Abstract

This work presents the results of a study that analyzed the processes and communication strategies by the entities represented in the National Health Council (NHC), 2018-2021 administration. The production of alternative communication by civil society constitutes one of the fundamental principles of democratic regimes for an important American institutionalist author (Robert Dahl). The emergence of the Internet and social networks has brought new demands for these organizations to disseminate their ideas and be present in this network society (Castells). Our study aimed to analyze the extent to which these entities are present in the digital media and to verify if there were significant differences in the communication capacity among the segments represented in the NHC. A survey was applied to the communication departments of the 42 NHC entities from September 2019 to February 2020. Thirty-four answers were obtained (81%). The results show the existence of 3 different levels of development in communication within these entities, regardless of the macro-institutional categories. Our article ends by discussing the results in light of the polyarchy and the digital democracy models and highlighting new steps towards effective democratic communication policies and participation.

Key words:
Civil Society; Health and Communication; Internet; Community Participation; Democracy

Introduction

Among a multiplicity of concepts, communication can be understood as the human capacity to send, receive, and circulate flows of expressions, information, and interests¹1 Matterlat A, Matterlat M. Histórias das teorias da comunicação. São Paulo: Edições Loyola; 2014., and is one of the ways to activate the production of meanings in society²2 Araújo IS, Cardoso JM. Comunicação e Saúde. Rio de Janeiro: Editora Fiocruz; 2014.. Observed through these concepts, the field of health is, per se, an uninterrupted production of communication, be it in the individual aspect of care relationships; be it in the collective dimension of the health-disease process and in the construction of health systems; be it in the political expression of the sector and its interaction with different societal actors²2 Araújo IS, Cardoso JM. Comunicação e Saúde. Rio de Janeiro: Editora Fiocruz; 2014.^,33 Paim JS. O que é o SUS. Rio de Janeiro: Editora Fiocruz; 2009.. This article elaborates on this third dimension, more precisely regarding the communication produced by the core Brazilian civil society entities from the health sectors of the National Health Council (NHC).

At the end of the 1970s, the Brazilian Sanitary Reform Movement (BSRM) was an important political actor in the formulation of proposals for a health system based on universality, equity, and the population’s participation³3 Paim JS. O que é o SUS. Rio de Janeiro: Editora Fiocruz; 2009.^,44 Fleury S. Reforma do estado, seguridade social e saúde no Brasil. In: Matta GC, Lima JCF, organizadores. Estado, sociedade e formação profissional em saúde: contradições e desafios em 20 anos de SUS. Rio de Janeiro: Editora Fiocruz; 2008. p. 49-87.. In its undying fight for the redemocratization of the Brazilian nation, the BSRM counted on pre-existing state structures to criticize the health system based on social security, which had been in place since the Vargas Era and maintained by the military governments⁴4 Fleury S. Reforma do estado, seguridade social e saúde no Brasil. In: Matta GC, Lima JCF, organizadores. Estado, sociedade e formação profissional em saúde: contradições e desafios em 20 anos de SUS. Rio de Janeiro: Editora Fiocruz; 2008. p. 49-87.. The mechanism of conferences was one of the loopholes of the State used by the BRSM and opened the door for creation of the 8^th National Health Conference (8^th NHC).

Held from March 17 to 21 1986, the 8^th NHC counted on ample participation from the sanitary movement, represented by academics and health professionals, as well as managers and other grassroots movements. The conference promoted the debate surrounding the foundations that would later become the Unified Health System (SUS), enacted within the Federal Constitution (FC) of 1988³3 Paim JS. O que é o SUS. Rio de Janeiro: Editora Fiocruz; 2009.^,44 Fleury S. Reforma do estado, seguridade social e saúde no Brasil. In: Matta GC, Lima JCF, organizadores. Estado, sociedade e formação profissional em saúde: contradições e desafios em 20 anos de SUS. Rio de Janeiro: Editora Fiocruz; 2008. p. 49-87..

