Abstract

This article deals with the issue of how studies on public policies can contribute to understand institutions, actors and processes related to public health policies. It is grounded on the fact that many studies tend to describe and/or analyze public health policies. However, few use the theoretical tools of public policy analysis, which is a broad field of knowledge already widespread in Brazil. In this regard, this paper aims to encourage the interdisciplinary debate between these fields - public health and public policy -, which are understood as conceptually and empirically complementary, but still distant from the national literature on public health. The article briefly reviews the “public policies cycle” literature and points out that it was insufficiently considered by national health policy studies. This was demonstrated through the analysis of articles published in the Saúde e Sociedade journal between 2005 and 2015 (627 articles were analyzed). The article ends with a discussion about the paths and challenges for a rapprochement between the two fields.

Keywords:
Public Policies; Public Health; Interdisciplinarity

Introduction

The objective of this article is to analyze the potential contribution of public policies to understand the institutions, actors and processes related to public health. Although it seems to be unpretentious, it is grounded on the fact that many papers on health public policies tend to describe and/or analyze them, but few use the proper instruments of public policies analysis. This is a comprehensive field of knowledge widespread among us. In this sense, this article aims to foster the interdisciplinary debate between two fields, namely public health and public policies, considering them conceptually and empirically attached and complementary one another, but still distant from the national literature’s analyses on public health.

It is worth mentioning that one of the pioneer authors in public policies analyses, Harold Lasswell, clearly advocated that these analyses, besides focusing on the solutions of problems in a normative framework, should also be multidisciplinary (Lasswell, 1951 apudHowlett; Ramesh, 2003HOWLETT, M.; RAMESH, M. Studying public policy: policy cycles and policy subsystems. 2. ed. Toronto: Oxford University Press, 2003.). The concept of multidisciplinarity has changed over time. However, as Howlett e Ramesh (2003HOWLETT, M.; RAMESH, M. Studying public policy: policy cycles and policy subsystems. 2. ed. Toronto: Oxford University Press, 2003.) state, there is a clear point: public policies analysts should master at least two fields: concepts and understandings of political sciences (comprising public policies) and those related to the specific public policy field in study - here, health policy. And this is exactly the purpose of this paper: strengthen the links between both fields not only to expand interdisciplinarity, but mainly to increase the accuracy of the health public policies analyses. Therefore, it is worth reinforcing Madel Luz’s (2009LUZ, M. Complexidade do campo da Saúde Coletiva: multidisciplinaridade, interdisciplinaridade e transdisciplinaridade de saberes e práticas: análise sócio-histórica de uma trajetória paradigmática. Saúde e Sociedade, São Paulo, v. 18, n. 2, p. 304-311, 2009.) argument in favor of interdisciplinarity:

Moreover, this paper defends the argument that the so-called “public health” field strongly interfaces with social sciences, giving rise that what is today known as “social sciences in health”. However, this interface is more frequent with sociology and anthropology, and less frequent with political science. The scientific production of this last is little used as theoretical ground to the analysis of health public policies. This is clearly observed in the survey of recent production of the Saúde e Sociedade journal, which is reviewed here to analyze the attachment and detachment of both fields.

To that, this article starts by briefly reviewing one of the main instruments of public policies to analyze these, i.e., the concept of “political policies cycle”. After introducing it, the paper works on public health topics under this view, showing how studies in the field of public health could be improved in that light. Finally, it ends by showing paths and challenges to the rapprochement of both fields.

Public Health and public policies: similar but different fields

One of the objects proposed by the Saúde e Sociedade journal is clearly that of “valuing the theoretical-methodological focus of human and social sciences, including several approaches: sociological; anthropological; historical; political science’s; social psychology’s; philosophic, political economy’s, etc.” (Ianni; Nakamura, 2016IANNI, A.; NAKAMURA, E. 25 anos de Saúde e Sociedade : qual o lugar das ciências sociais e humanas no campo da saúde pública/coletiva no Brasil? Saúde e Sociedade, São Paulo, v. 25, n. 1, p. 7-8, 2016. Editorial Especial., p. 8). Bearing that in mind, the paper will analyze the responsiveness (or absence) of the theoretical-methodological focus known as “public policies field”. The articles published on that journal consider public policies as part of political science. The importance of this analysis rests on the gains generated to studies on specific public polices - here, health - when these incorporate the public policies analysis instruments, as aforementioned (Lasswell, 1956LASSWELL, H. The decision process: seven categories of functional analysis. College Park: University of Maryland Press, 1956.). In addition, the analysis of the articles published by that journal in the last ten years (2005-2015) shows that, although many articles approach specific public policies (such as health systems management, policies focusing on elderly, youth or children, on human resources in health, among others) very few expand the theoretical horizons to other instruments that could be useful to explain such processes, rather than just describing and/or analyzing these based on the endogenous production in the field of health.

