Abstract

This paper aimed to identify the thinking currents used for scientific production on health councils and conferences, from 1990 to 2017. This is an integrative review of literature carried out at the SciELO, LILACS and CAPES journals portals that resulted in the selection of 152 papers. They were analyzed by year of publication, author’s institutional origin, dissemination media, object and type of study and theoretical approach. We identified that a gradual increase occurred in the number of publications over the study period and most empirical studies (92.8%) do not explicitly state the use of any theoretical approach in data analysis. The structuralist, post-structuralist and neo-institutionalist approaches used were mediated by a theoretical model, medium-range theories and concepts of authors of the European, North American and Latin American traditions. The knowledge produced about health council and conference in Brazil may benefit even more from the density of theoretical approaches to social and political sciences.

Key words:
Health Councils; Health Conferences; Participation; Knowledge

Introduction

As the achievement of the right to health, health councils and conferences stem from the political action of the Brazilian Health Reform movement (RSB)¹1 Paim JS. Reforma sanitária brasileira: Contribuição para a compreensão e crítica. Salvador: EDUFBA, Rio de Janeiro: Fiocruz; 2010.. The RSB movement’s dialogue dynamics in the power spaces, in both the Constitution and Law 8,142/90, has imprinted these arenas of participation in the political process of health policy planning and management, with the indispensability of social actors. Thus, health councils and conferences are open channels for the participation of civil society in the definition and conduct of health policies, and are a step forward in the democratization of this policy²2 Bispo Junior JP. Participação social e relações de poder no Conselho Estadual de Saúde da Bahia [tese]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca; 2013..

In the Unified Health System (SUS), health councils and conferences are a formal exercise of community participation in the construction of health policies. With the perspective of expressing the social and health demands of the population, the conferences define the principles and guidelines that should guide the whole process of formulating health policies. On the other hand, health councils consolidate the decisions defined in the conferences, formulating and strengthening health policies and establishing strategies to enforce, evaluate and control the execution of these policies by the Executive Branch³3 Oliveira TA. Participação do Conselho e das Conferências de Saúde no ciclo da Política Estadual de Saúde Mental (Bahia, 2001-2013) [dissertação]. Salvador: Universidade Federal da Bahia; 2015..

The significant amount of these formal spaces for participation in the country indicates greater possibilities for the democratization of health, along the lines of deliberative democracy, while at the same time stirring the growing interest of researchers⁴4 Labra ME. Política Nacional de Participação na Saúde: entre a utopia democrática do controle social e a práxis predatória do clientelismo empresarial. In: Fleury S, Lobato LVC, organizadores. Participação, democracia e saúde. Rio de Janeiro: Cebes; 2010. p. 176-203.^,55 Serapioni M. Os desafios da participação e da cidadania nos sistemas de saúde. Cien Saude Colet 2014; 19(12):4829-4839.. Since its institutionalization in 1990, the qualified spheres of affirmation of the right to health in Brazil have been widely debated in the scientific literature, mainly regarding the realms of representation, participation modes, interests advocated in these spaces, internal dynamics of functioning and studies evidencing the limits and potentialities of these collegiate bodies⁶6 Bispo Junior JP, Gerschman S. Legitimidade da representação em instâncias de participação social: o caso do Conselho Estadual de Saúde da Bahia, Brasil. Cad Saúde Pública 2015; 31(1):183-193.

7 Farias Filho MC, Silva AN, Mathis A. Os limites da ação coletiva nos Conselhos Municipais de Saúde. Cien Saude Colet 2014; 19(6):1911-1919.

8 Oliveira LC. As práticas de participação institucionalizadas e sua interface com a cultura política: um olhar sobre o cotidiano de um conselho municipal de saúde no nordeste brasileiro [tese]. Rio de Janeiro: Universidade Estadual do Rio de Janeiro; 2006.^-99 Espiridião MA. Controle social do SUS: conselhos e conferências de saúde. In: Paim JS, Almeida Filho N. Saúde coletiva: teoria e prática. Rio de Janeiro: MedBook; 2014..

Literature reviews on the subject, among other things, allowed systematizing the main factors related to the institutionalization process of participation arenas, academia’s understanding of society’s participation in the health area, and the realms of participation already studied¹⁰10 Cavalcanti MLT, Cabral MHP, Antunes LR. Participação em saúde: uma sistematização de artigos publicados em periódicos brasileiros - 1988/2005. Cien Saude Colet 2012; 17(7):1813-1823.