Through the configuration of this new pluralist democratic reality⁵5 Carvalho AI. Conselhos de Saúde, Responsabilidade Pública e Cidadania: a Reforma Sanitária como Reforma do Estado. In: Fleury S. Saúde e democracia: a luta do CEBES. São Paulo: Lemos Editorial; 1997., the political incidence of civil society was institutionalized with the establishment of social participation spaces⁶6 Escorel S, Moreira MR. Participação Social. In: Giovanella L, organizadora. Políticas e sistema de saúde no Brasil. Rio de Janeiro: Cebes; 2012. within the different sectors and spheres of government, occupied by previously blocked and/or recently created entities and social representations.

Nearly one decade later, an emerging sociotechnical network would lead to new forms of communication and, consequently, new social interactions and relations⁷7 Castells M. A Galáxia da Internet. Rio de Janeiro: Jorge Zahar Editor; 2003.. The Internet provided a gradual process of digitalization, concentration of content, and expansion of channels and contact points. As of 2006, the social networks even further boosted the capacity of production and dissemination of multimedia messages. Data from 2020 indicate that 152 million Brazilians - nearly 80% of the population of 10 years of age or older - are users of this medium, which illustrates the impact of the web on contemporary sociability⁸8 Comitê Gestor da Internet no Brasil (CGI). TIC domicílios 2020 - Pesquisa sobre o uso das tecnologias de informação e comunicação nos domicílios brasileiros. São Paulo: CGI; 2021..

If the Internet is gaining an ever-increasing relevance in society as a whole, then the digital production of civil society, especially as regards the health sector, deserves special attention. The facility of the diffusion of notes, positions, events, and activities has made the web an integral part of these organizations. In general, everyone speaks more and more of health, rights, and life. But under what conditions? Is it enough to be present in the virtual realm in order to have equality and similarity in the way and view of communicating? These are a few of the questions that this article proposes to clarify.

Theoretical references

Building a study that would encompass complexities among seemingly distinct fields and with a focus on quite different entities led to the formulation of an interdisciplinary theoretical and methodological approach, joining elements from Political Science, Communications, and Collective Health. This section will discuss the institutions of polyarchy, which include the practices of communication within civil society, and the updating of its concepts when faced with the debate on the themes of Communication and Health, as well as the construction of the model of social participation within SUS and the main transformations caused by the communication mediums and social activism brought about by the consolidation of the Internet.

The investigation concerning the historical construction of democracy in Western society and the transformation in the forms of political representation are part of the work conducted by the political scientist, Robert Dahl. In his manuscripts, the author shows how the ideas and practices of the “people’s government” were established and transformed in a fragmented sense and stem from diverse experiences, many of which are contradictory. To understand the variation in political regimes and their limitations, Robert Dahl coined the term polyarchy.

This construct is defined as an “historical result of the efforts toward the democratization and liberalization of the political institutions of the nation-state”⁹9 Dahl R. A Democracia e seus críticos. São Paulo: Editora WMF Martins Fontes; 2012.. In an instrumental manner, the concept involves seven institutions taken as indicators to assess, measure, and parameterize the political practices of the societies, relating the existence of these institutions to criteria that deal with the quality of the political processes practiced by them.

While the four first institutions (elected officials; free and fair elections; inclusive suffrage; and the right to run for office) list the conditions to conduct free elections, the latter three - grouped under the criterion of Enlightened Understanding - treat collective needs for democratic practices.

Associational autonomy guarantees the possibility of individuals to collectively organize around common ideas and demands. The guarantee of individuals or collectives to expose any ideas - critical or not - officially promoted by authorities and by the State, is validated by the institution of the freedom of expression.

Both associational autonomy and the freedom of expression mobilize the capacity of organizations to invest efforts in the production of their own communication media, such as printed newspapers, radio and television programs, and digital products, including sites, social networks, podcasts, streaming channels, and cell phone applications. This third term Dahl, in his academic works, initially called “Alternative Information Sources”¹⁰10 Dahl R. Poliarquia: Participação e Oposição. São Paulo: EdUSP; 2005., and later, “Alternative Information”⁹9 Dahl R. A Democracia e seus críticos. São Paulo: Editora WMF Martins Fontes; 2012..

