Contribution of universities to the review of the National Health Promotion Policy3 3 We thank the Pan American Health Organization for the funding of the research – PAHO Contract No. BR/CNT/1301743.001 of 06/2014.

Evelin Minowa Helena Akemi Wada Watanabe Fabiana Alves do Nascimento Elisabete Agrela de Andrade Sandra Costa de Oliveira Marcia Faria Westphal About the authors

Abstract

In 2014, the National Health Promotion Policy (PNPS) underwent a participatory review process, with collaboration of public managers, participants of social movements, professors and researchers from universities. In this process, it was necessary to know and analyze how the contributions of the various actors involved occurred and how they were incorporated into the new version of the Policy. The aim of this study is to discuss the contribution of universities to the review of the National Health Promotion Policy. Using the Delphi technique, questionnaires were sent by e-mail to the research group leaders of the Brazilian universities; the e-mails were sent in two rounds, and the second round was only conducted after analysis of cases of consensus and dissent in relation to the first. Based on the analysis of the forms, it was concluded that the universities’ contributions to the new National Health Promotion Policy are related to its structure, principles and values, objectives, priority themes, and operational axes.

Keywords:
Health Promotion; Health Policy; Social Policy; Public Policy; Research Groups

Introduction

Health promotion (HP), as an alternative model for health care, was developed in Brazil under the influence of international proposals (Brasil, 2002BRASIL. Ministério da Saúde. Secretaria de Políticas de Saúde. As cartas da promoção da saúde. Brasília, DF: Ministério da Saúde, 2002. Disponível em: <Disponível em: https://goo.gl/JMzZoq >. Acesso em: 26 out. 2017.
https://goo.gl/JMzZoq...
; Leavell; Clark, 1976LEAVELL, H.; CLARK, E. G. Medicina preventiva. São Paulo: McGraw-Hill, 1976.; Nunes, 1992NUNES, E. D. Henry Ernest Sigerist: pioneiro da história social da medicina e da sociologia médica. Educación Médica y Salud, Washington, DC, v. 26, n. 1, p. 70-81. 1992. Disponível em: <Disponível em: https://goo.gl/44AS95 >. Acesso em: 26 out. 2017.
https://goo.gl/44AS95...
) and of the movement of public health/health reform in the conception and institutionalization of the Brazilian National Health System (SUS).

This area of knowledge and practices in the SUS has come a long way - almost 20 years - to become established as a National Health promotion Policy (PNPS), expanding its possibilities of activity in relation to the completeness of health care and to the social determination of the health-disease process. Malta et al. (2016MALTA, D. C. et al. Política Nacional de Promoção da Saúde (PNPS): capítulos de uma caminhada ainda em construção. Ciência Saúde Coletiva, Rio de Janeiro, v. 21, n. 6, p. 1683-1694, 2016. Disponível em: <Disponível em: http://ref.scielo.org/vq473k >. Acesso em: 26 out. 2017.
http://ref.scielo.org/vq473k...
, p. 1684) state that this process occurred in three periods: (1) 1998-2004, called the “embryo of health promotion”; (2) 2005-2013, when “a PNPS was born, grew, and developed”; (3) 2013-2015, “reviewing, expanding, and disseminating the PNPS.” In this last period, there was the review to which this article refers.

In 2014, the need and opportunity for a process of review of the PNPS emerged as a possibility of update based on the results of evaluations about the policy and its difficulties regarding implementation, combined with situational issues in Brazil, related to health and other social areas and, especially, to the commitments assumed by the Brazilian Government in the then recent years concerning national and international policies and agendas, such as: The United Nations’ High-level Meeting on Non-communicable Diseases (2011), World Conference of Social Determinants of Health (2011), Rio+20 Conference (2012), and the 8th Global Conference on Health Promotion - Health in all policies (2013) (Baracho, 2013BARACHO, M. Pré-conferência testa metodologia para formulação da nova Política Nacional de Promoção da Saúde (PNPS). Portal DSS Nordeste, Recife, 2 set. 2013. Disponível em: <Disponível em: https://goo.gl/Z9MaHM >. Acesso em: 26 out. 2017.
https://goo.gl/Z9MaHM...
; Rocha et al., 2014ROCHA, D. G. et al. Processo de revisão da Política Nacional de Promoção da Saúde: múltiplos movimentos simultâneos. Ciência & Saúde Coletiva, Rio de Janeiro, v. 19, n. 11, p. 4313-4322, 2014. Disponível em: <Disponível em: http://ref.scielo.org/q6khc2 >. Acesso em: 26 out. 2017.
http://ref.scielo.org/q6khc2...
). According to Rocha et al. (2014ROCHA, D. G. et al. Processo de revisão da Política Nacional de Promoção da Saúde: múltiplos movimentos simultâneos. Ciência & Saúde Coletiva, Rio de Janeiro, v. 19, n. 11, p. 4313-4322, 2014. Disponível em: <Disponível em: http://ref.scielo.org/q6khc2 >. Acesso em: 26 out. 2017.
http://ref.scielo.org/q6khc2...
, p. 4315), “the discussions and documents from these agendas, as well as their necessary organization, stimulated the review of the PNPS.” Issues such as equity, intersectorality, respect for diversity, intrasectorality, sustainability, globalization, and initiative on the social determinants of health (SDH) assumed a great importance to the nation, opening possibilities for insertion in these global agendas.

The process of reviewing the PNPS 2006, held at the beginning of the third stage, in 2013, was formulated and coordinated by the Secretariat of Health Surveillance, Ministry of Health (SVS/MS), through its Steering Committee, in partnership with the Pan American Health Organization (PAHO) and the Health Promotion Group of the Brazilian Association of Post-Graduation in Collective Health (Abrasco), and involved health workers and workers from other sectors in their management levels, advisory boards, social movements, and universities that teach and research issues related to health promotion.

Considering that universities and their professors have specialized and contextualized knowledge and opinions, having an essential role in health training and being protagonists in HP, this group, through representatives related to the area of health promotion, was invited to give their opinion, suggesting subjects and propounding issues to be included in the new formulation of the PNPS 2013.

This article presents and analyzes the contributions of universities and research centers to the review of the 2013 PNPS, comparing with the theoretical framework based on which the policy was formulated in 2006.

The conceptual model of health promotion guiding the review of the PNPS

Health promotion in Brazil, as science and art associated with the historical-social dimension of the health-disease process, in connection with the guiding framework of the Brazilian National Health System and in accordance with the International conferences, formally enters the field of intersectoral public policies, to contribute to understanding the social, economic, political, educational, environmental, and cultural determinants of this process.