11 Rolim LB, Cruz RSBLC, Sampaio KJAJ. Participação popular e o controle social como diretriz do SUS: uma revisão narrativa. Saúde Debate 2013; 37(96):139-147.

12 Bastos Filho RA, Cunha WA, Oliveira AR. Conselhos Gestores de Saúde no Brasil: uma meta-análise da produção científica a partir da 12ª Conferência Nacional de Saúde. Rev Adm Roraima 2015; 5(2):164-188.

13 Paiva FS, Stralen CJ, Costa PHA. Participação social e saúde no Brasil: revisão sistemática sobre o tema. Cien Saude Colet 2014;19(2):487-498.

14 Maeyama MA, Bertucci FMD, Loblein JP, Dolny LL, Nilson LG, Munaro CA, Cutolo LRA. Participação social na saúde no Brasil - revisão integrativa. Rev Bras Tecnol Soc 2016; 3(1):23-36.

15 Melo RC, Possa LB. Democracia no SUS, como estamos? Um debate sobre a participação social a partir da literatura recente. Saúde Redes 2016; 2(4):393-408.^-1616 Gomes ACS, Carvalho FR, Bernardo GN, Oliveira LDC, Lima TS, Mendes MM. O papel das ouvidorias e dos conselhos de saúde no SUS: uma revisão integrativa de literatura. Rev Eletr Gestão Saúde 2017; 8(1):140-161.. However, the main theoretical and methodological approaches that have been used in the studies on the subject have not yet been systematized.

Showing how scientific production on health councils and conferences appropriates theoretical currents to think and analyze the concrete reality of these participative spheres is the challenge ahead, especially in the current situation of disrespect to these collegiate bodies, whose participation has been dispensed with in the reformulation of specific health policies¹⁷17 Observatório de Análise Política em Saúde (OAPS). Mudanças na Política Nacional de Saúde Mental: participação social atropelada, de novo [Internet]. 2018 [acessado 15 Mar 2018]. Disponível em: https://www.analisepoliticaemsaude.org/oaps/boletins/edicoes/31/#114
https://www.analisepoliticaemsaude.org/o... . This study proposes to pave the way in this perspective and, while not pretending or even having the competence to exhaust the theoretical debate on the theme, sought to identify the thinking currents used for scientific production on health councils and conferences, pointing out their potential in addressing with the analysis of the areas of dispute of health councils and conferences.

Methods

This is an integrative literature review that sought to answer the following question: what are the theoretical-methodological references used and explained in studies on health councils and conferences in Brazil, published between 1990 and 2017? The date of onset of the time-related selection corresponds to the year of institutionalization of health councils and conferences in Brazil through Law 8,142/1990, while 2017 was the final period of the research.

The search was initiated in March 2014 and updated annually until May 2017. In the search updates made in 2015, 2016 and 2017, the variable year of publication was filtered considering the period between the year of the last collection until that moment. In the SciELO, LILACS and CAPES journals portal, descriptors used were “participação social”, “participação cidadã”, “participação comunitária”, “conselhos de saúde” and “conferência de saúde”. The descriptors containing the word “participação” were individually cross-referenced using the Boolean operator “AND” with “conferência de saúde” and “conselhos de saúde”. Cross-referencing was performed in the advanced forms, and if not existing, in the free forms of the databases. This search strategy was used in the CAPES journals portal with the English descriptors, as recommended in this database. Databases were accessed through the CAPES journal portal, by remote access to the subscribed content through the referred portal for the Federal University of Bahia.

Inclusion criteria were papers published in Portuguese between 1990 and 2017, based on Brazilian health councils and conferences, since the intention was to study these participative collegiate bodies in the social dynamics of the country and, more still, search the deliberative spaces inserted in the singular context of the SUS. Papers that, even when addressing health participation, did not refer to health councils or conferences were excluded.

Papers were selected by reading titles and abstracts, which allowed the exclusion of duplicated papers, and 364 works were preselected. Following their reading, we excluded papers addressing community participation in non-health community forums; participation of users in therapeutic decisions, in self-care groups and in disease control; participation in management collegiate bodies in other countries; participation in the process of formulating health policies through social movements, without mentioning council or conference; perception of community and health professionals about the council; and works on the participation of society in the enforcement of the budgetary, financial and fiscal implementation of the SUS, from mechanisms other than health councils or conferences. This dynamic process returned 152 papers, of which 84 were from the SciELO database, 44 from LILACS and 24 from the CAPES journal portal.

