradox is created in the presence of the autonomy of the federated entities, at the same time, interdependent regarding the regional implementation of health policies that require intergovernmental pacts.

When analyzing the Brazilian regionalization and federalism, Dourado and Elias¹1 Dourado DA, Elias PEM. Regionalização e dinâmica política do federalismo sanitário brasileiro. Rev Saude Publica 2011; 45(1):204-211. problematize the difficulty of reconciling regional management mechanisms, political and financial concentration at the federal level and more effective participation of state governments, with the preservation of municipal autonomy in the implementation of health actions and services.

The SUS regional management constitutes a challenge, considering that Brazilian federalism does not contemplate the region, the unit to be built, managed and financed through agreements and negotiations, characterizing a political process that requires concessions from some entities, aiming to supplant private interests in function of the collective, interfering with power relations²2 Levi ML, Scatena JHG. Evolução recente do financiamento do SUS e considerações sobre o processo de regionalização. In: D'Ávila Viana AL, Lima LD. Regionalização e relações federativas na política de saúde do Brasil. Rio de Janeiro: Contra Capa; 2011. p. 81-113.. However, the Brazilian political scene is traditionally dominated by privatist negotiations³3 Arretche MTS. Democracia, federalismo e centralização no Brasil. Rio de Janeiro: FGV, Fiocruz; 2012.. Peculiarities in the health sector disclose the complexity of negotiating and implementing deals, living with tensions, both latent and manifest ones⁴4 Machado JA. Pacto de Gestão na saúde: Até onde esperar uma regionalização solidária e cooperativa? In: Hochman G. Federalismo e Políticas Públicas no Brasil. Rio de Janeiro: Fiocruz; 2013. p. 279-300..

The period of severe political, social and moral disturbance, with the reinforcement of the false dilemma of capitalism that praises fiscal austerity and reduces the guarantee of social rights, fall upon the underfunding of SUS, aimed to suffocate constitutional rights, through the financial route⁵5 Santos L. SUS-30 anos: um balanço incômodo? Cien Saude Colet 2018; 23(6):2043-2050.. The Constitutional Amendment (CA) 95/2016, the current economic goals and scenario point to the intention of dismantling SUS⁶6 Paim JS. Sistema Único de Saúde (SUS) aos 30 anos. Cien Saude Colet 2018; 23(6):1723-1728., aggravating the chronic public underfunding of health.

The challenges of regionalization demand more effective public policies and institutional environments more geared toward cooperation⁷7 Viana ALDA, Bousquat A, Melo GA, Negri Filho A, Medina MG. Regionalização e Redes de Saúde. Cien Saude Colet 2018; 23(6):1791-1798.; however, tendencies to increase disputes over financial resources between managers have been identified, creating difficulties for a cooperative and solidary regional logic.

The political weight⁸8 Oliveira MS, Artmann E. Regionalização dos serviços de saúde: desa?os para o caso de Angola. Cad Saude Publica 2009; 25(4):751-760. and the complexity of regionalizing a health system are emphasized by the challenges related to consensus generation, the construction of collective decision-making mechanisms, distribution of resources and the interaction between the actors⁹9 Fleury S, Ouverney A. Gestão de redes: a estratégia de regionalização da política de saúde. Rio de Janeiro: FGV; 2007.. Above all, it can be verified that the SUS underfunding crisis scenario emerges as a catalyst of conflicts and intense disputes. Therefore, the focus was placed on consensus building in a decision-making space, where power asymmetries predominated.

The Collegiates of Regional Management represented a health policy innovation, but their constitution was gradual and slow in some regions of the country, and the political coordination and execution modes of the regional network are not treated to their satisfaction and show a vast complexity¹⁰10 Viana ALDA, Lima LD, Ferreira MP. Condicionantes estruturais da regionalização na saúde: tipologia dos Colegiados de Gestão Regional. Cien Saude Colet 2010; 15(5):2317-2326..

Such Collegiates were replaced by the Regional Inter-manager Commissions (CIR), created by Decree 7508/2011, as an instance for SUS regional management, specifically for the decision-making process and consensus-building policy to strengthen regionalization.

Considering the interdependence and variety of the involved actors, in which participants preserve their autonomy, the objectives and strategies must be established as a result of the consensus obtained through negotiation processes, which can be too slow⁹9 Fleury S, Ouverney A. Gestão de redes: a estratégia de regionalização da política de saúde. Rio de Janeiro: FGV; 2007..