However, as already mentioned, the analysis and evaluation of the 2006/2010 PNPS (Brasil, 2010BRASIL. Ministério da Saúde. Secretaria de Vigilância em Saúde. Secretaria de Atenção à Saúde. Política Nacional de Promoção da Saúde. 3. ed. Brasília, DF: Ministério da Saúde , 2010.) showed that the practice did not always correspond to the theoretical-political trends described in its document-base. The theoretical framework was not consistent with practices proposed by the PNPS. Part of the literature on the subject draws attention to the general trend of many projects in the area, including some funded by the Ministry of Health, of being neoliberal and proposing practices that make the individuals culpable/responsible for their own health condition, exempting the State from part of its functions (Ferreira Neto et al., 2013FERREIRA NETO, J. L. F. et al. Processos da construção da Política Nacional de Promoção da Saúde. Cadernos de Saúde Pública, Rio de Janeiro, v. 29, n. 10, p. 1997-2007, 2013. Disponível em: <Disponível em: http://ref.scielo.org/dhwcpq >. Acesso em: 26 out. 2017.
http://ref.scielo.org/dhwcpq...
).

The team involved in the review of national policy considers the health promotion as founded on a positive definition of health, with complex issues related to social determinants. This is an emancipatory, cross-sectional political practice, an ethical imperative in the contemporary world, promoter of social equity and accomplished through intersectoral practices generated from the analysis of the issues identified in the territories. The team also considers the processes of power expansion, of autonomy building of the subject building, and of knowledge building, aspects that require an approach with the collectivities, the formation of commitment networks, and the valuing of potential, also pointing to the involvement in advocacy processes for the improvement of living and working conditions. To the health workers, the team indicates work processes that prioritize their mode of subjectivation (Westphal, 2008WESTPHAL, M. F. Promoção da saúde: uma nova agenda para a saúde. In: ROCHA, A. A.; CESAR, C. L. G. (Org.). Saúde pública: bases conceituais. São Paulo: Atheneu, 2008. p. 163-197.).

The coordination of the process of reformulation of PNPS 2013 synthesized all these principles, values, and strategies in the following concept of health promotion: “a set of strategies and ways of producing health, in the individual and collective spheres, aiming to meet the social and health needs and ensure the improvement of the quality of life of the population. The process emerges intrinsically marked by its own issues of right to health” (Malta et al., 2016MALTA, D. C. et al. Política Nacional de Promoção da Saúde (PNPS): capítulos de uma caminhada ainda em construção. Ciência Saúde Coletiva, Rio de Janeiro, v. 21, n. 6, p. 1683-1694, 2016. Disponível em: <Disponível em: http://ref.scielo.org/vq473k >. Acesso em: 26 out. 2017.
http://ref.scielo.org/vq473k...
, p. 1683).

Public policy analysis model: why and how to analyze the PNPS before, during, and after its reformulation

Rocha et al. (2014ROCHA, D. G. et al. Processo de revisão da Política Nacional de Promoção da Saúde: múltiplos movimentos simultâneos. Ciência & Saúde Coletiva, Rio de Janeiro, v. 19, n. 11, p. 4313-4322, 2014. Disponível em: <Disponível em: http://ref.scielo.org/q6khc2 >. Acesso em: 26 out. 2017.
http://ref.scielo.org/q6khc2...
, p. 4314), in the article in which they describe and analyze the PNPS review, state that “there is no question that the launch of the National Health Promotion Policy (PNPS), by the federal manager of the SUS, in 2006, in the context of new management pacts, meant a milestone for the definition of goals and for the allocation of specific resources for the area within the State and municipal spheres.” Despite the scarcity of resources for the area and controversies as to its place in the Ministry of Health, the initiative of institutionalizing a public policy of this nature and review it formally brought and keeps bringing benefits for its development. Souza (2007SOUZA, C. Estado da arte da pesquisa em políticas públicas. In: HOCHMAN, G.; ARRETCHE, M.; MARQUES, E. (Org.). Políticas públicas no Brasil. Rio de Janeiro: Fiocruz , 2007. p. 65-86.) already spoke of the benefits from the formulation of a public policy, showing that through the clarification of objectives, strategies, and guidelines, governments clarify their purposes, or rather, express their intentions of work.

These same authors (Rocha et al., 2014ROCHA, D. G. et al. Processo de revisão da Política Nacional de Promoção da Saúde: múltiplos movimentos simultâneos. Ciência & Saúde Coletiva, Rio de Janeiro, v. 19, n. 11, p. 4313-4322, 2014. Disponível em: <Disponível em: http://ref.scielo.org/q6khc2 >. Acesso em: 26 out. 2017.
http://ref.scielo.org/q6khc2...
) state that the PNPS review process was based on the public policy analysis model proposed by Walt and Gibson (apud Araújo Júnior; Maciel Filho, 2001ARAÚJO JÚNIOR, J. L. C.; MACIEL FILHO, R. Developing an operational framework for health policy analysis. Revista Brasileira Saúde Materno Infantil, Recife, v. 1, n. 3, p. 203-221, 2001. Disponível em: <Disponível em: http://ref.scielo.org/hgck6b >. Acesso em: 26 out. 2017.
http://ref.scielo.org/hgck6b...
), which considers as categories of analysis the following aspects: the context, the content, the process, and the social actors.

The methodology used in reviewing the policy and inspired by its conception of health promotion was highly participatory and aimed to obtain consult elements throughout the national territory, in the governmental contexts and in the regional contexts, with different population segments. It was the policy analysis based on the model of Walt and Gibson, as already mentioned, that, according to Rocha et al. (2014ROCHA, D. G. et al. Processo de revisão da Política Nacional de Promoção da Saúde: múltiplos movimentos simultâneos. Ciência & Saúde Coletiva, Rio de Janeiro, v. 19, n. 11, p. 4313-4322, 2014. Disponível em: <Disponível em: http://ref.scielo.org/q6khc2 >. Acesso em: 26 out. 2017.
http://ref.scielo.org/q6khc2...
p. 4315), signified the “democratization and expansion of the participation in the construction and implementation of the PNPS, thus seeking its translation into a sustainable public policy.”

Between 2013 and 2014, five simultaneous methodological movements were carried out for analysis of the structure and preparation of the revised version, with different approaches and themes related mainly to the principles, objectives, and strategies of the policy, building a process of commitment networks for the implementation of the future PNPS, namely:

  1. (1) consultations with health professionals, representatives of social movements, users, managers and technicians of state and municipal health secretariats and of secretariats and departments of the Ministry of Health, through electronic form (FormSUS);

  2. (2) workshops for regional consultation and consultation with the National Health Council: contextualized critical reflections promoted by the PNPS review group with diverse actors of HP in the five regions of Brazil, and more specifically with council members responsible for the decisions of the health sector;

  3. (3) sectoral and intersectoral approach with key informants of the Ministry of Health and of other government ministries and secretariats, as well as of non-governmental institutions and universities, through the Delphi technique;

  4. (4) consensus workshops conducted by the Ministry of Health, through the other methodological movements, to systematize the contributions to the new version of the PNPS;

  5. (5) national seminar with large participation, where the results of the process were presented and necessary adjustments of form and content were made in the text for the final review and submission for approval in the National Health Council.