First, however, it is worth mentioning that the main journals in the field of public health frequently publish “studies that specifically enter social and human sciences”, as stated by Minayo (2013MINAYO, M. C. S. A produção de conhecimentos na interface entre as ciências sociais e humanas e a saúde coletiva. Saúde e Sociedade, São Paulo, v. 22, n. 1, p. 21-31, 2013.). The Saúde e Sociedade journal is among those publishing more articles of this nature (59.7% in 10 months), second only to Interface (62.4%). Therefore, one cannot say there is not much room for human and social sciences in this area. On the other hand, it does not mean that public policies have gained the due room.

Under this assumption, this paper discusses how the public policies analysis instruments could be incorporated to other studies about health policies.

It is interesting to note that volume 22, number 1 of the journal, in 2013, published a dossier about the interface between social sciences and collective health, with articles by three important references to this debate: Amélia Cohn, Maria Cecília de Souza Minayo and Regina Marsiglia. The overall reference to political science is present in the three articles that, however, do not include specific references to public policies, which are somewhat neglected. Moreover, as aforementioned, the presence of political science is much weaker than that of sociology or anthropology when we talk about “social sciences in health”. In other words, the dialogue between health and sociology and anthropology is much more frequent than that between health and political science. This explains the poor presence of the field of public policies in the analyses of health policies and programs.

This absence does not lessen the importance of the balanced view of the authors regarding the interaction of both fields. Rather, it clearly demonstrates the weak presence of the public policies field, despite its core role to the research axes mentioned by them as “health policies and health services organization” or “human resources in health” (Marsiglia, 2013MARSIGLIA, R. M. G. Temas emergentes em ciências sociais e saúde pública/coletiva: a produção do conhecimento na sua interface. Saúde e Sociedade, São Paulo, v. 22, n. 1, p. 32-43, 2013.). Other examples would be the questioning about “new configurations between the public and the private dimensions of social life”, and if would be possible to ‘keep on conceiving and formulating health programs and policies in a staunch and segmented way, like health of women, black people, indigenous people, adolescent, elderly, etc.” (Cohn, 2013COHN, A. Ciências Sociais e Saúde Pública/Coletiva: a produção de conhecimento na sua interface. Saúde e Sociedade, São Paulo, v. 22, n. 1, p. 15-20, 2013., p. 19), among others.

This gap can be explained by the hard interdisciplinary dialogues. First of all, because of the institutional structure of universities, based on departments, which reinforces the disciplinary logic. Secondly, because professional associations, conferences and journals also adhere to this logic, reinforcing disciplinarity (Brewer, 1999 apudFaria, 2013FARIA, C. A. P. A multidisciplinaridade no estudo das políticas públicas. In: MARQUES, E.; FARIA, C. A. P. A Política Pública como Campo Multidisciplinar. São Paulo: Unesp; Rio de Janeiro: Fiocruz, 2013. p. 11-21.).

Beyond the corporate issues, Brewer (1999 apudFaria, 2013FARIA, C. A. P. A multidisciplinaridade no estudo das políticas públicas. In: MARQUES, E.; FARIA, C. A. P. A Política Pública como Campo Multidisciplinar. São Paulo: Unesp; Rio de Janeiro: Fiocruz, 2013. p. 11-21.) points out some discouragements to the interdisciplinary work, which deserve attention in the debate promoted by this paper:

Minayo et al. (2003MINAYO, M. C. S. et al. Possibilidades e dificuldades nas relações entre ciências sociais e epidemiologia. Ciência & Saúde Coletiva, Rio de Janeiro, v. 8, n. 1, p. 97-107, 2003.) reinforce some of these arguments when they state that:

Faria (2013FARIA, C. A. P. A multidisciplinaridade no estudo das políticas públicas. In: MARQUES, E.; FARIA, C. A. P. A Política Pública como Campo Multidisciplinar. São Paulo: Unesp; Rio de Janeiro: Fiocruz, 2013. p. 11-21.) adds two more issues: earlier socialization of researchers in the canon of disciplinarity (which could be explained by the structure of departments adopted by universities) and the fact that peer review is also a review based on disciplinarity. Focusing specifically on the Brazilian case, the author points out other factors. Here, it is worth highlighting the shortage of lines of funding in Brazil specifically devoted to interdisciplinary surveys, despite the priority attached to interinstitutional work (Faria, 2013FARIA, C. A. P. A multidisciplinaridade no estudo das políticas públicas. In: MARQUES, E.; FARIA, C. A. P. A Política Pública como Campo Multidisciplinar. São Paulo: Unesp; Rio de Janeiro: Fiocruz, 2013. p. 11-21., p. 14).

These difficulties help understanding the hard interdisciplinary dialogue. However, these fail in explaining the presence of some fields of study of social sciences and the absence of others when we talk about public health, in the broader sense, or about social sciences in health.