This is enhanced by highlighting the characteristics of metropolitan regions, the demographic importance, the concentration and polarization of health resources and the inequality and complexity found in the territory. It is impossible to have a single regionalization model for the country, and it is necessary to analyze the specific processes of regionalization implementation in the states, considering that there are very significant differences between the entities and their own territorial dynamics, which should be taken into account, such as the metropolitan areas¹¹11 Viana ALDA, Lima, LD. O processo de regionalização na saúde: contextos, condicionantes e papel das Comissões Intergestores Bipartites. In: Viana ALDA, Lima, LD. Regionalização e relações federativas na política de saúde do Brasil. Rio de Janeiro: Contra Capa; 2011. p. 11-24.. International experiences indicate the articulated development between decentralization and regionalization, different from the process identified in Latin America and Brazil¹²12 Lima LD, Viana ALA, Machado CV, Albuquerque MV, Oliveira RG, Iozzi FL, Scatena JHG, Mello GA, Pereira AMM, Coelho APS. Regionalização e acesso à saúde nos estados brasileiros: condicionantes históricos e político-institucionais. Cien Saude Colet 2012; 17(11):2881-2892.. Studies on the topic in Spain¹³13 Pereira AMM, Lima DL, Machado CV, Freire JM. Descentralização e regionalização em saúde na Espanha: trajetórias, características e condicionantes. Saúde Debate 2015; 39(esp.):11-27.^,1414 Pereira AMM, Lima DL, Machado CV. Descentralização e regionalização da política de saúde: abordagem histórico-comparada entre o Brasil e a Espanha. Cien Saude Colet 2018; 23(7):2239-2251. and Angola⁸8 Oliveira MS, Artmann E. Regionalização dos serviços de saúde: desa?os para o caso de Angola. Cad Saude Publica 2009; 25(4):751-760. address different elements of regionalization, but do not specify the decision-making process between managers in the health regions of metropolitan scenarios. There is a scarcity of studies analyzing the influence of SUS underfunding on negotiation and agreement processes between managers in metropolitan territories. Publications on the health sector and metropolitan areas that addressed financing, planning and intermunicipal consortia were identified¹⁵15 Mendes A. Saúde Pública subfinanciada: até quando suportaremos? Em defesa do SUS universal e igualitário. Le Monde Diplomatique, Ministério da Saúde (MS), Conselho Nacional de Saúde (CNS), Organização Pan-americana de Saúde (OPAS). 2015. [acessado 2016 Maio 30]. Disponível em: http://www.abrasco.org.br/site/wp-content/uploads/2015/12/encarte-SUS-le-monde.pdf
http://www.abrasco.org.br/site/wp-conten...

16 Lara NC, Mendes A. A regionalização e o financiamento do SUS na Região Metropolitana da Baixada Santista do Estado de São Paulo. Rev Fac Ciên Med Sorocaba 2015; 17(1):37-42.^-1717 Geremia DS. Federalismo e gestão metropolitana para o planejamento territorial dos serviços de saúde [tese]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2015., but they did not focus on the construction of SUS consensus and agreement in metropolitan regions. In these territories, following the same patterns of asymmetrical relations that occur between the federated entities in Brazil, consensuses can become a veiled form of concentration of authority in the larger municipalities, since the others will have neither the resources nor the political strength to disagree¹1 Dourado DA, Elias PEM. Regionalização e dinâmica política do federalismo sanitário brasileiro. Rev Saude Publica 2011; 45(1):204-211..

The consolidation of the collegiate management is related to the decision-making process, presuming that there should be no pre-established hierarchy and that the negotiation, aiming at cooperation between the actors aiming at consensus building, is the main rule¹⁸18 Silva SF. Redes de atenção à saúde no SUS: proposta de operacionalização. In: Silva SF, organizador. Redes de atenção à saúde: desafios da regionalização no SUS. Campinas: Saberes; 2013. p. 201-249.. However, structural conflicts and the correlation of asymmetric forces cannot be ignored, since there is an unmistakable separation between simple agreement and rational consensus, as well as between a false accommodation of conflicts and mobilization¹⁹19 Bahia L. Afinidades comunicativas e as políticas de saúde no Brasil. Cien Saude Colet 2010; 15(5):2281-2282.. It constitutes a political process that involves changes in the distribution of power and the establishment of interrelationships between different social actors⁷7 Viana ALDA, Bousquat A, Melo GA, Negri Filho A, Medina MG. Regionalização e Redes de Saúde. Cien Saude Colet 2018; 23(6):1791-1798..