According to Kingdon (1984 apud Baptista; Mattos, 2015BAPTISTA, T. W. F.; MATTOS, R. A. Sobre política (ou o que achamos pertinente refletir para analisar políticas). In: ______. (Org.). Caminhos para análise das políticas de saúde. Porto Alegre: Rede Unida, 2015. p. 83-129. Disponível em: <https://goo.gl/KccqKF>. Acesso em: 26 out. 2017.
https://goo.gl/KccqKF...
, p. 115), in the formulation of a policy agenda, participants of the decision-making process are divided into governmental and non-governmental, visible or invisible. Academics or specialists are presented in the group of invisible non-governmental actors, that is, that act indirectly on the formation of the agenda, through the production of policy alternatives and indicators, but, in the process studied, this did not happen that way. University professors had a visible leadership role in the process of reformulating the policy along with public agents in charge of this area of knowledge and practices in the Ministry of Health and in the Pan American Health Organization.

Universities, represented by their professors, as one of the groups participating in this process of analysis and formulation of the PNPS, and how they contributed to the process is what we describe and analyze below in this article.

Method

The systematization of the contribution of researchers of Brazilian universities in the PNPS review occurred between November 2013 and April 2014, and was conducted by the Center for Research and Documentation on Healthy Cities (Cepedoc) of the School of Public Health, University of São Paulo. The detailed description of this process is recorded in the technical document with the summary of the results of the consultation with the universities (Westphal; Minowa, 2014WESTPHAL, M. F.; MINOWA, E. Documento técnico com síntese dos resultados da consulta intrassetorial e com as IES/universidades sobre o eixo II do Plano Nacional de Enfrentamento das Doenças Crônicas a ser apresentado nas Oficinas de Consenso previstas pela metodologia de Revisão da Política Nacional de Promoção da Saúde. Brasília, DF: Ministério da Saúde: OPAS, 2014.). The term “universities,” in the PNPS review, represents broadly the group of teaching and research institutions with participation of researchers from universities, teaching and research foundations, and schools, in addition to universities, both public and private, from all regions of the country.

The Delphi technique was the method proposed by the Ministry of Health, within the process of reviewing the PNPS, to collect and systematize the opinion of specialists in health promotion of the Brazilian universities.

The Delphi technique and its application in the study

We used a process of distance consultation with a group of specialists, which had no face-to-face communication with one another, about a certain subject - in this case, the PNPS. This process - Delphi technique - consists of rounds of questions with specialists from a particular field, by means of successive questionnaires, seeking consensus on the topic of interest. At every round the answers were compiled, then identifying cases of consensus and dissent, returning the latter to new reviews, until reaching the saturation of answers and determining the final opinions, even without total consensus. However, sometimes, the final result is the disagreement on one or more issues (Akerman; Fischer, 2014AKERMAN, M.; FISCHER, A. Agenda Nacional de Prioridades na Pesquisa em Saúde no Brasil (ANPPS): foco na subagenda 18 - Promoção da Saúde. Saúde e Sociedade, São Paulo, v. 23, n. 1, p. 180-190, 2014. Disponível em: <Disponível em: https://goo.gl/sKm8BC >. Acesso em: 26 out. 2017.
https://goo.gl/sKm8BC...
; Gallardo; Olmos, 2008GALLARDO, R. Y.; OLMOS, R. C. La técnica Delphi y la investigación en los servicios de salud. Ciencia y Enfermeria, Concepción, v. 14, n. 1, p. 9-15, 2008. Disponível em: <Disponível em: http://ref.scielo.org/ggr86g >. Acesso em: 26 out. 2017.
http://ref.scielo.org/ggr86g...
; Piñeiro, 2003PIÑEIRO, E. M. La técnica Delphi como estrategia de consulta a los implicados en la evaluación de programas. Revista de Investigación Educativa, Medellín, v. 21, n. 2, p. 449-463, 2003. Disponível em: <Disponível em: https://goo.gl/amSMq8 >. Acesso em: 26 out. 2017.
https://goo.gl/amSMq8...
; Silva et al., 2009SILVA, A. M. et al. Utilização da técnica Delphi on-line para investigação de competências: relato de experiência. Revista Gaúcha de Enfermagem, Porto Alegre, v. 30, n. 2, p. 348-351, 2009. Disponível em: <Disponível em: https://goo.gl/kU5v8e >. Acesso em: 26 out. 2017.
https://goo.gl/kU5v8e...
; Valdés; Marín, 2013VALDÉS, M. G.; MARÍN, M. S. Empleo del método Delphi en investigaciones sobre salud publicadas en revistas científicas cubanas. Revista Cubana de Información en Ciencias de la Salud, Havana, v. 24, n. 2, p. 133-144, 2013. Disponível em: <Disponível em: http://ref.scielo.org/kz8kpz >. Acesso em: 26 out. 2017.
http://ref.scielo.org/kz8kpz...
).

The selection of researchers was made by searching in the Directory of Research Groups of the National Council for Scientific and Technological Development (CNPq)4 4 Available at: <http://dgp.cnpq.br/buscaoperacional>. Access on: 31 Oct. 2017. . The search was conducted using the term “health promotion,” with the filter “exact phrase,” in the field “consultation of groups,” and the term “health sciences” in the field “broad area of group.” This search resulted in 470 research groups of Brazil, identified up to January 18, 2014.

We used the following inclusion criteria for selection: (1) presenting the term “health promotion” in the title or description of the group, in the keywords or lines of research; (2) having been updated in the CNPq within at most one year; (3) the leader of the group should have in the Lattes curriculum vitae: graduate mentoring - master’s or doctorate degree - showing research production and group continuation and scientific production in the area of health promotion, especially articles in periodicals or chapters of books.

One hundred research groups met the inclusion criteria, and two others were appointed directly by the Ministry of Health, totaling 102 participants for Delphi.

We used an electronic platform in the internet for data collection, which facilitated the registration of research subjects and the sending of questionnaires via e-mail. For the analysis, the platform enabled the organization of answers on tables and the export of their content in editable formats.

The questionnaire was adapted from FormSUS (Ferreira Neto et al., 2013FERREIRA NETO, J. L. F. et al. Processos da construção da Política Nacional de Promoção da Saúde. Cadernos de Saúde Pública, Rio de Janeiro, v. 29, n. 10, p. 1997-2007, 2013. Disponível em: <Disponível em: http://ref.scielo.org/dhwcpq >. Acesso em: 26 out. 2017.
http://ref.scielo.org/dhwcpq...
), with inclusion of open-ended questions. We conducted two rounds of the Delphi technique so participants could reconsider their answers with the aid of information received from the other specialists, seeking a convergence of answers.