It is important here to make a necessary update of this term in light of the discussion on the themes of Communication and Health. Robert Dahl was also a contemporary of American scholars, Claude Shannon and Warren Weaver, authors of the mathematical theory of communication or the information model¹1 Matterlat A, Matterlat M. Histórias das teorias da comunicação. São Paulo: Edições Loyola; 2014.^,22 Araújo IS, Cardoso JM. Comunicação e Saúde. Rio de Janeiro: Editora Fiocruz; 2014.. The idea of the transmission of units of information through senders and receivers, with entrances, exits, and noise, has been widely used and replicated in academic productions prior to the debate on the New World Information and Communication Order (NWICO), from the MacBride Report¹¹11 Stevanin LF, Murtinho R. Direito à Comunicação e Saúde. Rio de Janeiro: Editora Fiocruz; 2021., as well as in Political Science practiced in the USA¹1 Matterlat A, Matterlat M. Histórias das teorias da comunicação. São Paulo: Edições Loyola; 2014..

Therefore, one concept that historically reinforces a narrow and concentrated understanding of the communication process does not necessarily treat the complexity of the analyzed processes. We thus resort to the concept of “alternative communication”, which understands communication as part of the processes of the mobilization of social movements in conformity with their capacity of organization and available resources. From this point of view, the communications products are evidence of the right to communication¹²12 Peruzzo CMK. Comunicação nos movimentos sociais: o exercício de uma nova perspectiva de direitos humanos. Contemp Comunic Cult 2013; 11(1):138-158.. Moreover, the term “alternative” insinuates a meaning close to that used by Dahl to highlight the communication processes at the margin of the State.

In this light, the process was sparked by the BSRM, with the creation of a wide range of organizations geared toward the debate and the mobilization of the right to health, which expressed, in the scope of Dahl’s theory, the strengthening of the civil society’s associational autonomy, freedom of expression, and freedom of alternative communication in the health sector.

Founded at the end of the 1970s, such entities as the Brazilian Center for Health Studies (Cebes, in Portuguese)¹³13 Fleury S. Saúde e democracia: a luta do CEBES. São Paulo: Lemos Editorial; 1997.; the Brazilian Association for Post-Graduate Studies in Collective Health (Abrasco, in Portuguese)¹⁴14 Paiva CHA, Fonseca CMO. A Abrasco na Construção do SUS (1979-1990): ação política na saúde. In: Lima NT, Santana JP, Paiva CHA, organizadores. Saúde coletiva: a Abrasco em 35 anos de história. Rio de Janeiro: Editora Fiocruz; 2015.; the Neighborhood Friends Movement of Nova Iguaçu (MAB, in Portuguese)¹⁵15 Pires-Alves FA, Lima NT, Paiva CHA. Na Baixada Fluminense, à sombra da 'Esfinge do Rio': lutas populares e políticas de saúde na alvorada do SUS. Cien Saude Colet 2018; 23(6):1849-1858., the East Zone Health Movement (MSZL, in Portuguese)¹⁶16 Palma J. Lutas Sociais e Construção do SUS. São Paulo: Hucitec Editora/Sobravime; 2015., among others, engendered a growing social participation of leaders and segments linked to the health sector and that had been excluded from the institutional debate.

The mobilization of the BSRM in the 8^th NHC and in the Constituent Assembly was important for the drafting of the chapter on Social Security within the FC of 1988, which defined, in article 198, the participation of the community as one of the guidelines of SUS. Through complementary laws¹⁷17 Brasil. Lei nº 8.080 de 19 de Setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União 1990; 19 set.^,1818 Brasil. Lei nº 8.142, de 28 de dezembro de 1990. Dispõe sobre a participação da comunidade na gestão do Sistema Único de Saúde (SUS) e sobre as transferências intergovernamentais de recursos financeiros na área da saúde e dá outras providências. Diário Oficial da União 1990; 31 dez., the former NHC was transformed into an instrument of social participation integrated within a new view of the health system, qualifying the insertion of society within the machinery of the State¹⁹19 Cortes SV, Silva MK, Réos JC, Barcelos M. Conselho Nacional de Saúde: histórico, papel institucional e atores estatais e societais. In: Cortes SV, organizadora. Participação e Saúde no Brasil. Rio de Janeiro: Editora Fiocruz; 2009.. Such instruments were instituted as of the advent of the New Republic, reinforcing the marks of a pluralist view, which Carvalho classified as “a mirage of the neutral State”⁵5 Carvalho AI. Conselhos de Saúde, Responsabilidade Pública e Cidadania: a Reforma Sanitária como Reforma do Estado. In: Fleury S. Saúde e democracia: a luta do CEBES. São Paulo: Lemos Editorial; 1997.. Currently, the NHC counts on 48 full member entities and 96 alternates.