The “consensual decision” is an expression present in normative documents and used by managers and technicians when referring to the type of decision in regional inter-managerial instances. However, it is necessary to analyze the construction of the consensus, showing what supports the decision and the agreement between the actors who are in the decision arena. This analysis requires the differentiation between an action of understanding, based on communicative action, and an activity oriented towards an end, based on strategic action. Therefore, the concepts of the Theory of Communicative Action²⁰20 Habermas J. Relaciones con el mundo y aspectos de la racionalidade de la acción en cuatro conceptos sociológicos de acción. In: Habermas J. Teoria de la acción comunicativa I. Madrid: Taurus; 1987. p. 110-146.^,2121 Habermas J. Pensamento pós-metafísico: estudos filosóficos. Rio de Janeiro: Tempo Brasileiro; 1990. and the Strategic Thinking in Health are activated²²22 Testa M. Pensar em Saúde. Porto Alegre: Artes Médicas; 1992.^,2323 Testa M. Pensamento estratégico e lógica de programação: o caso da saúde. São Paulo, Rio de Janeiro: Hucitec, Abrasco; 1995..

The teleological action is guided towards the fulfillment of a purpose and can become a strategic action when the actor turns towards attaining their success and the action aims at achieving a certain end, guiding themselves and influencing the decisions of other actors. The communicative action refers to the interaction between at least two actors who establish an interpersonal relationship and seek to understand a situation to coordinate their plans and actions and reaching a consensus by negotiating the definitions of the situation²⁰20 Habermas J. Relaciones con el mundo y aspectos de la racionalidade de la acción en cuatro conceptos sociológicos de acción. In: Habermas J. Teoria de la acción comunicativa I. Madrid: Taurus; 1987. p. 110-146..

According to Habermas²¹21 Habermas J. Pensamento pós-metafísico: estudos filosóficos. Rio de Janeiro: Tempo Brasileiro; 1990., the types of interaction are differentiated according to the action coordinating mechanism, and it is necessary to know whether language is used as a means of transmitting information, characterizing the strategic action; or as a source of social integration, dealing with the communicative action. In the strategic action, the coordination effect depends on the influence of the actors on each other and on the situation²¹21 Habermas J. Pensamento pós-metafísico: estudos filosóficos. Rio de Janeiro: Tempo Brasileiro; 1990..

An agreement, according to Testa²³23 Testa M. Pensamento estratégico e lógica de programação: o caso da saúde. São Paulo, Rio de Janeiro: Hucitec, Abrasco; 1995., is the result of a negotiation, in which each of the actors interested in the topic being discussed expresses their opinions, complaints or proposals. There are different levels of agreement, with a greater or lesser degree of concordance between the different social actors and the decision will be either made by majority or by imposition of the allied groups that have greater mobilizing power²³23 Testa M. Pensamento estratégico e lógica de programação: o caso da saúde. São Paulo, Rio de Janeiro: Hucitec, Abrasco; 1995..

This article analyzes the process of consensus building and agreement between SUS managers in Regional Inter-manager Commissions (CIR) of two metropolitan scenarios in the Northeast of Brazil.

Method

This was a multiple case study for the comparative analysis of two different regions in northeastern Brazil, which provides the opportunity to analyze contrasting situations and produce more powerful conclusions than those from a single isolated case²⁴24 Yin RK. Estudo de caso: planejamento e métodos. Porto Alegre: Bookman; 2010.. The Brazilian states of Bahia and Ceará were selected as cases, because important contrasts were identified in them regarding the SUS regionalization process¹⁰10 Viana ALDA, Lima LD, Ferreira MP. Condicionantes estruturais da regionalização na saúde: tipologia dos Colegiados de Gestão Regional. Cien Saude Colet 2010; 15(5):2317-2326.^,1212 Lima LD, Viana ALA, Machado CV, Albuquerque MV, Oliveira RG, Iozzi FL, Scatena JHG, Mello GA, Pereira AMM, Coelho APS. Regionalização e acesso à saúde nos estados brasileiros: condicionantes históricos e político-institucionais. Cien Saude Colet 2012; 17(11):2881-2892.^,2525 Lima LD, Queiroz LFN. Processo de descentralização e regionalização do SUS no contexto do Pacto pela Saúde. In: Machado CV, Baptista TWF, Lima LD, organizadores. Políticas de Saúde no Brasil: continuidades e mudanças. Rio de Janeiro: Fiocruz; 2012. p. 229-252.^,2626 Viana ALDA, Lima LD, organizadores. Regionalização e relações federativas na política de saúde do Brasil. Rio de Janeiro: Contra Capa; 2011..

