Abstract

This article aims to analyze the participation of the National Council in the construction and realization of the 15th National Health Conference (CNS), as well as the main components of this event, the institutional design regarding its participatory dynamics, and the approved proposals and guidelines, relating this political phenomenon to the Brazilian context. This case study on the 15th CNS had, as data sources, the interviews with 27 national counselors and the documentary review of minutes, news and other sources of the Council related to the 15th Conference. The National Council developed strategies to politicize the elaboration of guidelines and intensified society participation through free conferences. The Health debate in 2015 involved thousands of people in the country - after all, 4,706 municipal and 26 state, district and national conferences were held. The main agendas of the 15th Conference were the defense of democracy and the public financing of health. Nonetheless, the bureaucratic format still prevailed in the 15th CNS. In addition to innovations in the form of conferences, one must increase the permeability of decision-makers to social participation and democratize the health planning and management process.

Keywords:
National Health Conference; National Health Council; Social Participation

Introduction

In Brazil, National Health Conferences (CNS) have a history that precedes the creation of the Brazilian National Health System (SUS). They were originally instituted in 1937, in the antidemocratic context of Getúlio Vargas’s Estado Novo; however, the 1st CNS was held only in 1941. They were set as a strategy to strengthen Federal Government control over health actions developed in the country. However, over time, the Conferences have been translating other senses and formats. Linked to the emerging democratic movement, the 8th CNS in 1986 revealed a distinct nature. In the pulsating dimension of the Brazilian Sanitary Reform movement, this event ceased to have a technical-administrative character and acquired the perspective of popular participation (Souza et al., 2013SOUZA, C. H. L. et al. Conferências típicas e atípicas: um esforço de caracterização do fenômeno político. In: AVRITZER, L.; SOUZA, C. H. L. (Org.). Conferências nacionais: atores, dinâmicas participativas e efetividades. Brasília, DF: Instituto de Pesquisa Econômica Aplicada, 2013. p. 25-52.).

The creation of SUS in the 1988 Constitution and its regulation through the legislation on participation - that is, Law no. 8,142/1990 - defined a new institutional design for the CNS. Contemplating the legal and legitimate agenda of civil society and political participation, the CNSs took on the role of assessing the health situation and developing proposals to guide health policies according to the needs of the population. Although integrated into the constitutional purpose, the CNS still do not have within their legal framework the precise definition of what they should be and how they should work, as the functioning of such participatory arena is defined in the internal rules of each Conference. This gap gives rise to different conceptions and, especially, to high expectations, which can result in frustrations due to the low use of their guidelines by stakeholders in the formulation of health policies (Escorel; Bloch; 2005ESCOREL, S.; BLOCH, R. A. As Conferências Nacionais de Saúde na construção do SUS. In: LIMA, N. T.; GERSHMAN, S.; EDLER, F. C. (Org.). Saúde e democracia: história e perspectivas do SUS. Rio de Janeiro: Fiocruz, 2005. p. 83-119.; Souza; Pires, 2013SOUZA, C. H. L.; PIRES, R. R. C. Conferências Nacionais como interfaces socioestatais: seus usos e papéis na perspectiva de gestores federais. In: AVRITZER, L.; SOUZA, C. H. L. (Org.). Conferências nacionais: atores, dinâmicas participativas e efetividades. Brasília, DF: Instituto de Pesquisa Econômica Aplicada, 2013. p. 279-298.).

Albeit the CNSs have presented some innovations in their format since the Brazilian re-democratization process, especially with the undeniable expansion and diversity in the participation of delegates, they are also showing signs of wear and tear, as well as some innocuity. The expectation about the potential of this participatory arena to have an impact on the formulation of health policies has been diluted (Costa, 2015COSTA, A. M. Anotações sobre o artigo de Paulo Gadelha. Cadernos de Saúde Pública, Rio de Janeiro, v. 31, n. 10, p. 2047-2072, 2015.; Ricardi; Shimizu; Santos, 2017RICARDI, L. M.; SHIMIZU, H. E.; SANTOS, L. M. P. As Conferências Nacionais de Saúde e o processo de planejamento do Ministério da Saúde. Saúde em Debate, Rio de Janeiro, v. 41, p. 155-170, 2017. Número especial 3.). Faced with this set of elements, one must reflect on the CNS as an important democratic institution, to maximize its results in health policies.