Data were analyzed by two techniques: for the open-ended questions, qualitative content analysis was carried out through reading and identification of cases of consensus and dissent with the theoretical framework and between the respondents. The close-ended questions were submitted to quantitative analysis with simple percentage.

In the qualitative analysis, consensus was established when the item evaluated received no dissenting evaluation. The item that did not reach the criteria in the first round returned for the second round as dissent.

For the synthesis of research, we used a matrix of answers previously built by the team coordinating the PNPS review to facilitate joint analysis of all methodological movements included in the review process (Rocha et al., 2014ROCHA, D. G. et al. Processo de revisão da Política Nacional de Promoção da Saúde: múltiplos movimentos simultâneos. Ciência & Saúde Coletiva, Rio de Janeiro, v. 19, n. 11, p. 4313-4322, 2014. Disponível em: <Disponível em: http://ref.scielo.org/q6khc2 >. Acesso em: 26 out. 2017.
http://ref.scielo.org/q6khc2...
).

To analyze the data from this study, we compared the new version of the PNPS (the final version, officially published) with the matrix of answers obtained in Delphi with the first version of the policy (Brasil, 2007BRASIL. Ministério da Saúde. Secretaria de Vigilância em Saúde. Secretaria de Atenção à Saúde. Política Nacional de Promoção da Saúde. 2. ed. Brasília, DF: Ministério da Saúde , 2007. , 2014BRASIL. Ministério da Saúde. Portaria nº 2.446, de 11 de novembro de 2014. Redefine a Política Nacional de Promoção da Saúde (PNPS). Diário Oficial da União, Brasília, DF, 13 nov. 2014. Seção 1, p. 68. Disponível em: <Disponível em: https://goo.gl/hvezic >. Acesso em: 27 out. 2017.
https://goo.gl/hvezic...
). This analysis sought to determine the contributions presented by the group through the Delphi that had an impact on the final version of the new PNPS, that is, which notes, criticisms, suggestions for change, inclusion or exclusion of items and topics that were highlighted by the participants in the review that were not highlighted in the first version of the policy or did not exist and that were represented in some way in the current version.

The first round of the Delphi technique was initiated on February 10 and finished on February 24, 2014. Of the 102 questionnaires sent, 58 returned with answers of respondents (57%). The second round took place in the period from April 15 to 25, 2014. The second round was sent to the 58 participants who answered the first one; of these, 19 sent back the second questionnaire completed (33%).

Results and discussion

This research, as presented in the methodological procedures, was divided into two phases: the Delphi research itself and the participation in consensus workshops and in the National Seminar, representing the ideas and contributions of the university to the discussion and reformulation of the new policy.

This process brought major changes to the structure and content of the current policy. The structure of the 2006 PNPS consisted of: overall objective, specific objectives, guidelines, and specific actions. The 2014 PNPS review aimed to cover the approach between the behavioral view of HP and that focused on tackling the social determinants of the health-disease process. The final content addresses: values and principles, objectives - general and specific, guidelines, cross-sectional issues, operational axes, skills common to all spheres of management and of the different levels of governments, the financing and the establishment of priority themes for initiatives (Brasil, 2014BRASIL. Ministério da Saúde. Portaria nº 2.446, de 11 de novembro de 2014. Redefine a Política Nacional de Promoção da Saúde (PNPS). Diário Oficial da União, Brasília, DF, 13 nov. 2014. Seção 1, p. 68. Disponível em: <Disponível em: https://goo.gl/hvezic >. Acesso em: 27 out. 2017.
https://goo.gl/hvezic...
; Rocha et al., 2014ROCHA, D. G. et al. Processo de revisão da Política Nacional de Promoção da Saúde: múltiplos movimentos simultâneos. Ciência & Saúde Coletiva, Rio de Janeiro, v. 19, n. 11, p. 4313-4322, 2014. Disponível em: <Disponível em: http://ref.scielo.org/q6khc2 >. Acesso em: 26 out. 2017.
http://ref.scielo.org/q6khc2...
).

Rocha and David (2015ROCHA, P. R.; DAVID, H. M. S. L. Determinação ou determinantes? Uma discussão com base na Teoria da Produção Social da Saúde. Revista da Escola de Enfermagem da USP, São Paulo, v. 49, n. 1, p. 129-135, 2015. Disponível em: <Disponível em: http://ref.scielo.org/8t8v3f >. Acesso em 26 out. 2017.
http://ref.scielo.org/8t8v3f...
), when comparing the use of the terms “social determination of health” and “social determinants of health” based on the theory of social production of health, state that the first is understood as:

A perspective that considers the wider field in which the health-disease processes are produced, seeking to bring to the awareness plane an understanding that establishes mediations between the fragmented reality and the social totality, while the second expresses the prioritization of the identification of measurable social variables over a more descriptive and deep understanding of the contexts of health. (p. 134)

By assuming health as an eminently human phenomenon, rather than a biological-natural fact, the effort to understand the determination of health goes far beyond the use of causality schemes, and should not be confused with an empiricist association between health conditions and social factors (Nogueira, 2010NOGUEIRA, R. P. (Org.). Determinação social da saúde e reforma sanitária. Rio de Janeiro: Cebes, 2010.; Rocha; David, 2015ROCHA, P. R.; DAVID, H. M. S. L. Determinação ou determinantes? Uma discussão com base na Teoria da Produção Social da Saúde. Revista da Escola de Enfermagem da USP, São Paulo, v. 49, n. 1, p. 129-135, 2015. Disponível em: <Disponível em: http://ref.scielo.org/8t8v3f >. Acesso em 26 out. 2017.
http://ref.scielo.org/8t8v3f...
). To reach this formulation, there were interactions and negotiations between key actors and organizations that, in the end, agreed as to the terms of the revised PNPS (Rocha et al., 2014ROCHA, D. G. et al. Processo de revisão da Política Nacional de Promoção da Saúde: múltiplos movimentos simultâneos. Ciência & Saúde Coletiva, Rio de Janeiro, v. 19, n. 11, p. 4313-4322, 2014. Disponível em: <Disponível em: http://ref.scielo.org/q6khc2 >. Acesso em: 26 out. 2017.
http://ref.scielo.org/q6khc2...
).

Chart 1 presents a summary of the main contributions of the group of universities based on data obtained through the Delphi and the negotiations in the consensus workshops and the national seminar. For better understanding, the Chart brings a list of the 2006 PNPS items, the contributions of universities in the policy review, and the items changed in the final version of 2014 because of these contributions.