After selecting the states, it was verified that the Metropolitan Regions of Salvador and Fortaleza (capital cities of the states of Bahia and Ceará, respectively) had their municipalities subdivided into more than one health region. The health regions of the capitals were chosen because they were mainly constituted by metropolitan municipalities and for concentrating secondary and tertiary health services with influence over the entire state territory.

For data production, in-depth interviews were combined with direct observation and documental analysis. The fieldwork took place from July to November 2014 (in Ceará) and July 2014 to September 2015 (in Bahia).

A total of 42 semi-structured interviews were carried out with two representatives of the State Health Councils, one supporter of the Ministry of Health, 12 municipal managers, 6 regional managers and 14 state health managers, totaling 35 participants (14 in Ceará and 21 in Bahia). It was not possible to interview 3 municipal health secretaries in the health region of Salvador.

Meetings of the CIR, the Bipartite Inter-manager Commission (CIB) and the Council of Municipal Health Secretaries (COSEMS) were attended in person, totaling ten in Bahia and nine in Ceará. In the first case, there were separate meetings involving, respectively, the municipalities of the 1^st (Salvador) and 2^nd (Camaçari) health regions. In Ceará, there were joint meetings with 11 municipalities of the 1^st (Fortaleza) and 22^nd (Cascavel) health regions.

The documental analysis included resolutions, internal regulations and minutes of CIR meetings and focused on the organization and operations of the CIR, as well as information that supported the analysis of the regionalization process and regional management in the assessed cases.

The data analysis plan, focused on the understanding of the decision-making process of managers and the tensions within the core of actions and interactions, was based on Testa’s strategic thinking²²22 Testa M. Pensar em Saúde. Porto Alegre: Artes Médicas; 1992.^,2323 Testa M. Pensamento estratégico e lógica de programação: o caso da saúde. São Paulo, Rio de Janeiro: Hucitec, Abrasco; 1995.. The approach and problematization of data related to the dialogue and consensus production in inter-managerial relations was based on Habermas’s theory of communicative action²⁰20 Habermas J. Relaciones con el mundo y aspectos de la racionalidade de la acción en cuatro conceptos sociológicos de acción. In: Habermas J. Teoria de la acción comunicativa I. Madrid: Taurus; 1987. p. 110-146.^,2121 Habermas J. Pensamento pós-metafísico: estudos filosóficos. Rio de Janeiro: Tempo Brasileiro; 1990..

The content of the interviews was coded according to categories and descriptors of the analysis plan and processed following a comparative logic of the studied cases, from state, municipal, regional and federal actors. Then, the triangulation process was performed through cross-sectional and comparative analysis of data extracted from different sources (interviews, observations and documents). We sought to identify convergences and divergences between the managers and the analyzed metropolitan contexts.

The research project was approved by the Research Ethics Committee.

Results and discussion

The normative induction and the struggle for financial resources

In the metropolitan cases of Salvador and Fortaleza, as identified in Miranda’s studies²⁷27 Miranda AS. Análise estratégica dos arranjos decisórios na Comissão Intergestores Tripartite do Sistema Único de Saúde [tese]. Salvador: Universidade Federal da Bahia; 2003.^,2828 Miranda AS. Processo decisório em Comissões intergestores do Sistema Único de Saúde: governabilidade resiliente, integração sistêmica (auto)regulada. Rev Politica Planejamento e Gestão Saúde 2010; 1(1):117-139., a consensus is the product of a normative premise, which conditions behavior, or of a symbolic convention in which the actors often decide and make agreements, very often mortified by the imperatives of the system, of time, and of established power relations.

Furthermore, the reports signal an effort to build the consensus as a positive, advanced and innovative process of the SUS inter-management commissions, from the point of view of forums that bring together the federated entities. On the other hand, they establish limits for some advances, given the existing divergent and very conflicting positions, requiring the realignment of proposals and opinions to reach a consensus. According to one of the respondents it is necessary to reduce, cut, resize; this is in the nature of consensus building. Someone has to give in. Thus, the search for a consensus requires political mediation, the implementation of a compromise between the parties involved in the decision-making arrangements, so that everyone gives in to their initial positions to reach an agreement on an intermediate proposal²⁷27 Miranda AS. Análise estratégica dos arranjos decisórios na Comissão Intergestores Tripartite do Sistema Único de Saúde [tese]. Salvador: Universidade Federal da Bahia; 2003..