For such reflection, an accumulation of critical analysis by social movements, entities and representations of civil and political society is required, including the academy, so to point out ways to think about new formats and key dimensions to be modified. The reason for being of this article is within such endeavor, and we elect as a case of study the CNS that occurred in December 2015. This study aims to analyze the participation of the National Council in the construction and realization of the 15th Conference, as well as the main components of this event, the institutional design regarding its participatory dynamics and the proposals and guidelines approved, relating such data to the Brazilian context.

Method

This is a case study on the 15th CNS. The period of study goes from 2014 to 2016, which is justified because the debates on the Conference have taken place more systematically in the National Health Council plenary from 2014, and the guidelines, proposals, and motions approved in the final stage have been published in March 2016.

Data production was based on 27 semi-structured interviews conducted with counselors who held positions in the National Health Council from 2012-2015 and played a central role in producing the 15th Conference, as well as counselors with seats in the 2015-2018 management. Twenty-nine sources were also used in data collection, including: the Conference’s internal rules of procedure; the guiding document to support the debates; the methodological document; the national report consolidated in the state stage; the Resolution 507/2016, which gives publicity to the proposals, guidelines, and motions approved in the 15th CNS; 24 minutes of meetings produced between February 2014 and March 2016 (253, 256-258, 260-279), which record the debates around the Conference. A matrix of data collection containing the variables “identification of minutes”, “type, number and date of the meeting”, “category - 15th CNS”, “debate held” and “deliberation” was used in the analysis of minutes. News published on the website of the National Health Council between February 2014 and March 2016 were also monitored through a news matrix, recording the date, category (15th CNS), title and summary of the account, as well as its source and link.

Analysis of interviews was carried out through the content analysis proposed by Bardin (2011BARDIN, L. Análise de conteúdo. Rio de Janeiro: Edições 70, 2011.). After analyzed, the content from the reports was compared with other data sources and the literature. The final document of guidelines and proposals of the 15th CNS was analyzed based on the following categories: form (administrative, legislative) and nature of the guidelines (implementation of an existing policy, formulation of a new policy, improvement of a policy, general public policy, expanded access to an existing policy, monitoring of a policy, inclusion of a specific group in a policy, and extension of a policy or service).

Documents were available on websites of the National Health Council (minutes) and of the 15th CNS (other documents). Interviews were carried out after the interviewee signing the Informed Consent Form and giving prior authorization to record the conversation. The project was approved by the Research Ethics Committee of the Institute of Public Health (ISC) of the Federal University of Bahia (UFBA), under protocol no. 2,235,550.

Results and discussion

Process of construction of the 15^th Conference

The need to change the format of the conferences was pointed out by Government representatives, health professionals and the scientific community. The high number of guidelines and proposals in the final report, approved as a priority to guide the formulation of health policies, was highlighted as a hindrance to the effectiveness of the conferences. The conference model with participation focused on the performance of the counselor to the detriment of new entities was also pointed as an aspect to be changed.

The debate on health conferences, held in the National Council plenary between 2014 and 2015, was also marked by the discourse around the need to change the format of this participatory institution. Health Minister Arthur Chioro, as soon as he took office in 2014, in his first participation in the ordinary meeting of the Council highlighted the exhaustion of the conference model:

At the ordinary meeting of the Council in June 2014, this theme was put up for discussion aimed at accumulating a critical analysis to rethink the Health Conferences and to subsidize the construction of the 15th CNS. Debates pointed to broadening the social base, ensuring the effectiveness of the conference in health policies and the need to innovate the Conference methods. The proposals that came up in the plenary, with a view to substantially changing the format of the event, had a circumstantial dimension and were not widely debated and put to the vote, leaving only the record in the minutes.

The suggested changes were: the National Council of Municipal Health Secretariats (Conasems) proposed to replace municipal conferences at that time with those carried out from the health regions - the argument posed was that municipalities should hold their conferences in the beginning of their government to influence municipal management instruments; the Brazilian Association of Collective Health (Abrasco) suggested reversing the stages of the Conference, starting with the national, followed by state and finally free, municipal and regional conferences - the justification for this proposition was that the guidelines of the national phase, carried out in advance, could be part of the PPA construction (Brasil, 2014cBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Ata da ducentésima quinquagésima oitava reunião ordinária do Conselho Nacional de Saúde - CNS. Brasília, DF, 2014c. Disponível em: <Disponível em: https://bit.ly/2KEbzMZ >. Acesso em: 25 jun. 2019.
https://bit.ly/2KEbzMZ... , ^2014eBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Ata da ducentésima sexagésima reunião ordinária do Conselho Nacional de Saúde - CNS. Brasília, DF, 2014e. Disponível em: <Disponível em: http://bit.ly/2Ma4zsL >. Acesso em: 28 maio 2019.
http://bit.ly/2Ma4zsL... ).