In addition to the social participation, the political action of these entities is also carried out in the form of communication products and practices. Brazilian civil society has a tradition in the production of their own communication instruments, with pamphlets and newsletters distributed at the doorstep of the first factories installed in the country since the beginning of the 1900s²⁰20 Ferreira MN. Imprensa Operária no Brasil. São Paulo: Ática; 1988.. For more than 80 years of history, unions, grassroots movements, and associations have sought to follow up on the development of communication mediums - their trends, formats, and products - as well as to promote the professionalization and training of administrators, militants, and activists seeking to create their own languages¹²12 Peruzzo CMK. Comunicação nos movimentos sociais: o exercício de uma nova perspectiva de direitos humanos. Contemp Comunic Cult 2013; 11(1):138-158.^,2121 Gianotti V. O que é o jornalismo Operário? São Paulo: Brasiliense; 1988.. This communication process that emerged in the public sphere, which provides a means of expression and is overlapped by societal voices and demands, is called public communication²²22 Brandão EP. Usos e significados do conceito comunicação pública. In: Núcleo de Pesquisa Relações Públicas e Comunicação Organizacional do VI Encontro dos Núcleos de Pesquisa da Intercom. Brasília; 2006.. Despite the varying perceptions regarding this concept, its main feature is the shaping of a space of negotiation between different actors and their interests.

Such a perception of a negotiated public space also marked the consolidation of the Internet. Beginning at the end of the 1990s, as global movements and civil society organizations began to create webpages and their publications took on digital versions²³23 Gohn MG. Movimentos sociais e rede de mobilizações civis no Brasil contemporâneo. Petrópolis: Vozes; 2010., different views arose concerning the future of democracy within this new digital world. According to the American political scientist, Mathew Hindman, the first decade of the 2000s was marked by an integrated and utopic perspective, in which the web would be a virtual and virtuous arena, where politics would be “its most important and the most noisily declared promise”²⁴24 Hindman MS. The myth of digital democracy. Oxfordshire: Princeton University Press; 2009.. Other reading bet on an apocalyptic and dystopic web, a tool of social control that served the large corporations, while more market-oriented views believed that the medium would be the territory for hype, an English expression which identifies what is new, what is the current trend²⁵25 Fragoso S, Recuero R, Amaral A. Métodos de pesquisa para internet. Porto Alegre: Sulina; 2015..

These perspectives, among others, were addressed by the Spanish sociologist, Manuel Castells, who coined the concept of network society²⁶26 Castells M. A Sociedade em Rede. 7ª ed. São Paulo: Paz e Terra; 2003. so as to synthesize the set of transformations in the organization of the production of value and that of social relations, including the State, the market, and civil society. Technological convergence; an increase in the economic, political, and cultural concentration of the mediums; an increase in the capacity to disseminate content; the centrality of the native processes and products of digital communication; the precarious conditions of work relationships; as well as activism that promotes identity discourses and criticism of the concept of the class system are a few of the aspects discussed in Castells’ work.

The mapping of this set of elements in the current productive structure of communication within social activism has been beneficial in the formulation of categories of analysis that structure the qualitative instrument used in the field of research.

Methodology

The path of theoretical readings and discussions that guided the construction of the methodology will be detailed in their stages: the formulation of categories of analysis, the set-up and testing of the instrument, the validation criteria of the participants, and data collection.

To conduct this study, the qualitative approach was chosen, as it allows one, according to Minayo²⁷27 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 13ª ed. São Paulo: Hucitec; 2013., “to disclose relatively unknown social processes to private groups, foster the construction of new approaches, and review and create new concepts and categories during the investigation”²⁷27 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 13ª ed. São Paulo: Hucitec; 2013..