A factor that could help us understanding the weak presence of policy sciences in public health is that, in opposition to what happens with other academic practices, it is an analytical perspective oriented to specific social and political issues, also aiming at intervention, making the approach a multidisciplinary one, clearly oriented by values. Putting it in another way, and once again quoting Brewer, “problems determine theory and methods, and not the opposite, clearly contrasting with the investigation based on disciplinarity” (1999 apud Faria, 2013FARIA, C. A. P. A multidisciplinaridade no estudo das políticas públicas. In: MARQUES, E.; FARIA, C. A. P. A Política Pública como Campo Multidisciplinar. São Paulo: Unesp; Rio de Janeiro: Fiocruz, 2013. p. 11-21., p. 17). This hypothesis, which this paper does not intend to accept or reject, is based on the fact that this “order reversal” is not always well assimilated by disciplinary surveys, thus reinforcing the rejection to inter or multidisciplinary analyses¹1Here we should resume the difference between multi, inter and transdisciplinarity, as explained by Faria (2013): Multidisciplinarity “happens when the solution of a given problem requires adding information from more than one science or field of knowledge, with no concern about interconnecting the disciplines, or without changing or improving these in the process. [...] In interdisciplinarity, two or more disciplines interact in the same investigation, with interchange and integration, and concepts and theories employed are jointly rethought and methodologies are shared by different disciplines. [...] In transdisciplinarity, considered to be a higher stage of interaction between disciplines, cooperation between different areas is so huge that they can be hardly set apart, what could lead to the creation of a new macro-discipline” (Free translation, Faria, 2013, p. 15-16)..

Without going into the causes that led to the detachment between public health and public policies, now we will focus on the analysis of articles published on the Saúde e Sociedade journal between 2005 and 2015. All articles published on the “Artigos” section were analyzed, disregarding those in the sections “Tema em Debate”, “Editorial”, “Editorial Especial”, “Dossiê” or “Relato de Experiência”. Altogether, 627 articles were reviewed regarding keywords, abstracts and reference bibliography. Articles were tabulated and classified according to the two main keywords, selected from the abstract and from the analysis of the article’s object of study, or from the intended dialogue in the pertinent field of knowledge.

The article database showed that, of the 627 articles, 34 presented the term “public policy” as keyword (5.4% of the total) and 28 presented the term “health policy” (4.5% of the total). Other terms related to the field of public policies also worthy of attention are “social participation” or “social control” (22 articles, 3.5% of the total) and “health management” or “health service management” (19 articles, 3% of the total). In total, there are 103 articles in a universe of 627, corresponding to 16.4% of the reviewed articles.

Figures are not expressive, and this paper does not intend to speculate why. However, what really draws attention is not the number of articles approaching public policies-related topics, but the fact that, among these, very few appropriate the theoretical referential of this field of knowledge. Data presented in Table 1 evidences this:

Data show that only one fourth of the works with keywords related to the field of public policies effectively appropriate the theoretical instruments of the area. Added to that, less than 5% of the total articles use these instruments, although handling with analysis of public health programs and experiences, even when not using the selected descriptors.

These data deserve attention, mainly from interdisciplinary researchers dealing with public policies, mainly because, as Secchi (2010SECCHI, L. Políticas públicas: conceitos, esquemas de análise, casos práticos. São Paulo: Cengage Learning, 2010.) warned:

Therefore, it is not about a corporative defense of the area, but about showing a gap and, then, trying to point out paths for studies in public health to appropriate it. To that, the next section presents the main concepts in the field of public policies and some possibilities of appropriation by the public health-related topics and problems, as a draft “research agenda” to the area.

Public policies analysis and health policy: bringing fields together

The term ‘policy analysis’ was introduced by Lasswell still in the 1930s, establishing dialogue between social scientists and government (Souza, 2006SOUZA, C. Políticas públicas: uma revisão da literatura. Sociologias, Porto Alegre, v. 8, n. 16, p. 20-45, 2006.). However, it was not before the Second World War that it started to be systematically studied. The needs for fiscal adjustment and reform of social programs, from the 1970s and 1980s onwards, which aimed to understand “government in action”, reinforced policy analysis.

It is not focused on the governmental structure or on what governments should do, but on what governments effectively do.

In this sense, Harold Lasswell, one of its “founding fathers”²2Term used by Celina Souza (2006) in an intensive review of literature on Public Policies., tried to “integrate the study of political theory and political practices without falling into the sterility of formal, legalist studies” (Howlett; Ramesh, 2003HOWLETT, M.; RAMESH, M. Studying public policy: policy cycles and policy subsystems. 2. ed. Toronto: Oxford University Press, 2003., p. 3). As studies developed, they left aside the normative trait, as proposed by Lasswell, and started evaluating policies in terms of efficiency or efficacy, and on to which extent governments effectively drive their efforts towards achieving the established goals.

Other definitions for public policies arose from the field development. Dye (1972DYE, T. R. Understanding public policy. Englewood Cliffs: Prentice-Hall, 1972., p. 2) defines it as “any action governments decide to perform or not perform”. Although quite inaccurate, because it could comprise far-reaching policies and purchase of office supplies by the government, as pointed out by Howlett and Ramesh (2003HOWLETT, M.; RAMESH, M. Studying public policy: policy cycles and policy subsystems. 2. ed. Toronto: Oxford University Press, 2003.), this decision draws attention to an important aspect to public policies analyses: action and non-action are also a political decision. Bachrach and Baratz (1963BACHRACH, P.; BARATZ, M. S. Decisions and nondecisions: an analytical framework. The American Political Science Review, Cambridge, v. 57, n. 3, p. 632-642, 1963.) had already elaborated this concept in their seminal work “Decisions and nondecisions: an analytical framework”. On the other hand, the definition approaches governmental action, excluding non-state actors.