The 152 papers were read in full, with the extraction of a set of information that was included in a matrix. This group had the following variables: identification/title, year of publication, publication vehicle, authors, institutional origin of authors, object of study, health council/conference level, type of study and theoretical and methodological approach used.

Thus, in the set of selected works, we could identify those that explained, in their content, the theoretical and methodological reference used. In this study, the conception of theoretical and methodological reference was adopted as an articulated network of concepts linked to a theory capable of providing rupture with common sense¹⁸18 Laville C, Dionne J. A construção do saber: manual de metodologia da pesquisa em ciências humanas. Porto Alegre: Artmed, Belo Horizonte: Editora UFMG; 2008.. The epistemological rupture with common sense means putting in abeyance the vulgar pre-constructions and the principles generally applied in the realizations of these constructions¹⁹19 Bourdieu P, Chamboredon JC, Passeron JC. O fato é conquistado contra a ilusão do saber imediato. In: Bourdieu P, Chamboredon JC, Passeron JC. A profissão do sociólogo. Preliminares epistemológicas. Petrópolis: Vozes; 1999. [indicar paginação].

Results and discussions

Bibliometric indicators

The scientific production on participation in health councils and conferences evidences a gradual increase in the number of papers during the period studied (Graph 1), although there has been a year-on-year variation with moments of a higher number of publications. Twenty papers were identified in 2012, while other periods did not show a record of publications, such as four years in the 1990s.

The analysis of the institutions, post-graduate programs, departments or undergraduate courses to which the authors of the studies are linked reveals that most of these are bound to institutions and programs in the area of health sciences (122 = 80.3%), and of these, mostly the Collective Health subarea (67 = 54.9%) followed by Nursing (24 = 19.7%). We also identified authors from institutions and programs in the area of human sciences (21 = 13.8%), applied social sciences (8 = 5.2%) and even agricultural sciences (1 = 0.7%). This finding indicates the interdisciplinary way in which SUS participatory levels are being handled by research institutions. It also points to the centrality of the theme of social participation within collective health.

The papers analyzed were published in 46 journals, of which five concentrated most of the works (94 = 61.8%), namely, Ciência & Saúde Coletiva (29 = 19.1%), Saúde e Sociedade (27 = 17.8%), Cadernos de Saúde Pública (17 = 11.2%), Saúde em Debate (11 = 7.2%) and Physis (10 = 6.5%).

Councils are more frequently studied (92 = 60.5%) than conferences (22 = 14.5%), especially municipal councils (59 = 64%), and no study addresses the National Health Council, whereas, in the group of studies on conferences, papers on national conferences predominate (13 = 59%), as shown in Table 1. The fact that councils are more frequently studied may be related primarily to their quality of being a permanent collegiate body, while conferences occur only once every four years in each sphere of government. Brazil has 5,570 municipal health councils²⁰20 Moreira MR, Escorel S. Conselhos Municipais de Saúde do Brasil: um debate sobre a democratização da política de saúde nos vinte anos do SUS. Cien Saude Colet 2009; 14(3):795-805., which explains the significant amount of studies on this collegiate space within the municipal sphere.

The case study consists of the predominant approach (79 = 52%), of which most speak only about council (70 = 88.6%), while documentary research occurs more frequently on conferences (09 = 56.2%), as shown in Table 2.

Methodological approaches

A novelty evidenced in this work is the use of evaluative research approaches in studies on health councils and conferences²¹21 Vieira M, Calvo MCM. Avaliação das condições de atuação de Conselhos Municipais de Saúde no Estado de Santa Catarina, Brasil. Cad Saúde Pública 2011; 27(12):2315-2326.

22 Coelho VSP, Ferraz A, Fanti F, Ribeiro M. Mobilização e participação: Um jogo de Soma Zero? Novos Estudos 2010; 86:121-139.

23 Vaz ACN. Participação política, efeitos e resultados em políticas públicas: notas crítico-analíticas. Opinião Pública 2011; 17(1):163-205.

24 Batista AA, Muniz JN, Ferreira Neto JA, Cotta RMM. A Contribuição da Pesquisa Avaliação para o Processo de Implementação do Controle Social no SUS. Saúde Soc 2010; 19(4):784-793.