The elaboration of these categories of analysis took into account aspects that made it possible to understand the communication process of the institutions through different dimensions and, within each of these dimensions, locate singularities through attributes, in turn identifying internal logics of the communicative production of civil society within the health sector.

The profile of the survey participants consisted of a first dimension, seeking to typify the participant through criteria to be presented later. Next, the dimension of the communication department structure sought to list elements that refer to the procedural conditions for the development of communication activities, involving employment relationships, a work execution plan, the number of people on the team, etc.

By contrast, the dimension of digital practices speaks directly about the presence of the entities on the Internet and the degree of appropriation and use of digital tools. The political-communicational dimension referred to the exercise of communication as the producer and result of meanings, taking into consideration publication policy instruments; the view of the target public; priority themes, including SUS and NHC in their publications; among others.

The tool chosen to set up an electronic survey was the Survey Monkey platform, as it facilitates the reach and participation of the study participants, as well as the tabulation of the data. Entitled “Organize, Embrace, or Reproduce? A depiction of the communication departments of the main entities of the NHC - 2018-2021 administration”, the questionnaire brings the short version of the Free and Informed Consent Form (FICF), the agreement to participate in the study, and 36 questions in different formats divided into four dimensions. Chart 1 details the matrix of the categories of analysis, with the attributes and number of questions per dimension.

In all, nine versions of the study instrument were formulated. The final version passed through two pre-testing stages. The first took place during the 16^th NHC, held from August 4 to 7, 2019, when the survey was presented to journalists who were participating in the collaborative coverage of the conference and to some national counselors. After adjustments from their answers, 11 communication professionals and partner researchers were invited to answer and comment on the instrument, leading to the final adjustments. The pre-test stage ended on September 27, 2019.

In addition to serving as the pre-test, the 16^th NHC event also consolidated the decision surrounding the criteria for the identification of the key participants. We opted for the selection of full member entities, that is, those that exercise the entitlement of the entity’s structure, thereby validating a realm of investigation including 42 entities.

After, the participant acceptance criteria and the validation of participation were defined. Each full member entity should indicate only one participant. Preferably, this key informant should be a professional who is the head of the communications department. As a second option, the administrator responsible for the area of communications, or the closest thereof, can be appointed to participate. If the entity did not have any communications professional nor a administrator allocated for this function, the questionnaire could be answered by the head administrator and/or the national health counselor. Validation and exclusion criteria included questionnaires with more than 50% of the questions answered, discarding those returned with less than half of the questions answered.

Data collection was conducted from September 11 to December 20, 2019, through a direct and individual approach, with the delivery of the form conducted by Survey Monkey, e-mail, instant message, and/or text message. Dialogue was also maintained with the NHC’s president and head of communications. In all contacts, the importance of the investigation for social control and aspects such as privacy and survey integrity were highlighted.

At the end of the study period, 39 questionnaires had been filled out - 31 complete, 3 incomplete, and 5 in blank, the name given to the forms that had only filled out the acceptance to participate in the study (Q1) but with no questions answered.

On January 8, 2020, contact was again made but only with the three entities that presented incomplete answers. An adaptation for the inclusion of a new participant was made, who filled out the form in full. Even if incomplete, the other 2 entities had answered more than 76% of the questionnaire, leading to the validation of their participations. Data collection was concluded on February 6, 2020, with 34 of the 42 member entities having answered the questionnaire, corresponding to an 81% participation. The unanswered rate was of 19%. Table 1 shows the entire composition of the NHC, with the number of full member seats and percentages per segments and typologies, as well as the distribution and percentage of participation of the interviewees.

Results

A set of operations was carried out to transform the survey data into results, reaching a total of 40 tables, in a work conducted from March to June 2020.

The analysis of information led to key readings about the work of communication of the full member entities of the NHC. It was possible to identify expressive features of the institutional communicative production, map the digital presence, and propose an ordering and ranking of the communications from the studied organization. Once these elements had been gathered for examination, it was then possible to analyze the weight of the juridical-legal aspects of these entities in these productions and compose a summary table.