William Jenkins refines the definition, approaching public policy as a process:

It means that the author also adds the fact that decisions by political actors are subject to the institutional capacities made available to them to effectively achieve the objectives. Public policies are defined by these political actors. Therefore, public policy is not restricted to decisions by governmental actors, but also comprises responsive decisions, i.e., in line with the surrounding institutional environment. Finally, it is not about an action of actors with endless possibilities, but delimited by the context.

Lastly³3The author decided for presenting the three definitions object of study by Howlett and Ramesh (2003) that satisfactorily illustrate the concept evolution., James Anderson defines public policy introducing a core element, object of several further studies: perception an existing problem that deserves attention and action by actors. In his words, it is “purposive course of action that an actor or group consistently follow in dealing with a problem or focus of concern” (Anderson, 1984 apud Howlett; Ramesh, 2003HOWLETT, M.; RAMESH, M. Studying public policy: policy cycles and policy subsystems. 2. ed. Toronto: Oxford University Press, 2003., p. 7).

From these definitions we can infer several questions related to public policies analyses, as follows: (i) the public policy actors (either governmental or non-governmental), their decisions and nondecisions; (ii) the objectives of public policies and institutional means to reach them; (iii) problems that drew the decision-making actor’s attention and are transformed - and how - into topics of public policies; (iv) the processes of implementation and evaluation of the policy to improve it.

These questions clearly show that describing public policies is an important step towards understanding it, but is far from accounting for the different aspects involved in definition, implementation or evaluation. Public policies deal with a complex set of actors, decisions and results. To understand the different aspects that make up this patchwork, the idea of “public policies cycle” was developed in the field of public policies. This cycle aims at understanding the different stages involving the policy making process⁴4Rita Barradas Barata’s work (2013) is a rare example of work in the field of collective health dealing with the idea of “public policies cycle”, analyzing the epidemiology and its contribution to the formulation, implementation and evaluation of health public policies..

The public policies cycle is a theoretical simplification to understand a quite complex reality. It is a theoretical-methodological resource rather than a theory itself. It involves the following five stages⁵5Some authors works with a simpler division - three phases - and others with a more detailed division of the process - seven phases. These are methodological differences, and all of these keep the solution of dividing this process as a way to better understand the actors and institutions involved in different moments of long path run between incorporating a problem into the governmental agenda and its implementation and further evaluation.: agenda setting; policy formulation; decision-making process; implementation; and, evaluation. As proposed by Frey, it can be defined as follows:

As Oliveira (2013OLIVEIRA, V. E. As fases do processo de políticas públicas. In: MARCHETTI, V. (Org.). Políticas públicas em debate. São Bernardo do Campo: UFABC, 2013. p. 15-37.) highlighted, the first three phases pooled in what is known as “decision-making process” are more intensively studied by the Brazilian political science. The phases approach studies on the Executive/Legislative relation in the approval of bills and constitutional amendments; the Judiciary Power’s influence on policies designed by the remainder powers or stakeholders; and, political pressures on governmental programs, among others.

For processes of decision-making and public policies formulation, following are the highlights in the Brazilian discussions on public policies: “punctuated equilibrium model” of True, Baumgartner and Jones (1999TRUE, J. L.; BAUMGARTNER, F. R.; JONES, B. D. Punctuated equilibrium theory: explaining stability and change in American policymaking. In: SABATIER, P. A. Theories of the policy process. Oxford: Westview Press, 1999. p. 97-116.); the “garbage can model” of Cohen, March and Olsen (1972COHEN, M.; MARCH, J.; OLSEN, J. A garbage can model of organizational choice. Administrative Science Quarterly, New York, v. 17, n. 1, p. 1-25, 1972.); the “multiple flows model” of John Kingdon (1995KINGDON, J. Agendas, alternatives, and public policies. Boston: Little Brown, 1995.); and the “advocacy coalitions model” of Sabatier and Jenkins-Smith (1999SABATIER, P.; JENKINS-SMITH, H. The advocacy coalition framework: an assessment. In: SABATIER, P. A. (Ed.) Theories of the policy process. Boulder: Westview Press, 1999. p. 117-166.), analyzed in detail by Frey (2000FREY, K. Políticas públicas: um debate conceitual e reflexões referentes à prática da análise de políticas públicas no Brasil. Planejamento e Políticas Públicas, Brasília, DF, n. 21, p. 211-259, 2000.), Souza (2006SOUZA, C. Políticas públicas: uma revisão da literatura. Sociologias, Porto Alegre, v. 8, n. 16, p. 20-45, 2006.) and Capella (2007CAPELLA, A. C. Perspectivas teóricas sobre o processo de formulação de políticas públicas. In: HOCHMAN, G.; ARRETCHE, M.; MARQUES, E. Políticas públicas no Brasil. Rio de Janeiro: Fiocruz, 2007. p. 87-124.). Likewise, the “path dependency model” gained visibility in the field of public policies. The most widely disseminated explanation for this process is that presented by Paul Pierson (2000PIERSON, P. Increasing returns, path dependence, and the study of politics. The American Political Science Review, Cambridge, v. 94, n. 2, p. 251-267, 2000.), according to which past decisions determine and restrict the possibilities of future paths, hindering actors from taking alternative courses of action.