25 Ouverney AM, Moreira MR, Ribeiro JM. Democratização e educação permanente: percepção de egressos do QualiConselhos sobre contribuições aos conselhos de saúde. Saúde Debate 2016; 40(esp.):186-200.^-2626 Gonçalves AO, Gonçalves RS, Tavares AL. O Olhar dos Conselheiros de Saúde Sobre os Relatórios de Prestação de Contas no Município de Natal (Rio Grande do Norte), Brasil. Saúde Soc 2011; 20(13):659-672.. However, the perspective adopted in the evaluative research only addresses specific realms of the implementation and functioning of the council, through criteria, standards, indicators and models, and no research with this methodological design that assess the results of health councils and conferences in the health policy or health of the population are identified.

Although it is fundamentally necessary to know the impact of social participation, especially considering the dimension of these participatory spaces in the Brazilian scenario and the high investment in various spheres (political, economic, social, ideological, cultural, subjective) of society in health councils and health conferences, the results of social participation in the health policy and population health are still hardly known in Brazil⁵5 Serapioni M. Os desafios da participação e da cidadania nos sistemas de saúde. Cien Saude Colet 2014; 19(12):4829-4839.^,2323 Vaz ACN. Participação política, efeitos e resultados em políticas públicas: notas crítico-analíticas. Opinião Pública 2011; 17(1):163-205..

It is a gap of strategic relevance to the field of collective health that can hardly be answered with an isolated study. However, it was possible to identify studies²⁷27 Oliveira AGB, Conciani ME. Participação social e reforma psiquiátrica: um estudo de caso. Cien Saude Coley 2009; 14(1):319-331.

28 Alves-Sousa RA, Saliba O. A saúde bucal em pauta: análise de registros dos Conselhos Municipais de Saúde de municípios pertencentes à 17a Regional de Saúde do Estado do Paraná, Brasil. Cad Saúde Pública 2003; 19(5):1381-1388.

29 Oliveira TA, Teixeira CF. Participação das instâncias de controle social na Política de Saúde Mental da Bahia, 2001-2013. Saúde Debate 2015; 39(esp.):132-144.

30 Kleba ME, Zapiron K, Comerlatto D. Processo decisório e impacto na gestão de políticas públicas: desafios de um Conselho Municipal de Saúde. Saúde Soc 2015; 24(2):556-567.

31 Bispo Junior JP, Pinheiro GML. Participação social e relação de poder na definição das políticas de saúde no estado da Bahia. Público Privado 2016; 27:17-37.^-3232 Ditterich RG, Ditterich ACR, Baldani MH. A política de saúde bucal em pauta no Conselho Municipal de Saúde no Município de Nova Friburgo - RJ. Rev Odontol UNESP 2015; 44(3):143-151. that have advanced in this direction. The methodological approach adopted in these initiatives was similar and consisted in following consecutively the incorporation of the deliberations of social control into the health policy cycle, considering the joint action of arenas and actors (inter-agency commission, health council and conference, health secretariat and chamber of councilors or legislative assembly) involved in the process of building the health policy.

This strategy allows the overcoming of fragmented and alienating analyses that fail to capture the results of participation obtained over time and end up being overshadowed in the procedures of the various hands that lead decisions regarding health policy. In agreement with Schraiber³³33 Schraiber LB. Engajamento ético-político e construção teórica na produção científica do conhecimento em saúde coletiva. In: Baptista TWF, Azevedo CS, Machado CV, organizadores. Políticas, planejamento e gestão em saúde: Abordagens e métodos de pesquisa. Rio de Janeiro: Fiocruz; 2015. p. 33-57., it is a question of studying the concept of a delimited totality of participation in health, without this appearing in the idea of exhausting variables.

The real possibility of producing knowledge about the results of participation in health policies through a retrospective longitudinal case study, considering the actors and arenas related to the construction of health policy, disallows the arguments that the evaluation of the impact of the participation presupposes necessarily of robust⁵5 Serapioni M. Os desafios da participação e da cidadania nos sistemas de saúde. Cien Saude Colet 2014; 19(12):4829-4839., normative and generalizable models²³23 Vaz ACN. Participação política, efeitos e resultados em políticas públicas: notas crítico-analíticas. Opinião Pública 2011; 17(1):163-205., also because such models would hardly allow apprehending the totality that involves the participatory process and its unfolding, and whose expression also presents itself in the heterogeneous and variant situation of each Brazilian municipality and state.