Of the answers obtained in the field of study, what emerged were aspects inherent to the process of organization and completion of the communication work, heavily overlapped by the institutionality of the entities, thus constituting four intrinsic capacities of the communication work. These are:

1) Organization of the Communications Department: When the internal organization is observed, one can see that 28 entities of the civil society and social health movements have minimally defined communications departments, with people responsible for disclosing the stance on actions for SUS and other themes concerning health and/or answer for the area, among communicators - professional or grassroots - and administrators. The communications departments are linked directly to the coordination or presidency of the organizations and, the more organized they are, the larger the internal structure and definition of their political line.

2) Workforce: Of the 34 participating entities, 20 count on communicators constructed in four sectors. In this first group, the majority (8) are contracted According to Brazilian labor laws, followed by service providers (5), and third parties (3). By contrast, the grassroots communicators, that is, people responsible for the entities’ regular communication but who do not receive a salary, totaled 8 participants, half of which (4) had degrees in journalism. It can be confirmed that there is no direct link between work capacity and formal employment relationships, in which it is possible for entities to count on the dedication of unpaid grassroots communicators to show results from their work that are as good as that of professionals with formal, paid employment relationships.

3) Productive process flows and routines: There is a nucleus of clearly identified flows and routines geared toward the production of content for webpages and social media, common within 24 of the 34 entities. The activities cited by more than 70% of the participants include Internal thematic network feeds from Google Groups or similar; the production of content and maintenance of accounts/profiles in social networks; design/diagramming of digital/electronic material; informative and news texts for webpages, portals, websites, newsletters; photographic coverage; and the production of graphic design, this last as a service contracted/outsourced by most of the entities. Other routines and communication processes are embraced according to greater professionalization, as well as better political and strategic consolidation of the departments.

As they are used by all of the participating entities and clearly viewed as the platforms with the best performance/interaction with the public (88.2%), when compared to the website/webpage (38.2%) and to the printed newspaper/newsletter (11.8%), the social networks are worth highlighting. In the order of citation, Facebook is by far the leader of the mediatic chain, comprised of Instagram, YouTube, and Twitter, the “first tier” of social media, along with the application WhatsApp. The existence, updating, and audience of the site itself, as well as the use of tools to monitor the metrics and advertising resources, complete this nucleus, today called digital presence.

4) Communication policies and strategies: Most of the participants claim that the communication work of the entities gives priority to internal and endogenous communication rather than to the health sector. The communication policies are referenced by the Board of Directors and/or Executive Secretary in 25 entities. Decisions and documents about the communication approved in assemblies, forums, thematic meetings, and congresses define the strategies of 11 entities, which reinforces this focus on speaking primarily “within” and on the accountability of a communicative production that should represent such demands. However, when asked about other publics, it remains unclear if there are communication strategies for other segments.

Having identified the intrinsic capacities of communications, it was possible to locate majoritarian patterns, minoritarian lines, and even points outside the curve that show distinctions and similarities among the entities, enabling the construction of a gradient with three distinct levels of the development of communications carried out by the organizations analyzed in this study.

I) Basic communication: Joins 10 entities that do not have the practice of mobilizing actions, routines, and decision-making for systematic communications projects. Administrators and/or volunteer communicators are not exclusively dedicated to the communication activities. These entities reported webpages with a minimal following and irregular updating, out-of-date, or even offline. In the social medias, the entities mainly rely on Facebook and, to a lesser extent, on other “first tier” platforms. However, as they operate with only basic communication processes, they do not produce messages with sophisticated technical resources and do not have the habit of following up on metrics and indicators to assess their actions and subsidize new strategies.

II) Intermediate communication: Unites 16 entities that have organized communication departments, with productive flows and processes and with the implementation of decisions and deliberations with some degree of structure and formalization, from the Board of Directors’ decision-making to the execution and disclosure of the communications. The workforce consists of individuals dedicated to the activity, organized in small to mid-sized teams, comprised of communications professionals, grassroots communicators and volunteers, and/or administrators. Processes identified as basic or intermediate are developed, counting on mixed services and/or those done exclusively by outsourced companies. Their webpages are updated regularly, whether periodically or daily. They use social networks other than those of the “first tier”. Their communicators know how to take advantage of the metrics provided by the platforms, as well as express skills and technical knowledge about other digital tools.