Chart 1
Comparison between the items of the National Health Promotion Policy that were changed due to the contribution of the universities, 2015

The research participants agreed with the principles and values of the PNPS proposed in the form and that these had not been been made explicit in the previous version of the policy. The group expressed their opinion valuing participation, empowerment, and autonomy as cores of health promotion, without which this area of knowledge and practices is disqualified. Regarding the other principles, such as completeness and equity, they commented: “they are in the foundations of the SUS,” in the same way that sustainability and social justice, which were highly valued by respondents (Westphal; Minowa, 2014WESTPHAL, M. F.; MINOWA, E. Documento técnico com síntese dos resultados da consulta intrassetorial e com as IES/universidades sobre o eixo II do Plano Nacional de Enfrentamento das Doenças Crônicas a ser apresentado nas Oficinas de Consenso previstas pela metodologia de Revisão da Política Nacional de Promoção da Saúde. Brasília, DF: Ministério da Saúde: OPAS, 2014.). These were favorable to making them explicit, warning that, although important in theory, in practice, completeness and equity hardly have been used to guide health promotion initiatives.

It should be noted that the major contribution of the group of universities for the reformulation of the PNPS’ general objective was to bring it closer to the theoretical-philosophical framework, expressed in the positive and expanded conception of health promotion. This is intended to address the causes of the problems with positive and sustainable strategies and proposals of comprehensive, intrasectoral, and intersectoral initiatives, as opposed to the emphasis given to risk factors and reduction of vulnerabilities in the previous version of the PNPS, which led, in many cases, to the construction of prescriptive and normative initiatives that assigned culpability to individuals, as pointed out by Traverso-Yépez (2007)TRAVERSO-YÉPEZ, M. A. Dilemas na promoção da saúde no Brasil: reflexões em torno da política nacional. Interface: Comunicação, Saúde e Educação, Botucatu, v. 11, n. 22, p. 223-238, 2007. Disponível em: <Disponível em: https://goo.gl/p22P8j >. Acesso em: 26 out. 2017.
https://goo.gl/p22P8j...
, Ferreira Neto et al. (2013)FERREIRA NETO, J. L. F. et al. Processos da construção da Política Nacional de Promoção da Saúde. Cadernos de Saúde Pública, Rio de Janeiro, v. 29, n. 10, p. 1997-2007, 2013. Disponível em: <Disponível em: http://ref.scielo.org/dhwcpq >. Acesso em: 26 out. 2017.
http://ref.scielo.org/dhwcpq...
, and Rocha et al. (2014ROCHA, D. G. et al. Processo de revisão da Política Nacional de Promoção da Saúde: múltiplos movimentos simultâneos. Ciência & Saúde Coletiva, Rio de Janeiro, v. 19, n. 11, p. 4313-4322, 2014. Disponível em: <Disponível em: http://ref.scielo.org/q6khc2 >. Acesso em: 26 out. 2017.
http://ref.scielo.org/q6khc2...
). This contribution can be observed in the new formulation of the general objective.

Regarding the specific objectives, there were points of consensus that were object of review by the consensus group. An example was the change in the wording of Objective VI of the 2006 policy - “Enhance and optimize the use of public spaces of coexistence and health production for the development of HP initiatives.” The group of universities suggested replacing the words “public spaces” with “spaces of society” - taking into consideration the formulations of Habermas, that the expression “public spaces” is synonymous with spaces for policy formulation, as stated by Losekann (2009LOSEKANN, C. Esfera pública habermasiana, seus principais críticos e as possibilidades do uso deste conceito no contexto brasileiro. Pensamento Plural, Pelotas, n. 4, p. 37-57, jan./jun. 2009. Disponível em: <Disponível em: https://goo.gl/Mv4eJu >. Acesso em: 26 out. 2017.
https://goo.gl/Mv4eJu...
). The result was the change in the wording of this objective, which became the Objective V of the new PNPS.

The participants pointed out the absence, in the previous version of the specific objectives, of essential elements of the health promotion process, discussed by Traverso-Yépez (2007)TRAVERSO-YÉPEZ, M. A. Dilemas na promoção da saúde no Brasil: reflexões em torno da política nacional. Interface: Comunicação, Saúde e Educação, Botucatu, v. 11, n. 22, p. 223-238, 2007. Disponível em: <Disponível em: https://goo.gl/p22P8j >. Acesso em: 26 out. 2017.
https://goo.gl/p22P8j...
, Buss and Carvalho (2009BUSS, M. P.; CARVALHO, A. I. Desenvolvimento da promoção da saúde no Brasil nos últimos vinte anos (1988-2008). Ciência e Saúde Coletiva, Rio de Janeiro, v. 14, n. 6, p. 2305-2316, 2009. Disponível em: <Disponível em: https://goo.gl/8UrWAf >. Acesso em: 26 out. 2017.
https://goo.gl/8UrWAf...
), and Rocha et al. (2014ROCHA, D. G. et al. Processo de revisão da Política Nacional de Promoção da Saúde: múltiplos movimentos simultâneos. Ciência & Saúde Coletiva, Rio de Janeiro, v. 19, n. 11, p. 4313-4322, 2014. Disponível em: <Disponível em: http://ref.scielo.org/q6khc2 >. Acesso em: 26 out. 2017.
http://ref.scielo.org/q6khc2...
), such as: empowerment, autonomy, social participation, governance, sustainability, human rights, continuing education, training for multidisciplinary work, and evaluation.

Agreement in the consensus group as to this absence led to changes, exclusion, joining, and additions of some objectives, totaling thirteen specific objectives at the end. Chart 1 presents the new objectives to which contributed elements offered by the group of universities. Their contents are related to the previous assessment made by Campos, Barros, and Castro (2004CAMPOS, G. W. S.; BARROS, R. B.; CASTRO, A. M. Avaliação da política nacional de promoção da saúde. Ciência e Saúde Coletiva, Rio de Janeiro, v. 9, n. 3, p. 745-749, 2004. Disponível em: <Disponível em: https://goo.gl/y3bnkw >. Acesso em: 26 out. 2017.
https://goo.gl/y3bnkw...
) and also by Campos and Campos (2006)CAMPOS, G. W. S.; CAMPOS, R. T. O. Co-construção de autonomia: o sujeito em questão. In: CAMPOS, G. W. S. et al. Tratado de saúde coletiva. São Paulo: Hucitec; Rio de Janeiro: Fiocruz, 2006. p. 669-688., expressing their points of view on which would be the axes of activity of the National Health Policy that should guide the objectives of the 2014 PNPS.

Regarding the “Guidelines,” it was a consensus among the subjects of the research that the 2006 PNPS was based on principles and values that were not declared on that policy, which consequently influenced the preparation. The new PNPS altered the previous guidelines, and two guidelines were included considering the arguments propounded by the group of universities concerning sustainable development, territorialization, the creation of healthy environments, and intersectorality. The second and seventh guidelines express this inclusion.

The subjects of the research reinforced the importance of intersectorality and intersectoral networks to enhance participatory processes in health promotion. The problematization of the intersectorality and its importance for health promotion have been emphasized by several authors, such as Akerman et al. (2016AKERMAN, M. et al. Intersetorialidade? IntersetorialidadeS! Ciência & Saúde Coletiva, Rio de Janeiro, v. 19, n. 11, p. 4291-4300, 2016. Disponível em: <Disponível em: https://goo.gl/f3P3mv >. Acesso em: 26 out. 2017.
https://goo.gl/f3P3mv...
), indicating that although very important, the issue is still open, requiring further initiatives of research on the subject.