Theoretical-conceptual contributions

Extensive reading of the papers revealed that only eight (7.2%) of the 111 empirical studies explicitly substantiate their analysis in theoretical constructs²⁷27 Oliveira AGB, Conciani ME. Participação social e reforma psiquiátrica: um estudo de caso. Cien Saude Coley 2009; 14(1):319-331.^,2929 Oliveira TA, Teixeira CF. Participação das instâncias de controle social na Política de Saúde Mental da Bahia, 2001-2013. Saúde Debate 2015; 39(esp.):132-144.^,3434 Fernandes ASA. Conselhos Municipais: participação, efetividade e institucionalização - a influência do contexto político na dinâmica dos conselhos - os casos de Porto Alegre e Salvador. Cad EBAPE 2010; 8(3):438-452.

35 Wendhalsen ALP. Relaciones de poder y democracia en los consejos de salud en Brasil: estudio de un caso. Rev Española Salud Pública 2006; 80(6):697-704.

36 Farias Filho MC, Silva AN, Mathis A. Os limites da ação coletiva nos Conselhos Municipais de Saúde. Cien Saude Colet 2014; 19(6):1911-1919.

37 Santos SF, Vargas AMD, Lucas SD. Conselheiros Usuários do Conselho Municipal de Saúde de Belo Horizonte: características sociais e representatividade. Saúde Soc 2011; 20(2):483-495.

38 Muller Neto JS, Artmann E. Discursos sobre o papel e a representatividade de conferências municipais de saúde. Cad Saúde Pública 2014; 30(1):68-78.^-3939 Miranda AS, Moreira AEMM, Cavalcanti CGCS, Bezerra FM, Oliveira JC, Rezende R. Discursos práticos sobre ocorrências, processos decisórios e decorrências de Conferências Municipais de Saúde. Interface (Botucatu) 2016; 20(58):559-571.. Most works (103 = 92.8%) seek, above all, to describe the event of participation. The mere description is a partial contribution to scientific production since it is necessary to consider the empirical and theoretical components of the event in order to construct a scientific object. The negligible publication of studies that showed, in their text, the theoretical-methodological contributions used in the data analysis indicate that the scientific production on health council and conference in Brazil is marked by theoretical or conceptual rarefaction, whose reflection occurs in the superficial knowledge built on the theme³³33 Schraiber LB. Engajamento ético-político e construção teórica na produção científica do conhecimento em saúde coletiva. In: Baptista TWF, Azevedo CS, Machado CV, organizadores. Políticas, planejamento e gestão em saúde: Abordagens e métodos de pesquisa. Rio de Janeiro: Fiocruz; 2015. p. 33-57..

The theoretical components identified in the empirical studies on health council and conference are shown in Box 1.

The theoretical premises identified in the studies belong to the sociological and political science matrix, and theoretical models, concepts and medium-range theories are evidenced since the use of a grand theory can only be verified through the mediation of more specific ones that can narrow its domain coping with phenomena at the concrete level⁴⁹49 Bunge M. Os conceitos de modelo. Modelos na ciência teórica. In: Bunge M. Teoria e realidade. São Paulo: Perspectiva; 1974. p. 11-40.. The concepts used are related to the structuralist, poststructuralist and neo-institutionalist approaches. It is noteworthy the lack of studies directly adopting the classic social theories of Weber and Durkheim, or approaches that combined, in their theoretical framework, more from an analytical perspective. Works resorted to the approaches of authors such as Foucault, Habermas, Gramsci, Kingdon, Olson, Maslow, Collier, Lourau and Lapassade and Testa, and no studies that made use of social and historical analysis (Bourdieu) were identified.

The adoption of sociological theories based on the tradition of the conflict allows for a fruitful analysis of participation in deliberative levels, since the procedure adopted for deliberation in these spaces is based on voting that, to a large extent, is preceded by disputes of conflicting interests and discourses that are more similar to strategic action than consensus-based rationality. In this perspective, it is considered that Testa’s strategic thinking⁴⁸48 Testa M. Pensamento estratégico e lógica da programação. O caso da Saúde. São Paulo, Rio de Janeiro: Ed. Hucitec; 1995. has an analytical potential for the review of the political process of participation in health. Linked to the Marxist current, the central category of this theoretical-methodological contribution is health power, in the way it is disputed and appropriate in the societal and social space of the health sector⁵⁰50 Federico L. Análise política em saúde: a contribuição do pensamento estratégico. Salvador: EDUFBA; 2015..