III) Advanced communication: There are eight entities that notedly inject more resources into communications, which can be perceived in the size of the teams and in the mobilized processes. The communication departments are structured to be the core machinery in the political work of these entities, which count on large teams comprised of educated and contracted professionals, in addition to a broad array of mixed and/or exclusively outsourced services. They develop nearly all of the communication processes and routines identified as basic or intermediate, as well as other innovative activities, produced specifically to attend to the demands of those that they represent. Their webpages show high numbers of followers and are updated daily. They work with structures advertising strategies, using a wide range of social networks, digital platforms, and campaigns, producing specific messages for each. The departments count on professionals and/or contract service providers to monitor the metrics and indicators, which boosts the advertising and provides key elements to define new strategies.

The methodological procedures described above situated the production of communication of the entities, and established the conditions through which to join the two points of this investigation and to attempt to answer what explains the difference in the entities’ communications.

The institutionalist perspective guided the study question to the juridical-legal aspects of the entities, that is, the elements of the institutional framework that define the entities concerning their legal organization, their typology, and the representative segment within the NHC’s bylaws. Understood here as institutional asymmetries, would these then be the categories that directly influence the communication processes and the strategies?

For this confirmation, similarities and differences were identified between the studied entities, both internally for each of the three categories, as well as among them, using the communicative capacities and digital presence as references.

The procedure demonstrated a high diversity among the entities, with quite different answers when broken down and analyzed according to the macro-institutional categories, in which the organizations showed no clear answer pattern for the tree aspects.

The distinction due to the legal personality, for example, could cause a leveling among the public-law organizations, as they are professional federal councils and have regular financial resources, resulting from tax collection. However, no alignment was perceived in the development of the communicative capacities, nor uniformity in the answers from the four entities involved in this institutional category, nor in the group of 30 more participants from the category of public-law organizations.

The typology is a category that joins 10 systematized nomenclatures, regardless of the segment, even if there is some degree of overlapping. Observing precisely the cases of the entities from a similar typology and from distinct segments, no clear symmetries were found.

Among the three macro-institutional categories, this segment presented a greater uniformity of answers and greater capacity to influence the communications of the entities. The constitution of these four representative groups of society and of the health sector organization - managers, health professionals, health service providers, and users of SUS - is the touchstone of the concept of social participation in health.

Within the four segments, the service provider and management entities present a certain synchrony in the development of the communicative capacities and unity in the majority of the answers provided, which were classified as advanced communication. Nevertheless, resources may vary among the corporate entities, further expanding the variety found within the procedural repertoires applied at this level of development.

No trace of uniformity was found when the entities from the SUS health worker and user segments were observed. Our study found both user organizations with a high level of professional training, as well as worker organizations with minor communications solutions, in which representatives from both segments at the three levels of development were found.

In sum, Chart 2 shows a chart of the institutional communications, correlating the three levels of productive development, including the four intrinsic capacities, the three characteristic elements of digital presence, and the three macro-institutional categories.

Discussion

This article focuses on the debate surrounding the civil society’s communicative production within the health sector for the formulation of relations between the different categories presented in the models of polyarchy and digital democracy, in an attempt to broaden knowledge and produce implications for the consolidation and strengthening of social participation in health.

Both groups of categorizations presented and studied herein contribute, each in its own way, to the understanding of the current scenario of the entities’ communications. They also bring elements to contemplate the role of civil society within Brazilian democracy.

From the model of polyarchy, this study used the reference of the three institutions named by Dahl as Enlightened Understanding. Through the prism of studied categories, associational autonomy can be understood by the variety of NHC member groups, internally organized by the macro-institutional categories of typology and segment. This same institution of polyarchy can also be represented by the organizational capacities of the communications departments and of the construction of the workforce, bearing in mind that entities with organized communications departments and with economic, political, or social autonomy to create adequate teams to meet their needs and aspirations, will have better conditions in which to organize those that they represent and, thus, strengthen civil society as a whole.