In the field of public health, some topics on agenda setting, public policies formulation and decision-making processes have also been explored⁶6To illustrate the topics mentioned in each phase of the public policies cycle, the author searched the related terms at SciELO database. She analyzed the articles and use of analytical models in the field of public policies, like happened in the first section of this article. In this section, however, the author was not limited to works on the Saúde e Sociedade journal, but also sought examples in all journals listed on the SciELO database matching the terms (in Portuguese) “formulation” and “health policy” (37 articles), “decision-making process” and “health policy” (one article), “agenda” and “health policy” (27 articles), and “actors” and “health policy” (40 articles). The objective was not to systematically map productions in this area, but to illustrate the most frequent topics in each phase of health public policies. The same process was applied to the remainder cycle phases analyzed throughout the section.. The first and most evident one is that of institutionalization and/or consolidation of the Brazilian Unified Health System (SUS or Sistema Único de Saúde) in Brazil. Some topics are worth of highlight regarding the SUS institutionalization process, actors and arenas in which they interact: the role played by the Brazilian Health Council (Conselho Nacional de Saúde) and inter-managerial commissions in the institutionalization of SUS (for example, Côrtes, 2009CÔRTES, S. V. Sistema Único de Saúde: espaços decisórios e a arena política de saúde. Cadernos de Saúde Pública, Rio de Janeiro, v. 25, n. 7, p. 1626-1633, 2009.); decision about the adoption of a public and universal health system, with the private sector participation (for example, Menicucci, 2006MENICUCCI, T. Implementação da reforma sanitária: a formação de uma política. Saúde e Sociedade, São Paulo, v. 15, n. 2, p. 72-87, 2006.); decisions about investments in health (for example, Santos et al., 2015SANTOS, F. de A. et al. A definição de prioridade de investimento em saúde: uma análise da participação dos atores na tomada de decisão. Physis: Revista de Saúde Coletiva, Rio de Janeiro, v. 25, n. 4, p. 1079-1094, 2015.); coalitions of political parties involved in the process of approving the SUS (for example, Pereira, 1996PEREIRA, C. A política pública como Caixa de Pandora: organização de interesses, processo decisório e efeitos perversos na Reforma Sanitária brasileira, 1985-1989. Dados - Revista de Ciências Sociais, Rio de Janeiro, v. 39, n. 3, 1996.); or legislative production in health and the resulting process of development and consolidation of the SUS (for example, Baptista, 2010BAPTISTA, T. W. F. Análise da produção legislativa em saúde no Congresso Nacional brasileiro (1990-2006). Cadernos de Saúde Pública, Rio de Janeiro, v. 26, n. 1, p. 97-109, 2010.).

A second set of works approaches the ideas and interests involved in the decision-making processes, analyzing the interaction between public and private actors in the process of defining public policies (for example, Coelho, 1998COELHO, V. S. Interesses e instituições na política de saúde. Revista Brasileira de Ciências Sociais, São Paulo, v. 13, n. 37, p. 115-128, 1998.); analyses about the “institutional arrangements resulting from relations between political actors” (for example, Gershman; Santos, 2006GERSHMAN, S.; SANTOS, M. A. B. O Sistema Único de Saúde como desdobramento das políticas de saúde do século XX. Revista Brasileira de Ciências Sociais, São Paulo, v. 21, n. 61, p. 177-190, 2006.) or about disputes between concepts and scientific knowledge in the policy formulation processes (for example, Souza; Contandriopoulos, 2004SOUZA, L. E. P. F. de; CONTANDRIOPOULOS, A. P. O uso de pesquisas na formulação de políticas de saúde: obstáculos e estratégias. Cadernos de Saúde Pública, Rio de Janeiro, v. 20, n. 2, p. 546-554, 2004.). Others regard decisions by governments and specific programs and policies in the SUS, like the different governmental options regarding the adoption of public policies models; decisions by governments or managerial councils about public health management at federal (for example, Menicucci, 2011MENICUCCI, T. A Política de Saúde no Governo Lula. Saúde e Sociedade, São Paulo, v. 20, n. 2, p. 522-532, 2011.), state (for example, Lima et al., 2015LIMA, L. D. et al. Interdependência federativa na política de saúde: a implementação das Unidades de Pronto Atendimento no estado do Rio de Janeiro, Brasil. Ciência e Saúde Coletiva, Rio de Janeiro, v. 20, n. 2, p. 595-606, 2015.) or municipal (for example, Kleba, Zampirom and Comerlatto, 2015KLEBA, M. E.; ZAMPIROM, K.; COMERLATTO, D. Processo decisório e impacto na gestão de políticas públicas: desafios de um Conselho Municipal de Saúde. Saúde e Sociedade, São Paulo, v. 24, n. 2, p. 556-567, 2015.) levels.