During consensus building, structural conflicts and the correlation of asymmetric forces cannot be ignored¹⁹19 Bahia L. Afinidades comunicativas e as políticas de saúde no Brasil. Cien Saude Colet 2010; 15(5):2281-2282.. Negotiations and pacts are permeated by conflicts arising from asymmetries between the entities, contributing to the intensification of tensions in the inter-managerial relations, especially regarding the dispute for the provision of financial resources.

The process of negotiation and consensus building in the CIR is restricted by the conflicting “struggle for resources” between municipal managers, whose interests are guided by the SUS underfunding. These conflicts can be conceived as the most direct and evident expression of opposing interests and indirect indicators of the existing contradictions²⁷27 Miranda AS. Análise estratégica dos arranjos decisórios na Comissão Intergestores Tripartite do Sistema Único de Saúde [tese]. Salvador: Universidade Federal da Bahia; 2003..

Conflicts for power and financial resources are typical of the federative system and intergovernmental relations²⁹29 Souza C. Regiões Metropolitanas: trajetória e influência das escolhas institucionais. In: Ribeiro LCQ, organizador. Metrópoles: entre a coesão e a fragmentação, a cooperação e o conflito. São Paulo, Rio de Janeiro: Fundação Perseu Abramo, FASE; 2004. p. 61-96.. The construction and maintenance of a political system focused on the division of territorial power, both political and tributary, without an imbalance between the entities is an intrinsically contradictory task, generating conflicts and tensions²⁹29 Souza C. Regiões Metropolitanas: trajetória e influência das escolhas institucionais. In: Ribeiro LCQ, organizador. Metrópoles: entre a coesão e a fragmentação, a cooperação e o conflito. São Paulo, Rio de Janeiro: Fundação Perseu Abramo, FASE; 2004. p. 61-96..

It is worth noting that the PPI (Pactual and Integrated Programming) and financing were recognized by the respondents as especially controversial topics or barriers to building a consensus. In fact, in both assessed scenarios, they were shown to be marked sources of tension and conflict creation within the SUS regional management.

In the metropolitan scenarios of Salvador and Fortaleza, underfunding showed to be a constraint for the regional management, as it emerged as the basis of the conflicting relationship between managers, reflecting on the possibilities of regionalizing services. The respondents indicated the need for greater decentralization of resources and revision of the logic of financing as a condition for effective regionalization, considering the difficulties of providing services to a health region, with more concentrated costs in a municipality.

These aspects reinforce, among others, the need for financing to be also thought and defined regionally and not only focused on specific municipalities. The current financing logic and the constraints imposed on the SUS contribute for the decision-making interests and criteria to be predominantly based on a competitive financial dimension, with an impact on the negotiation and agreement process operated in the regional inter-managerial instances, conceived as a synonym of mercantilism, money exchange or street fair, to the detriment of processes based on solidary responsibility. It is noteworthy that such arguments were more frequent and stressed in the interviews carried out in the state of Bahia.

There is a game of losses and gains that becomes more evident at the moment of decision-making regarding resource transfers, as the decentralization of public policies, by predicting transfers of financial resources and government burdens, further exacerbates the conflicts and disputes³⁰30 Guimarães ML. Processo decisório e conflitos de interesse na implementação da descentralização da saúde: um estudo das instâncias colegiadas na Bahia. Caderno CRH 2003; 39:105-132..

There is a predominance of logic focused on financial resources as the defining point of the conversation and dialogue, elements of communication and the relationship between managers, disclosed in several reports: “You cannot sit down to talk without saying how much money is coming, because for the people, that’s their reasoning!”; “The relationship is based on the financial aspect, on the financing. If we don’t have it, we can’t regionalize!”; “ALWAYS (speaks with emphasis) , every conversation ends in financing!”