On the other hand, with regard to the categories “power” and “communicative action” for the analysis of participation in health council and conference, the pure adoption of communicative action theory must start from the analysis of a concrete case that gathers real conditions for their use, since the perspective of communicative action presupposes a community of dialogue based on consensus and whose unfeasibility operates in a space marked by power asymmetry and predominance of authoritarian, corporate and co-opted traditional political culture. The cautious use of the perspective of Habermas’ communicative action in participatory collegiate bodies’ studies was also indicated by Muller Neto and Artmann⁵¹51 Muller Neto JS, Artmann E. Política, gestão e participação em Saúde: reflexão ancorada na teoria da ação comunicativa de Habermas. Cien Saude Colet 2012; 17(12):3407-3416.. In analyzing the potential of Habermasian concepts for the analysis of councils and conferences, these authors emphasized the need for these concepts to be mediated and contextualized.

The analysis of the power relations in the internal dynamics of the councils and the spaces of the health conferences, as well as between these channels of participation with the social and state actors that dispute the definition and the conduction of the health policy can benefit from Foucault’s and Testa’s approaches on power. This is because both perspectives recognize the existence and relevance of conflict as an inherent aspect of the concrete reality of democratic societies. However, the Testian analysis of power, mainly when referring to the typology of technical, administrative and political power, limits the use of power resources to the scope of organizations³⁹39 Miranda AS, Moreira AEMM, Cavalcanti CGCS, Bezerra FM, Oliveira JC, Rezende R. Discursos práticos sobre ocorrências, processos decisórios e decorrências de Conferências Municipais de Saúde. Interface (Botucatu) 2016; 20(58):559-571.. From the Foucaultian viewpoint, one can analyze, for example, ways of exercising power different from those in the state machine³⁵35 Wendhalsen ALP. Relaciones de poder y democracia en los consejos de salud en Brasil: estudio de un caso. Rev Española Salud Pública 2006; 80(6):697-704..

Kingdon’s theoretical model⁴²42 Kingdon JW. Agendas, Alternatives and Public Policies. United States of America: Addison-Wesley Longman; 1995. is useful for analyzing how a particular social demand becomes a political issue. Thus, it shows the capacity of councils and conferences to include health problems that are priorities in the political agenda of the government²⁹29 Oliveira TA, Teixeira CF. Participação das instâncias de controle social na Política de Saúde Mental da Bahia, 2001-2013. Saúde Debate 2015; 39(esp.):132-144.. Like Kingdon’s theoretical model⁴²42 Kingdon JW. Agendas, Alternatives and Public Policies. United States of America: Addison-Wesley Longman; 1995., Testa’s strategic thinking⁴⁸48 Testa M. Pensamento estratégico e lógica da programação. O caso da Saúde. São Paulo, Rio de Janeiro: Ed. Hucitec; 1995. allows the analysis of the participation of councils in the construction of the health policy, for example. However, the central object of the analysis provided by Testa’s strategic thinking is the power relation, the political process and its relationships with the production of political facts, including the analysis of situations and their relationships with health policy⁵²52 Teixeira CT, Silveira P, organizadores. Glossário de análise política em Saúde. Salvador: Edufba; 2016.. Thus, with Kingdon’s perspective⁴²42 Kingdon JW. Agendas, Alternatives and Public Policies. United States of America: Addison-Wesley Longman; 1995., it is possible to develop a health policy analysis and a political health analysis with Testa’s strategic thinking.

Studies whose central concern is to understand the reasons that lead actors to engage in social movements may be benefited by Maslow’s motivational theory⁴⁶46 Maslow AH. A theory of human motivation. Psychological Review 1943; 50:390-396. and the perspective of collective action in which Olson’s theory of social groups⁴⁵45 Olson M. A lógica da ação coletiva: os benefícios públicos e uma teoria dos grupos sociais. São Paulo: EDUSP; 1999. is anchored. It is emphasized that these approaches adopt the individual as a level of analysis, so that the central study object adopted in these theoretical contributions consists of the conference advisor or delegate, to the detriment of the council or the conference⁷7 Farias Filho MC, Silva AN, Mathis A. Os limites da ação coletiva nos Conselhos Municipais de Saúde. Cien Saude Colet 2014; 19(6):1911-1919..