The phases of governmental programs’ implementation and evaluation, although not much studied in the national context, as observed by Faria (2005FARIA, C. A. P. A política da avaliação das políticas públicas. Revista Brasileira de Ciências Sociais, São Paulo, v. 20, n. 59, p. 97-109, 2005.), are considered important variables for governments to succeed in the execution of their public policies. Implementation can firstly serve as a barrier to properly or improperly formulated policies: if poorly formulated, these cannot even be implemented or, if implemented, results will be unsatisfactory. On the other hand, if soundly formulated but with implementation problems, they do not reach the intended objectives.

According to Sabatier (1997 apudOliveira, 2013OLIVEIRA, V. E. As fases do processo de políticas públicas. In: MARCHETTI, V. (Org.). Políticas públicas em debate. São Bernardo do Campo: UFABC, 2013. p. 15-37.), the analyses on public policies implementation could be pooled in three sets:

The analyses on public policies implementation typically emphasize the role of governmental and non-governmental actors engaged in this process. Therefore, more than analyzing institutions and their rules, the analyses on implementation demand looking carefully into the work of each public policy actor throughout the process. Therefore, many works about this phase of the public policies cycle use the qualitative survey in methodological terms.

When we analyze the processes of health public policies implementation, we think about how other policy-formulating and implementing actors interact in a process that feeds back and has direct impacts on the results of the implemented public policies. Therefore, the works⁷7To gather examples of works approaching the implementation of health public policies, searches were made on SciELO database using the terms (in Portuguese) “implementation” and “health policy” (59 articles), “actors” and “health policy” (40 articles), “implementation” and “public policies” and “health” (36 articles. The search procedure was the same as that explained before. approaching the implementing bureaucracy, like health community agents (e.g., Lotta, 2012LOTTA, G. S. Saberes locais, mediação e cidadania: o caso dos agentes comunitários de saúde. Saúde e Sociedade, São Paulo, v. 21, p. 210-222, 2012. Suplemento 1.), interaction of bureaucracy and policy-formulation agents (e.g., Costa; Neves, 2013COSTA, L. A.; NEVES, J. A. B. Burocracia e inserção social: um estudo sobre o Ministério da Saúde na gestão do Sistema Único de Saúde (SUS). Saúde e Sociedade, São Paulo, v. 22, n. 4, p. 1117-1131, 2013.), or interaction between health professionals and the State (e.g., Dowbor, 2009DOWBOR, M. Da inflexão pré-constitucional ao SUS municipalizado. Lua Nova: Revista de Cultura e Política, São Paulo, n. 78, p. 158-222, 2009.) are emblematic. Others deal with the programs implementation process per se (e.g., Lima et al., 2015LIMA, L. D. et al. Interdependência federativa na política de saúde: a implementação das Unidades de Pronto Atendimento no estado do Rio de Janeiro, Brasil. Ciência e Saúde Coletiva, Rio de Janeiro, v. 20, n. 2, p. 595-606, 2015.) or implementation of reform processes (e.g., Menicucci, 2006MENICUCCI, T. Implementação da reforma sanitária: a formação de uma política. Saúde e Sociedade, São Paulo, v. 15, n. 2, p. 72-87, 2006.), or with the link between planning and implementation and its results (e.g., Vilasbôas; Paim, 2008VILASBÔAS, A. L. Q.; PAIM, J. Práticas de planejamento e implementação de políticas no âmbito municipal. Cadernos de Saúde Pública, Rio de Janeiro, v. 24, n. 6, p. 1239-1250, 2008.).

Finally, evaluation should point out issues of existing public policy found only after implementation, as well as the successful results. For the first, when problems exist, the evaluation indicates (or should indicate) possibilities of correcting it and the paths to properly enforce the policy to reach the intended results and, therefore, the government success in that area and/or policy (Oliveira, 2013OLIVEIRA, V. E. As fases do processo de políticas públicas. In: MARCHETTI, V. (Org.). Políticas públicas em debate. São Bernardo do Campo: UFABC, 2013. p. 15-37.). In addition, it may point out the need for full reformulation of the policy, suppressing the actions underway. According to Faria (2005FARIA, C. A. P. A política da avaliação das políticas públicas. Revista Brasileira de Ciências Sociais, São Paulo, v. 20, n. 59, p. 97-109, 2005.), in a more accurate definition of the term, evaluation can be considered as: (1) activity oriented to measure results of a course of action that is ending; (2) instruments to provide elements to design new interventions / improve ongoing policies and programs; (3) part of rendering of accounts and liability of state agents, i.e., part of accountability.

One should bear in mind that in the 1970s and 1980s the evaluation of social programs was a useful instrument to assist governments in the State reform processes. Therefore, it assisted the decision about what should be reformulated, abolished or what deserved continuity. Moreover, it challenged not only if government performance was adequate, but also if governmental institutions should remain responsible for the policies they executed up to then (Caiden; Caiden, 2001CAIDEN, G. E.; CAIDEN, N. Enfoques y lineamiento, la medición y la evaluación del desempeño en programas del sector público. Revista do Serviço Público, Brasília, DF, v. 52, n. 1, p. 78-103, 2001.). In this sense, as Derlien (2001DERLIEN, H. U. Una comparación internacional en la evaluación de las políticas públicas. Revista do Serviço Público, Brasília, DF, v. 52, n. 1, p. 105-123, 2001.) states, evaluation was considered to be a mechanism to justify budget reallocation and not necessarily to improve policies.