The findings agree with the results of the study by Machado⁴4 Machado JA. Pacto de Gestão na saúde: Até onde esperar uma regionalização solidária e cooperativa? In: Hochman G. Federalismo e Políticas Públicas no Brasil. Rio de Janeiro: Fiocruz; 2013. p. 279-300., regarding the perception that the previous allocation of resources to serve the mentioned population in the reference municipalities would not be a sufficient condition for solidary motivations to overcome the self-interested conducts of the actors seeking an agreement. On the other hand, it is also important to consider that the Brazilian federative fiscal structure and the SUS underfunding can be considered fundamental indicators for this situation.

In Federal States, there are conflicts and disputes in the implementation of policies, generated even after the decision to decentralize, especially regarding the process of transferring resources from the federal level to states and municipalities³⁰30 Guimarães ML. Processo decisório e conflitos de interesse na implementação da descentralização da saúde: um estudo das instâncias colegiadas na Bahia. Caderno CRH 2003; 39:105-132.. In Brazil, there are municipalities with little possibility of taxation and that depend, to a greater degree, on resources from other levels to provide basic public services³¹31 Rodrigues R, Elias PEM, Dourado DA, Vianna PVC, Bousquat AEM. Federalismo, relação público-privado e gasto público em saúde no Brasil. Rev Politica Planejamento e Gestão Saúde 2010; 1(1):141-156..

This scenario delineates asymmetrical conditions and relationships, which are reproduced in the struggle for financial resources in negotiations and agreements between managers in regional decision-making instances, making decisions tend towards those with greater technical, administrative and political power. This is expressed in the speech of one of the respondents, stating that certain stronger actors, whether due to technical or political characteristics, impose themselves more and end up influencing all others. In Bahia, there were reports affirming the reproduction of this tendency not only in the regional inter-manager instances but also state instances.

Between the strategic and the communicative: what agreement or (dis) agreement are we dealing with?

The consensus requires the differentiation between an action of understanding, based on communicative action, and an activity oriented towards an end, based on a strategic action²¹21 Habermas J. Pensamento pós-metafísico: estudos filosóficos. Rio de Janeiro: Tempo Brasileiro; 1990.. It is observed that the consensus would require the actors, involved in the interaction, to talk, dialogue, understand and decide based on the shared understanding of the situation. However, this characterization did not emerge from the respondents.

The managers’ reports about decisions by consensus showed that they did not result from exhaustive dialogue processes that were guided by technical criteria or basic principles of the SUS. Overall, the consensus seemed to be associated with financial resources, political issues, tacit agreements or to accommodate hostilities, but that in daily life, after that formal decision-making space, would not be fulfilled.

A teleological game is established, in which an end-oriented activity is identified, rather than an action of understanding²¹21 Habermas J. Pensamento pós-metafísico: estudos filosóficos. Rio de Janeiro: Tempo Brasileiro; 1990.. There is no recognition that what has been said is true and there are inconsistencies between having a consensus and everyone agreeing to do so, as consensually agreed. There are also difficulties in understanding and/or lack of dialogue between the managers, with damage to the illocutionary effect, based of which they could understand and accept the speech actions, concentrated on the use of information in the consensus spaces and on the construction of the PPI, constituting the differences in technical power between the managers.

The agreement was expressed as a ritual of formality to be performed, but without a greater process of discussion and understanding of the situation, aiming to build the resolution of regional problems and needs. The use of information in this agreement format demonstrates something much more informative and unidirectional, contributing to the fact that formal agreements do not work, only fulfill a notarial role.

In both states, respondents converged on statements regarding non-compliance with PPI and formalized agreements on management instruments, including suggesting the need for coercive measures to enforce compliance with the signed agreements and consensuses: “He does not comply with them, no one enforces them. Why am I going to reach a consensus here, am I going to comply with it?”; “What he hired was very different from what was predicted in the PPI”; “We cannot get a mechanism to follow and make the managing municipality comply.” A game is revealed between different actors and levels of government, with different degrees of power, showing that the consensus is far from being repeated when the policy is implemented³⁰30 Guimarães ML. Processo decisório e conflitos de interesse na implementação da descentralização da saúde: um estudo das instâncias colegiadas na Bahia. Caderno CRH 2003; 39:105-132..

We observe stratagems to increase the financial ceiling of the municipality and to breach the agreed consensuses, with the strategic action prevailing over the communicative action. One must recall that the end-oriented rationality and understanding-oriented rationality are not interchangeable²¹21 Habermas J. Pensamento pós-metafísico: estudos filosóficos. Rio de Janeiro: Tempo Brasileiro; 1990..