The debate regarding the institution of the freedom of expression has a vast academic production and was not within the scope of this study’s investigation. However, considering the weight of all of the limitation of our society, the organizations studied herein have a significant editorial independence and freedom of expression within the Brazilian State, regardless of their legal personality, be they public-law organizations - mixed-capital autarchies that oversee the professional exercise of health - be they private-law organizations - free associations of individuals of different natures and interests. Added to one’s exercise of freedom, the voicing of the ideas of an organization is developed through the greater or lesser capacity to create, define, and execute communications policies and strategies, influencing the impact of the interventions of and within civil society.

Alternative communication can be understood both as an independent institution and as a result of previous institutions. Autonomous organizations have the need to develop communications processes and strategies within their particular technical, thematic, technological, and budget features, with significant editorial independence and freedom of expression within the State to expose opinions and stances, as well as report their own associational daily routines through productive flows and routines, which lead to actions, products, and communication vehicles of free circulation and access. Plural by nature, alternative communication stands out within the institutions of polyarchy, as it is able to express diversity, capillarity, quality, and purpose, essential conditions that validate a democracy as the current political regime in Brazilian society.

However, outside of the models and faced with a complex reality, the mere existence and full functioning of alternative communication and of the other institutions are not enough to ensure that a political regime is necessarily democratic.

To refute the idyllic view of digital democracy, Hindman brings the debate to the realm of contemporary capitalism, a central system, both economically and politically, as well as culturally, and that works against the diffusion and multiplication of messages that do not reproduce dominant values²⁴24 Hindman MS. The myth of digital democracy. Oxfordshire: Princeton University Press; 2009.. Hence, even if the indicator points to a greater occupation of virtual spaces by social segments and communities, there is still a greater capacity of vocalization in the political debate, and that such entities present levels of development advanced and intermediate communication, in turn generating a bigger and better social dialogue, it is necessary to view the phenomenon without the utopias that signaled the emergence of the Internet.

Together with the process of economic, political, and cultural concentration, the logic of the appropriation of the clusters of data, technology, and media present a double aspect, as they are, simultaneously, arena and agent in the dispute for attention, interaction, and consumption²⁸28 Intervozes - Coletivo Brasil de Comunicação Social. Monopólios digitais: concentração e diversidade na Internet [Internet]. 2018 [acessado 2021 maio 13]. Disponível em https://intervozes.org.br/arquivos/interliv012monodig.pdf.
https://intervozes.org.br/arquivos/inter... . The presence of the entities within the communication vehicles follows the logic of scheduling guided both by productive dynamics of the news and content, as well as by the economic and political interests of media companies, which can block or privilege information flows, messages, and social actors.

The same occurs in the social medias, in which the attraction of an audience goes beyond the digital presence or even the purchase of advertising space through sponsored posts, moving also through the scheduling of themes and adaptation to the formats determined by the market, which are highly uniform and ever-increasingly guided by the logic of algorithms and marketing.

The political culture is another key aspect to be confronted in a realistic manner in this debate. The overlapping of counselors and administrators and the low level of the general participation of Brazilians within associational life²⁹29 Labra ME. Conselhos de saúde - visões "macro" e "micro". Civitas 2006; 6(1):199-221. show that the legal and infralegal institutionality of 30 years of social participation in SUS has still not been enough to boost and consolidate a greater political awareness within society, nor to improve the quality of participation.

Such indicators, however, do not lessen the role of alternative communication produced by the entities of civil society within the health sector. As they are full members of the NHC, a structural agency of SUS, the communication processes applied by them can and should be understood as part of the exercise of social control and of the rights to communication and health. As rights, it is the role of the Brazilian State not only to provide the possibility of the existence of this type of communication, but also to provide support to the means of promotion, structuring, and disclosure of that which is produced and debated by these departments.

For the model of social participation to be able to break the identified barriers in order to produce a high-quality democracy, it is necessary to expand the capacity of communication, as well as the digital presence of the set of organizations, in all segments and typologies. Incentive and qualification of the grassroots communicators and of the entities with less resources, government procurement announcements for equipment and articulations on the web among the NHC member entities for the exchange of materials, and productions focused on the right to health and communication are only a few of the elements that could be included in a public policy geared toward the valuation and strengthening of the communication of the social control of health, in an attempt to expand the communicative and technical capacity of this significant portion of civil society. It is necessary to break free from the limiting bonds in order to improve this network that serves to communicate both health and citizens’ rights.

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