For health policy, most of the works⁸8Search on the SciELO used the terms (in Portuguese) “evaluation” and “health policy” (58 articles) and “evaluation”, “public policies” and “health” (46 articles), as explained for previous searches herein. analyze the results of governmental policies and programs. Some examples are the works on basic care evaluation (Tanaka, 2011TANAKA, O. Y. Avaliação da atenção básica em saúde: uma nova proposta. Saúde e Sociedade, São Paulo, v. 20, n. 4, p. 927-934, 2011.), evaluation of environmental policies (Assis et al., 2012ASSIS, M. P. et al. Avaliação de políticas ambientais: desafios e perspectivas. Saúde e Sociedade, São Paulo, v. 21, p. 7-20, 2012. Suplemento 3.; Fernandes et al., 2012FERNANDES, V. et al. Metodologia de avaliação estratégica de processo de gestão ambiental municipal. Saúde e Sociedade, São Paulo, v. 21, p. 128-143, 2012. Suplemento 3.), etc. A second group evaluates health services management and its different models (e.g., Luedy; Mendes; Ribeiro Júnior, 2012LUEDY, A.; MENDES, V. L. P. S.; RIBEIRO JÚNIOR, H. Gestão pública por resultados: contrato de gestão como indutor de melhorias em um hospital universitário. Organizações & Sociedade, Salvador, v. 19, n. 63, p. 641-659, 2012.), human resources management (e.g., Pierantoni; Vianna, 2003PIERANTONI, C. R.; VIANNA, A. L. Avaliação de processo na implementação de políticas públicas: a implantação do Sistema de Informação e Gestão de Recursos Humanos em Saúde (SIG-RHS) no contexto das reformas setoriais. Physis: Revista de Saúde Coletiva, Rio de Janeiro, v. 13, n. 1, p. 59-92, 2003.), evaluation of expenses or users’ evaluation (Sala et al., 2011SALA, A. et al. Integralidade e Atenção Primária à Saúde: avaliação na perspectiva dos usuários de unidades de saúde do município de São Paulo. Saúde e Sociedade, São Paulo, v. 20, n. 4, p. 948-960, 2011.).

Generally speaking, the works aim to evaluate the efficiency, efficacy and/or effectiveness of health policies, linking the proposed objectives of policies and programs and the results achieved, checking to which extent these met the objectives and established goals. However, as observed in the remainder stages of the health public policies cycle, few were supported by the theories of public policies evaluation to analyze the programs and policies object of study. Usually, they do not analyze results based on a theoretical discussion bound to the field of public policies and to the evaluation stage.

To some extent, this is partially due to the difficulties faced to perform evaluation processes (shortage of personnel and resources; difficulty to measure some activities such as children well-being; acknowledgement of the relevance of evaluation processes) and to use the evaluation results (Caiden; Caiden, 2001CAIDEN, G. E.; CAIDEN, N. Enfoques y lineamiento, la medición y la evaluación del desempeño en programas del sector público. Revista do Serviço Público, Brasília, DF, v. 52, n. 1, p. 78-103, 2001.; Faria, 2005FARIA, C. A. P. A política da avaliação das políticas públicas. Revista Brasileira de Ciências Sociais, São Paulo, v. 20, n. 59, p. 97-109, 2005.). Despite such difficulties, evaluations are crucial to close the cycle. They should imply the cycle’s abolishment or improvement. In this last, it should point out the need for policy reformulation. When it does not happen, it opens two possibilities: or policies move on with the identified problems, or are extinguished, starting new policies that are redesigned with more or less elements of the prior policy.

Diagrammatically we would have:

However, Oliveira (2013OLIVEIRA, V. E. As fases do processo de políticas públicas. In: MARCHETTI, V. (Org.). Políticas públicas em debate. São Bernardo do Campo: UFABC, 2013. p. 15-37.) calls attention to an important aspect regarding analyses based on the idea of “public policies cycle”. According to the author,

Another aspect that deserves attention is the issue of interconnection between phases and the participating actors. Some public policies present strong links between the different phases. Some are more prone to “sharing actors”, i.e., to demand or facilitate the participation of some actors in different phases of the public policies process (agenda setting, policy formulation, decision-making process, implementation and evaluation). These could be divided into governmental and non-governmental actors (Kingdon, 1984 apud Vianna, 1996VIANNA, A. L. Abordagens metodológicas em políticas públicas. Revista de Administração Pública, Rio de Janeiro, v. 30, n. 2, p. 5-43, 1996.): the first are members of the Executive (elected and senior management bureaucrats, as well as the bureaucratic staff in charge of implementation, regardless if they are approved by contest or appointed), of the Legislative (elected representatives and staff members) and of the Justice system (Judiciary, Public Prosecutor’s Office and Police). The second ones, in turn, are the pressure groups, academics and researchers, the media, political parties and public opinion, as summarized below.