Evidence indicates that, at the formal moment when the agreements are established, there are many more assertions about achieving one’s success in the negotiation, which is the allocation of the resource within its financial ceiling and of the service in one’s territory, but without guarantees of compliance with the agreed pact. That is, the truth of speech is not identified, nor the use of the language for the shared understanding of the situation, proper aspects of communicative action.

The emergence of speeches alluding to a “financial rationality”, “free market”, “money exchange” Habermas²¹21 Habermas J. Pensamento pós-metafísico: estudos filosóficos. Rio de Janeiro: Tempo Brasileiro; 1990. considerations are disclosed about the money-driven market model, in which strategic action can be maintained as a concept of action that is appropriate for the means of direction. The information that flows through the money code limits the action decisions, due to a preference structure, without the need to appeal to riskier, value-oriented perceptions of understanding²¹21 Habermas J. Pensamento pós-metafísico: estudos filosóficos. Rio de Janeiro: Tempo Brasileiro; 1990..

The types of interaction differ according to the action coordinating mechanism. If in communicative acting the consensual force of linguistic understanding becomes effective to coordinate actions, in strategic acting, the effect of coordination depends on the influence of the actors on each other and on the situation²¹21 Habermas J. Pensamento pós-metafísico: estudos filosóficos. Rio de Janeiro: Tempo Brasileiro; 1990.. By focusing the evidence under the view of the types of interaction described by Habermas, it can be affirmed that the agreements defined between managers do not result from the motivating understanding of conviction, typical of the communicative action. They are the product of the influence that induces behavior, typical of the strategic action, in which there is reciprocal influence of actors, who are positioned one in relation to the other, guided by success²¹21 Habermas J. Pensamento pós-metafísico: estudos filosóficos. Rio de Janeiro: Tempo Brasileiro; 1990..

One can identify that, in the metropolitan scenarios of Fortaleza and Salvador, as well as in the study by Miranda²⁷27 Miranda AS. Análise estratégica dos arranjos decisórios na Comissão Intergestores Tripartite do Sistema Único de Saúde [tese]. Salvador: Universidade Federal da Bahia; 2003., the consensus resulted from negotiations engendered from strategic actions. When problematizing these consensuses, also called agreements or pacts, which are decided between the managers, peculiar interpretations are revealed from the viewpoint of Testa or that of Habermas. Both show considerations that guide the analysis of the empirical, finding possible elements for the breach of the pacts and (dis) agreements.

According to Testa²³23 Testa M. Pensamento estratégico e lógica de programação: o caso da saúde. São Paulo, Rio de Janeiro: Hucitec, Abrasco; 1995., an agreement is the result of a negotiation, in which each of the actors interested in the topic under discussion expresses their opinion, complaints or proposals. It is evident that such agreements are weakened in decision-making dynamics characterized by political, technical and administrative asymmetries that affect the ability to negotiate, manifest and listen to the opinions and proposals of managers from different municipalities, especially small ones.

There are different levels of consensuses, in which there may be agreement or disagreement between the different social actors and the decision will be made by the majority or by imposition of the allied groups that have greater mobilizing power²³23 Testa M. Pensamento estratégico e lógica de programação: o caso da saúde. São Paulo, Rio de Janeiro: Hucitec, Abrasco; 1995.. This type of agreement, different from the consensus based on true dialogue and understanding, is present in the reality of the CIRs of the investigated metropolitan scenarios, especially in CIR Salvador, considering the reports of different managers stating the decision by the majority. However, this type of decision-making has not converged with their fulfillment in daily life. According to reports from two respondents from Bahia, what you say is different from what you do and it is not through the majority that you will prosper, as you want to approve decisions that you expect everyone will put into practice.

According to Habermas²¹21 Habermas J. Pensamento pós-metafísico: estudos filosóficos. Rio de Janeiro: Tempo Brasileiro; 1990., an agreement cannot be imposed from the outside or forced by either party, either through direct intervention in the situation or indirectly through influence. For this author, what is obtained through rewards, threat, suggestion or deception cannot be intersubjectively valid as an agreement, and such an intervention harms the conditions under which illocutionary forces awaken convictions. Therefore, the agreed pacts or agreements tend to be weakened and disregarded, as they were not motivated by convictions but by influences, deceptions, gratifications or threats.