There was also the addition of a guideline related to permanent education, field in which teaching and research institutions have a key role.

The greatest contention between Delphi participants of universities was about the exclusion or maintenance of the so-called “specific initiatives,” reflecting the great controversy that exists both in the literature and in the institutions participating in the consensus workshops that produced the the final version of the 2014 PNPS, as they considered that it carried a tendency of assigning responsibility/culpability to individuals concerning their own health condition and of indicating a standardization of the everyday life of individuals, as pointed out by Westphal (2008WESTPHAL, M. F. Promoção da saúde: uma nova agenda para a saúde. In: ROCHA, A. A.; CESAR, C. L. G. (Org.). Saúde pública: bases conceituais. São Paulo: Atheneu, 2008. p. 163-197.), Ferreira Neto et al. (2013)FERREIRA NETO, J. L. F. et al. Processos da construção da Política Nacional de Promoção da Saúde. Cadernos de Saúde Pública, Rio de Janeiro, v. 29, n. 10, p. 1997-2007, 2013. Disponível em: <Disponível em: http://ref.scielo.org/dhwcpq >. Acesso em: 26 out. 2017.
http://ref.scielo.org/dhwcpq...
, and others.

The opinions of some members of the group of universities on the issue of specific initiatives are presented below:

The policy should foster specific initiatives, but does not need to list them. It can point to general topics which each federated entity can address and build their local plans, covering the local and regional specificities, being cross-sectional with planning instruments of the SUS and the public service - PPA-LOAS. (Member of the Group of Universities)

I don’t know if the specific initiatives should compose the text of the new ordinance. They can be included in another secondary document. I’m concerned a little bit with the comprehensive detailing of a policy, it’s as if you’re talking about the same thing more than once and in different ways. For example: if I ratify building healthy habits, do I need to mention the smoking habit? (Member of the Group of Universities)

The phrases presented and the data indicate that there is a significant number of respondents who questioned the existence of specific initiatives defined in the policy, as they incur the risk of, on behalf of the guiding concept of health promotion initiatives and of its principles and values, guide to building behavioral practices that deviate from these same principles. On the other hand, the group of universities considered the operational axes important, as they evaluate that they signify progress for the implementation of the concepts, values, and objectives (Brasil, 2014BRASIL. Ministério da Saúde. Portaria nº 2.446, de 11 de novembro de 2014. Redefine a Política Nacional de Promoção da Saúde (PNPS). Diário Oficial da União, Brasília, DF, 13 nov. 2014. Seção 1, p. 68. Disponível em: <Disponível em: https://goo.gl/hvezic >. Acesso em: 27 out. 2017.
https://goo.gl/hvezic...
, p. 15).

Considering the criticism and the support, the new PNPS maintained nearly all the specific initiatives, but with the name of “priority themes,” with the exception of the initiative “Dissemination and Implementation of the National Health Promotion Policy,” which was replaced with the theme “Training and Permanent Education” to meet the general criticism that appeared throughout the research process, stating that the PNPS addressed little this theme.

The new topics in the PNPS, entitled “Cross-sectional Themes” and “Operational Axes,” submitted to consultation during the Delphi with universities, incorporated these issues into their essence. It was observed that the axes pointed out as most important by the participants were maintained, with only minor changes in wording.

It was observed, however, that even the axes with greater dissent in Delphi were also maintained, with change of wording. These axes were: “Communication and media,” renamed to “Social communication and media,” and “Regulation and Control,” included in the axis called “Management.” Some suggestions compiled in Delphi were included in the final wording of the topic “Operational Axes,” such as the change in the wording of “Workforce qualification” to a title close to “Continuing education and training” - the final title in the new PNPS was defined as “Education and training.”

In addition to the themes that today are part of the national policy, the researchers of the universities, in this part of specific initiatives/priority themes, suggested new themes, interesting to stand out, such as:

  • Add and deepen the issue of governance;

  • Focus on the theme of inclusion, adding initiatives directed to deal with situations of vulnerability in a specific block of social inclusion that comprises urban and rural situations and their singularities;

  • Add to another block the specific initiatives aimed at the political and social process that characterizes the HP - empowerment, popular education in health and art.

Despite the other methodological strategies and movements that composed the complex process of review, the authors consider that the universities contributed significantly to the preparation of the new PNPS. In most points of the revised version, specified in Chart 1 and discussed previously, it was possible to identify changes that correspond to suggestions and criticisms presented as consensus by the group.

Limitation of the study and technique

One of the limitations of the study was the short period of time (seven months) established by the Ministry of Health for the delivery of results of this stage of the review of the PNPS with the group of universities. One of the consequences of this fact was the offer of a range to return of participants in 14 days in the first round of Delphi and 10 in the second. The second limitation, as a result of the first, was this period having involved school holidays and long holidays.

These are limitations that interfere with the ideal conditions for application of the Delphi technique, since the interactivity between respondent and researcher is not immediate and instantaneous, which can hinder or even prevent the discussion. As to the questions concerning the research and/or questionnaire, denials of participation, dropouts and their reasons - pieces of information that are fundamental to the process of investigation -, if they are not well prepared, they become unfavorable to the researcher’s registry. In this sense, the researchers responsible for this part of the PNPS review point out that the Delphi methodology can be more effective when the subject about which a decision is sought features a single dimension, that is, the fact that the PNPS review deals with a nationwide public policy and that the field of health promotion is multidimensional made difficult the synthesis process (Piñeiro, 2003PIÑEIRO, E. M. La técnica Delphi como estrategia de consulta a los implicados en la evaluación de programas. Revista de Investigación Educativa, Medellín, v. 21, n. 2, p. 449-463, 2003. Disponível em: <Disponível em: https://goo.gl/amSMq8 >. Acesso em: 26 out. 2017.
https://goo.gl/amSMq8...
).

Universities have an important role in the formulation of public policies. They are responsible for the production of knowledge and innovation through teaching, research, and extension; they are the institutions training higher level professionals, which in addition to being directly in the public and private health services, usually also access the posts of health service management and the institutional spaces of formulation, monitoring and evaluation of public policies. However, the scarcity of studies prevents us from assessing the real influence of the academy in the formulation or review of public health policies in the country. The fact that the opinion of health promotion specialist consulted in the PNPS review is significantly represented in the new version of the policy may be a positive indicator of this influence.

Many criticisms and suggestions were not included in the new version of the PNPS, and the reason may be the fact that the policy review was not only a process of joining compilations and reports and transcribing them into a comprehensible text. The PNPS review was a synthesis process, with the participation of a broad range of segments, and which had a coordination responsible for conducting, gathering, and systematizing the final result, which was a new version of a national public policy. That is, it is an essentially political process, which involves interpretations, interests and specific priorities, which may result in certain directions.