However, we should restate that the idea of “cycle” is nothing but a methodological construct to facilitate the analysis of the public policies process. Therefore, dividing the cycle into stages or phases is a decision of the researcher. Some divide it into a larger number of stages (for example, Lasswell, 1956LASSWELL, H. The decision process: seven categories of functional analysis. College Park: University of Maryland Press, 1956.; Brewer, 1974BREWER, G. The policy sciences emerge: to nurture and structure a discipline. Policy Sciences, Amsterdam, v. 5, n. 3, p. 239-244, 1974.), while others divide it in only three stages: formulation, implementation and evaluation. The main criticism to the model lays on the fact that it spreads the idea that decision-makers work in a linear and systematic way. However, this is not true most of the times (Sabatier; Jenkins-Smith, 1999SABATIER, P.; JENKINS-SMITH, H. The advocacy coalition framework: an assessment. In: SABATIER, P. A. (Ed.) Theories of the policy process. Boulder: Westview Press, 1999. p. 117-166.). In addition, it makes us believe that the different public policies processes are independent from each other. But that is not this way. The results achieved in the implementation of a policy usually influence the design of other simultaneous or further policies. Finally, many times the process is not started by the perception of an issue and inclusion of it in a “governmental agenda”. It can happen if formulation precedes the agenda setting. This is what Kingdon (1984 apud Howlett e Ramesh, 2003HOWLETT, M.; RAMESH, M. Studying public policy: policy cycles and policy subsystems. 2. ed. Toronto: Oxford University Press, 2003.) called “solutions seeking for problems”.

A common and valid point in analyses based on the public policies cycle is the perception of this process’ complexity comprising different phases - that usually overlap in practice -, actors and institutional arenas where conflicts and agreements take place. Understanding this complexity and the causal mechanisms that make it up is the core objective of public policies, whose analytical instruments should be used to understand the policy processes in a wide range of areas, as stated by Lasswell (1956LASSWELL, H. The decision process: seven categories of functional analysis. College Park: University of Maryland Press, 1956.).

Final considerations

This article aimed to promote dialogue between the fields of public health and public policies, mainly due to the evident (potential) attachment of both, but (actual) detachment found in scientific productions. To that, it analyzed 625 articles published on the Saúde e Sociedade journal between 2005 and 2015, in an effort to map those approaching public policy and using the field’s theoretical referential. This is clearly just one of the possibilities of assessing the interaction between the fields, and is far from being the fullest one. Nonetheless, this mapping seems to be satisfactory to a first attempt of analysis of state-of-the-arts interdisciplinary production in question.

In the field of public health there are many works analyzing health public policies, and the interaction between public health and social sciences, as previously emphasized. However, the brief bibliography review presented in the first section showed how works on health public policies could make more intensive and better use of theories in the field of public policies, including from the perspective of public policies cycle which remains weakly incorporated to the field of public health. The second section presented few examples of incorporation of public policies analyses to discuss and understand health policies. These were performed based on keywords for the main phases of public policies cycle (agenda, decision-making and formulation processes; implementation and evaluation). Far beyond being just a methodology, this approach enables understanding the different actors, and the institutions and arenas where they interact. That means to say that understanding a policy as a whole - considering its complexity, as well - implies acknowledging the different paths and processes through which actors, institutions and arenas interact.

All public health topics quoted as examples, sparse voices in the universe of studies on health policy in Brazil, and many others about agenda setting, public policies formulation and decision-making processes could take advantage of the public policies analyses. Although being minority, these works showed a rapprochement between the fields that tend to be gradually expanded. That is so because the field of public policies is gaining room in Brazil, acquiring theoretical density and, thus, influencing sector-specific studies (Arretche, 2003ARRETCHE, M. Dossiê agenda de pesquisas em políticas públicas. Revista Brasileira de Ciências Sociais, São Paulo, v. 18, n. 51, p. 7-10, 2003.; Souza, 2003SOUZA, C. Estado do campo da pesquisa em políticas públicas. Revista Brasileira de Ciências Sociais, São Paulo, v. 18, n. 51, p. 15-20, 2003.). In this sense, distance between the fields tends to be shortened, expanding interdisciplinary dialogue and benefiting both.

Finally, this work did not absolutely intend to elucidate the weakness of works previously published, but to show the lack of closer dialogue, despite the widely known difficulty posed to the interdisciplinary dialogue. Such dialogue assumes the mastering not only of one field of scientific knowledge, with its narratives, methods and theoretical tools of analysis, but of two fields, making dialogue more complex and, therefore, less likely. This is not an easy task. As stated by Minayo et al. (2013MINAYO, M. C. S. A produção de conhecimentos na interface entre as ciências sociais e humanas e a saúde coletiva. Saúde e Sociedade, São Paulo, v. 22, n. 1, p. 21-31, 2013., p. 104), one must be confident in both areas to build interdisciplinarity. Reinforcing this dialogue by building theoretical bridges oriented to improve social reality - an interdisciplinary science that is socially engaged and committed to the improvement of health public policies - is a worthwhile effort.

Acknowledgment

The author would like to thank the priceless contribution of Matheus Nunes de Freitas to the elaboration of the database part of this article.

References

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