There is an unequivocal separation between mere agreement and rational consensus, as well as between an illusory accommodation of conflicts and mobilization, representing the centrality of power and the need to clarify its constitution, with a concern based on the politician’s specificity¹⁹19 Bahia L. Afinidades comunicativas e as políticas de saúde no Brasil. Cien Saude Colet 2010; 15(5):2281-2282.. In this sense, it is worth explaining singularities that emerged during the interviews in both states. In Ceará, some respondents mentioned political-partisan aspects, but without associating them to the agreement. In Bahia, many reports emphatically pointed out the relations between political-partisan electoral elements and the inter-managerial agreement process.

Such evidence shows that the agreement is not necessarily explicit, so that the actors continue to maintain their viewpoints, declaring themselves defeated but not convinced²³23 Testa M. Pensamento estratégico e lógica de programação: o caso da saúde. São Paulo, Rio de Janeiro: Hucitec, Abrasco; 1995.. Situations in which language only fulfills information functions are perceived, when consensus building is removed from the understanding, so that the validity of the utterance cannot be directly understood, and the action of speech is only exhortation in appearance²¹21 Habermas J. Pensamento pós-metafísico: estudos filosóficos. Rio de Janeiro: Tempo Brasileiro; 1990.. Therefore, the discussion and consensual pacts in the collective spaces of regional management may not correspond to the managers’ daily actions.

The true intentions or interests are not explicit, with latent strategic action and omissions being observed. These intentions or interests that underlie the decisions between these managers, but are not verbalized, converge with financial aspects and electoral political-partisan intentions, which are part of the invisible networks, hidden “in the tacit agreements” and in the shadows of opacity, a characteristic that permeates power relations²³23 Testa M. Pensamento estratégico e lógica de programação: o caso da saúde. São Paulo, Rio de Janeiro: Hucitec, Abrasco; 1995..

The testimonies of municipal, state and regional managers in Bahia indicate that, in informal spaces and inter-managerial instances of regional management, the telos of speech and action-relation between them connects to electoral purposes and, in some cases, to disputes for financial resources. Evidence shows that the basis of negotiation and consensus outlined in the process of agreeing upon services and procedures is directed by electoral and financial political-partisan intentionality, to the detriment of basic principles such as citizens’ universal access to the different levels of the technological density of SUS.

In Minas Gerais, we simultaneously identified a conflicting bargaining game in intergovernmental relations and a game of electoral success in each municipality, both with the purpose of obtaining electoral gains⁴4 Machado JA. Pacto de Gestão na saúde: Até onde esperar uma regionalização solidária e cooperativa? In: Hochman G. Federalismo e Políticas Públicas no Brasil. Rio de Janeiro: Fiocruz; 2013. p. 279-300.. There was also the crossing-over of partisan policies in the management of a health region in the countryside of Bahia³²32 Santos AM. Gestão do cuidado na microrregião de saúde de Vitória da Conquista (Bahia): desafios para constituição de rede regionalizada com cuidados coordenados pela Atenção Primária à Saúde [tese]. Rio de Janeiro: Escola Nacional de Saúde Pública Sérgio Arouca; 2013..

Final considerations

There certainly have been advances along the implementation of SUS, but challenges still need to be overcome in different areas, including the decision-making process built in the CIRs. It is necessary to confront the naïve perception of the consensus, under penalty of the uncritical incorporation of the so-called transforming elements that are merely reformism, as they preserve the past by overcoming it, obfuscating the real situation.

There is an effort to build a consensus, considered a positive and innovative process of SUS inter-managerial committees, from the point of view of forums that bring together federated entities in Brazil. However, the consensus emerged associated to a normatively induced obligation and dependent on ministerial deadlines, and not necessarily linked to a process of dialogue or understanding, nor the product of technical criteria privileging regional equity and other fundamental principles of the SUS.

The problems related to PPI and SUS underfunding were the converging points between the state and metropolitan scenarios studied. Such problems are intertwined and affect the relationship between the federated entities, pointing out the dispute for resources as an obstacle to the agreement and consensus building based on dialogue and understanding.

It can be observed that the pacts or agreements built between managers are based on influence, deceit, rewards and / or threats, controlled by the bias of obtaining or cutting resources and financial incentives, as well as the possible electoral and political-partisan gains, not being primarily motivated by beliefs or shared understanding of the situation, according to the assumptions of communicative action. The managers’ strategic action is thus constituted, in which the illocutionary force of understanding and acceptance is lost, with the acceptance of the alleged (dis) agreement being motivated by influences outside the language and by claims of power, not by claims of validity.

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