Conclusions

It can be affirmed that the contribution of universities was significant in the new version of the PNPS. It is observed that several opinions, criticisms and suggestions provided by the group appear in the items of the new policy. For example, the topics related to permanent training and education, continuing education and vocational training were mentioned with relevance by the group and were added to parts of the PNPS revision.

It should be noted, too, that the impact of the universities’ contribution refers to their own relevance in the PNPS review process, but it can also refer: to the relevance of the themes that emerged in the process of reviewing the PNPS; to existing interests in the setting and context of the review; and to the directionings and negotiations in the construction of the final version of the policy.

Given that the policy review is a dialectical issue, which does not end when the policy is officially published, the academy’s contribution is continuous and will occur as long as this policy exists. The article of Rocha et al. (2014ROCHA, D. G. et al. Processo de revisão da Política Nacional de Promoção da Saúde: múltiplos movimentos simultâneos. Ciência & Saúde Coletiva, Rio de Janeiro, v. 19, n. 11, p. 4313-4322, 2014. Disponível em: <Disponível em: http://ref.scielo.org/q6khc2 >. Acesso em: 26 out. 2017.
http://ref.scielo.org/q6khc2...
) and especially that of Malta et al. (2016MALTA, D. C. et al. Política Nacional de Promoção da Saúde (PNPS): capítulos de uma caminhada ainda em construção. Ciência Saúde Coletiva, Rio de Janeiro, v. 21, n. 6, p. 1683-1694, 2016. Disponível em: <Disponível em: http://ref.scielo.org/vq473k >. Acesso em: 26 out. 2017.
http://ref.scielo.org/vq473k...
) substantiate this premise. The authors of the latter article mentioned claim that a “public policy needs to be in constant review” (p. 1692). The authors mention Stephen Ball (Malta et al., 2016MALTA, D. C. et al. Política Nacional de Promoção da Saúde (PNPS): capítulos de uma caminhada ainda em construção. Ciência Saúde Coletiva, Rio de Janeiro, v. 21, n. 6, p. 1683-1694, 2016. Disponível em: <Disponível em: http://ref.scielo.org/vq473k >. Acesso em: 26 out. 2017.
http://ref.scielo.org/vq473k...
, p. 1684), critical of the segmented and linear perspective of the process of analysis of public policies, who proposes an approach in cycle, based on the idea that the policies are constituted of a complex movement, marked by elements of instability and contradiction that are specific of each historical moment and, therefore, need to be in constant review. The interaction of different actors, readings and interpretations in the production of policies, as well as of its official documents, is a key element of the analysis of disputes and conflicts present in this process: the whole time there is formulation/production of new texts in light of the multiple interrelations, even because of the national situation. The academy, through its professors and political scientists, remains vigilant, always watching and acting so the policy stays alive and updated according to the changes in the relations of power and knowledge.

Acknowledgments

Denise Coelho and Maria Laura da Costa Louzada for the encouragement, support, and general suggestions in the process of writing.