Gramsci’s concepts⁴⁰40 Gramsci A. Maquiavel, a política e o Estado Moderno. Rio de Janeiro: Civilização Brasileira; 1980. of extended state, civil society, and political society have been used chiefly in reflection studies to understand the channels of social participation since they are hybrid spaces for the meeting of governmental and social actors. However, the operationalization of these concepts in empirical studies on health councils and conferences is hampered by the breadth of these Gramscian categories, which are based on the idea of social class struggle.

Thus, regardless of whether the scope of the theoretical premise used in research on health participation is about broad and medium-range theories (Gramsci⁴⁰40 Gramsci A. Maquiavel, a política e o Estado Moderno. Rio de Janeiro: Civilização Brasileira; 1980., Olson⁴⁵45 Olson M. A lógica da ação coletiva: os benefícios públicos e uma teoria dos grupos sociais. São Paulo: EDUSP; 1999. and Maslow⁴⁶46 Maslow AH. A theory of human motivation. Psychological Review 1943; 50:390-396.), theoretical models (Kingdon⁴²42 Kingdon JW. Agendas, Alternatives and Public Policies. United States of America: Addison-Wesley Longman; 1995.) or analytical theory-linked categories (Habermas⁴⁷47 Habermas J. Teoria da la Acción Comunicativa. Madri: Ed. Taurus Humanidades; 1987., Testa⁴⁸48 Testa M. Pensamento estratégico e lógica da programação. O caso da Saúde. São Paulo, Rio de Janeiro: Ed. Hucitec; 1995., Foucault⁴¹41 Foucault M. Microfísica do poder. Rio de Janeiro: Edições Graal; 1979., Collier⁴⁴44 Collier D, Collier R. Shaping the political arena. Critical junctures, the labor movement, and regime dynamics in Latin America. Princeton: Princeton University Press; 1991., Lourau and Lapassade⁴³43 Lourau R. A Análise Institucional. Petrópolis: Vozes; 1975.), it is vital to keep a continuous coherence between the methodology chosen and the dynamics of the object. This epistemological vigilance facilitates the production of estrangement in daily situations, necessary to improve existing knowledge, avoiding automatism that annihilates the reflective power of research¹⁹19 Bourdieu P, Chamboredon JC, Passeron JC. O fato é conquistado contra a ilusão do saber imediato. In: Bourdieu P, Chamboredon JC, Passeron JC. A profissão do sociólogo. Preliminares epistemológicas. Petrópolis: Vozes; 1999. [indicar paginação].

Final considerations

Brazil has a vast production of papers on health councils and conferences. However, these studies have low conceptual density; that is, they poorly articulate between the empirical formulation and a given theoretical reference³³33 Schraiber LB. Engajamento ético-político e construção teórica na produção científica do conhecimento em saúde coletiva. In: Baptista TWF, Azevedo CS, Machado CV, organizadores. Políticas, planejamento e gestão em saúde: Abordagens e métodos de pesquisa. Rio de Janeiro: Fiocruz; 2015. p. 33-57.. The theoretical rarefaction of these studies also indicates that the knowledge produced on the subject is still superficial, requiring a more significant epistemological in-depth analysis than can produce contextualized interpretations of the empirical data.

The analysis of participation through more than one theoretical perspective (structuralist, post-structuralist, neo-institutionalist) indicates that there is not a single, unanimously accepted finalist model to approach participatory spaces. Thus, the construction of knowledge about councils and conferences can benefit from the contributions of social and political sciences and also from concepts and models developed by health planning authors.

This study’s limitation is having used only the production of papers as a research source, leaving aside theses, dissertations and books that, admittedly, have a relevant critical mass on the subject. It is also essential to consider that, despite efforts to gather all published studies on health council and conference, the search was only performed in the three primary bibliographic databases, and, therefore, the methodological strategy adopted does not presuppose an exhaustive review of all the already produced papers. Finally, it should be highlighted that papers that made use of theoretical contributions were considered only those that explicitly stated the references in their text.

The study sparks some crucial aspects to be further analyzed by Brazilian scientific production on health councils and conferences. These aspects lie within the scope of the impact of institutionalized social participation on health policies; besides the occasional issue of the existence of few studies on the national health council, the highest level of participation in the national health policy, of strategic importance to the SUS; and especially the low theoretical density of studies on the subject. These elements open new perspectives for future research.

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