References

  • AKERMAN, M.; FISCHER, A. Agenda Nacional de Prioridades na Pesquisa em Saúde no Brasil (ANPPS): foco na subagenda 18 - Promoção da Saúde. Saúde e Sociedade, São Paulo, v. 23, n. 1, p. 180-190, 2014. Disponível em: <Disponível em: https://goo.gl/sKm8BC >. Acesso em: 26 out. 2017.
    » https://goo.gl/sKm8BC
  • AKERMAN, M. et al. Intersetorialidade? IntersetorialidadeS! Ciência & Saúde Coletiva, Rio de Janeiro, v. 19, n. 11, p. 4291-4300, 2016. Disponível em: <Disponível em: https://goo.gl/f3P3mv >. Acesso em: 26 out. 2017.
    » https://goo.gl/f3P3mv
  • ARAÚJO JÚNIOR, J. L. C.; MACIEL FILHO, R. Developing an operational framework for health policy analysis. Revista Brasileira Saúde Materno Infantil, Recife, v. 1, n. 3, p. 203-221, 2001. Disponível em: <Disponível em: http://ref.scielo.org/hgck6b >. Acesso em: 26 out. 2017.
    » http://ref.scielo.org/hgck6b
  • BAPTISTA, T. W. F.; MATTOS, R. A. Sobre política (ou o que achamos pertinente refletir para analisar políticas). In: ______. (Org.). Caminhos para análise das políticas de saúde. Porto Alegre: Rede Unida, 2015. p. 83-129. Disponível em: <https://goo.gl/KccqKF>. Acesso em: 26 out. 2017.
    » https://goo.gl/KccqKF
  • BARACHO, M. Pré-conferência testa metodologia para formulação da nova Política Nacional de Promoção da Saúde (PNPS). Portal DSS Nordeste, Recife, 2 set. 2013. Disponível em: <Disponível em: https://goo.gl/Z9MaHM >. Acesso em: 26 out. 2017.
    » https://goo.gl/Z9MaHM
  • BRASIL. Ministério da Saúde. Secretaria de Políticas de Saúde. As cartas da promoção da saúde. Brasília, DF: Ministério da Saúde, 2002. Disponível em: <Disponível em: https://goo.gl/JMzZoq >. Acesso em: 26 out. 2017.
    » https://goo.gl/JMzZoq
  • BRASIL. Ministério da Saúde. Secretaria de Vigilância em Saúde. Secretaria de Atenção à Saúde. Política Nacional de Promoção da Saúde. 2. ed. Brasília, DF: Ministério da Saúde , 2007.
  • BRASIL. Ministério da Saúde. Secretaria de Vigilância em Saúde. Secretaria de Atenção à Saúde. Política Nacional de Promoção da Saúde. 3. ed. Brasília, DF: Ministério da Saúde , 2010.
  • BRASIL. Ministério da Saúde. Portaria nº 2.446, de 11 de novembro de 2014. Redefine a Política Nacional de Promoção da Saúde (PNPS). Diário Oficial da União, Brasília, DF, 13 nov. 2014. Seção 1, p. 68. Disponível em: <Disponível em: https://goo.gl/hvezic >. Acesso em: 27 out. 2017.
    » https://goo.gl/hvezic
  • BUSS, M. P.; CARVALHO, A. I. Desenvolvimento da promoção da saúde no Brasil nos últimos vinte anos (1988-2008). Ciência e Saúde Coletiva, Rio de Janeiro, v. 14, n. 6, p. 2305-2316, 2009. Disponível em: <Disponível em: https://goo.gl/8UrWAf >. Acesso em: 26 out. 2017.
    » https://goo.gl/8UrWAf
  • CAMPOS, G. W. S.; BARROS, R. B.; CASTRO, A. M. Avaliação da política nacional de promoção da saúde. Ciência e Saúde Coletiva, Rio de Janeiro, v. 9, n. 3, p. 745-749, 2004. Disponível em: <Disponível em: https://goo.gl/y3bnkw >. Acesso em: 26 out. 2017.
    » https://goo.gl/y3bnkw
  • CAMPOS, G. W. S.; CAMPOS, R. T. O. Co-construção de autonomia: o sujeito em questão. In: CAMPOS, G. W. S. et al. Tratado de saúde coletiva. São Paulo: Hucitec; Rio de Janeiro: Fiocruz, 2006. p. 669-688.
  • FERREIRA NETO, J. L. F. et al. Processos da construção da Política Nacional de Promoção da Saúde. Cadernos de Saúde Pública, Rio de Janeiro, v. 29, n. 10, p. 1997-2007, 2013. Disponível em: <Disponível em: http://ref.scielo.org/dhwcpq >. Acesso em: 26 out. 2017.
    » http://ref.scielo.org/dhwcpq
  • GALLARDO, R. Y.; OLMOS, R. C. La técnica Delphi y la investigación en los servicios de salud. Ciencia y Enfermeria, Concepción, v. 14, n. 1, p. 9-15, 2008. Disponível em: <Disponível em: http://ref.scielo.org/ggr86g >. Acesso em: 26 out. 2017.
    » http://ref.scielo.org/ggr86g
  • LEAVELL, H.; CLARK, E. G. Medicina preventiva. São Paulo: McGraw-Hill, 1976.
  • LOSEKANN, C. Esfera pública habermasiana, seus principais críticos e as possibilidades do uso deste conceito no contexto brasileiro. Pensamento Plural, Pelotas, n. 4, p. 37-57, jan./jun. 2009. Disponível em: <Disponível em: https://goo.gl/Mv4eJu >. Acesso em: 26 out. 2017.
    » https://goo.gl/Mv4eJu
  • MALTA, D. C. et al. Política Nacional de Promoção da Saúde (PNPS): capítulos de uma caminhada ainda em construção. Ciência Saúde Coletiva, Rio de Janeiro, v. 21, n. 6, p. 1683-1694, 2016. Disponível em: <Disponível em: http://ref.scielo.org/vq473k >. Acesso em: 26 out. 2017.
    » http://ref.scielo.org/vq473k
  • NOGUEIRA, R. P. (Org.). Determinação social da saúde e reforma sanitária. Rio de Janeiro: Cebes, 2010.
  • NUNES, E. D. Henry Ernest Sigerist: pioneiro da história social da medicina e da sociologia médica. Educación Médica y Salud, Washington, DC, v. 26, n. 1, p. 70-81. 1992. Disponível em: <Disponível em: https://goo.gl/44AS95 >. Acesso em: 26 out. 2017.
    » https://goo.gl/44AS95
  • PIÑEIRO, E. M. La técnica Delphi como estrategia de consulta a los implicados en la evaluación de programas. Revista de Investigación Educativa, Medellín, v. 21, n. 2, p. 449-463, 2003. Disponível em: <Disponível em: https://goo.gl/amSMq8 >. Acesso em: 26 out. 2017.
    » https://goo.gl/amSMq8
  • ROCHA, D. G. et al. Processo de revisão da Política Nacional de Promoção da Saúde: múltiplos movimentos simultâneos. Ciência & Saúde Coletiva, Rio de Janeiro, v. 19, n. 11, p. 4313-4322, 2014. Disponível em: <Disponível em: http://ref.scielo.org/q6khc2 >. Acesso em: 26 out. 2017.
    » http://ref.scielo.org/q6khc2
  • ROCHA, P. R.; DAVID, H. M. S. L. Determinação ou determinantes? Uma discussão com base na Teoria da Produção Social da Saúde. Revista da Escola de Enfermagem da USP, São Paulo, v. 49, n. 1, p. 129-135, 2015. Disponível em: <Disponível em: http://ref.scielo.org/8t8v3f >. Acesso em 26 out. 2017.
    » http://ref.scielo.org/8t8v3f
  • SILVA, A. M. et al. Utilização da técnica Delphi on-line para investigação de competências: relato de experiência. Revista Gaúcha de Enfermagem, Porto Alegre, v. 30, n. 2, p. 348-351, 2009. Disponível em: <Disponível em: https://goo.gl/kU5v8e >. Acesso em: 26 out. 2017.
    » https://goo.gl/kU5v8e
  • SOUZA, C. Estado da arte da pesquisa em políticas públicas. In: HOCHMAN, G.; ARRETCHE, M.; MARQUES, E. (Org.). Políticas públicas no Brasil. Rio de Janeiro: Fiocruz , 2007. p. 65-86.
  • TRAVERSO-YÉPEZ, M. A. Dilemas na promoção da saúde no Brasil: reflexões em torno da política nacional. Interface: Comunicação, Saúde e Educação, Botucatu, v. 11, n. 22, p. 223-238, 2007. Disponível em: <Disponível em: https://goo.gl/p22P8j >. Acesso em: 26 out. 2017.
    » https://goo.gl/p22P8j
  • VALDÉS, M. G.; MARÍN, M. S. Empleo del método Delphi en investigaciones sobre salud publicadas en revistas científicas cubanas. Revista Cubana de Información en Ciencias de la Salud, Havana, v. 24, n. 2, p. 133-144, 2013. Disponível em: <Disponível em: http://ref.scielo.org/kz8kpz >. Acesso em: 26 out. 2017.
    » http://ref.scielo.org/kz8kpz
  • WESTPHAL, M. F. Promoção da saúde: uma nova agenda para a saúde. In: ROCHA, A. A.; CESAR, C. L. G. (Org.). Saúde pública: bases conceituais. São Paulo: Atheneu, 2008. p. 163-197.
  • WESTPHAL, M. F.; MINOWA, E. Documento técnico com síntese dos resultados da consulta intrassetorial e com as IES/universidades sobre o eixo II do Plano Nacional de Enfrentamento das Doenças Crônicas a ser apresentado nas Oficinas de Consenso previstas pela metodologia de Revisão da Política Nacional de Promoção da Saúde. Brasília, DF: Ministério da Saúde: OPAS, 2014.

  • 3
    We thank the Pan American Health Organization for the funding of the research – PAHO Contract No. BR/CNT/1301743.001 of 06/2014.

  • 4
    Available at: <http://dgp.cnpq.br/buscaoperacional>. Access on: 31 Oct. 2017.

Publication Dates

  • Publication in this collection
    18 Dec 2017
  • Date of issue
    Oct-Dec 2017

History

  • Received
    17 Sept 2016
  • Reviewed
    10 Oct 2017
  • Accepted
    24 Oct 2017
Faculdade de Saúde Pública, Universidade de São Paulo. Associação Paulista de Saúde Pública. SP - Brazil
E-mail: saudesoc@usp.br