In the Council’s plenary debates about the 15th Conference, there was therefore a concern to anticipate the event to follow the legal planning time at a federal level, so that its guidelines could support the construction of management tools, especially the PPA and the National Health Plan (PNS). However, the 2016-2019 PPA was prepared in the first half of 2015, since its submission to the National Congress occurs in August, and the National Conference occurred later, in December 2015. The 2016-2019 PNS, in turn, sent to the National Council in April 2016 and approved by the plenary in July of that year, contained guidelines of the 15th CNS.

Thus, in order for the Conference guidelines to be minimally made available in a timely manner, at the moment of forming the government agenda, two dimensions need to be considered: the first refers to the legally established technical time for the budget and planning cycle. The second element to be taken into account is the political time of management in the spheres of government. Thus, to increase the possibility of effectiveness of the Conference proposals, one of the important aspects to be considered is that the National Council can adapt its period of realization to the budget and planning cycle. Ricardi, Shimizu and Santos (2017RICARDI, L. M.; SHIMIZU, H. E.; SANTOS, L. M. P. As Conferências Nacionais de Saúde e o processo de planejamento do Ministério da Saúde. Saúde em Debate, Rio de Janeiro, v. 41, p. 155-170, 2017. Número especial 3.) point out that, although planning instruments are reviewed annually, the temporal mismatch between the Conference and medium-term planning instruments compromises the participatory influence in the elaboration of health policies, although the due time alignment is not an assurance that such policies will be elaborated based on CNS guidelines.

Another aspect raised in the debate was the growing number of proposals approved at the conferences over the years, which, while reflecting the diversity of participation of social actors in these spaces, makes it difficult to identify the priority guidelines to guide health policy, leading to its low impact on policy formulation. At the same time, the persistent challenge of ensuring greater participation in the Conferences was pointed out, especially of those entities and social movements that are not part of Health Councils (Brasil, 2014cBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Ata da ducentésima quinquagésima oitava reunião ordinária do Conselho Nacional de Saúde - CNS. Brasília, DF, 2014c. Disponível em: <Disponível em: https://bit.ly/2KEbzMZ >. Acesso em: 25 jun. 2019.
https://bit.ly/2KEbzMZ... ).

It is a dilemma arising from the conference itself as a participatory and democratic institution, inserted in the process of building a public health policy that presents as a concrete starting point the limitation of resources, including financial resources, for the implementation of its guidelines. The dilemma refers to the need to ensure participation of various segments of society capable of representing the plurality of interests in the struggle for hegemony in the field of Health, and at the same time to develop guidelines that are a priority for the formulation of policies, maintaining the commitment to its implementation. Gadelha (2015GADELHA, P. Conferência Nacional de Saúde: desafios para o país. Cadernos de Saúde Pública, Rio de Janeiro, v. 31, n. 10, p. 2047-2072, 2015.), when discussing the event during the 15th CNS, highlights as one of its main methodological challenges the construction of guidelines that are also enriched by the broad participation of society, without dispersion.

Faced with such impasse, the strategy adopted by the National Health Council consisted in developing actions capable of intensifying the process of mobilizing society, bringing to this space actors hitherto discarded from discussions about public health. Thus, in addition to the traditional municipal, state, and national stages of the CNS, the free conferences were created as a mobilization activity constituted by popular plenaries and are held in the five geographic regions of the country. From the popular plenaries came guests with right to voice - not to vote -, both in plenary sessions as in the working groups of the 15th CNS national stage (Brasil, 2014eBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Ata da ducentésima sexagésima reunião ordinária do Conselho Nacional de Saúde - CNS. Brasília, DF, 2014e. Disponível em: <Disponível em: http://bit.ly/2Ma4zsL >. Acesso em: 28 maio 2019.
http://bit.ly/2Ma4zsL... , ^2015fBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Resolução nº 500, de 12 de fevereiro de 2015. Aprova o Regimento da 15ª Conferência Nacional de Saúde. Diário Oficial da União, Brasília, DF, 6 out 2015f. Disponível em: <Disponível em: https://bit.ly/2KEUrHg >. Acesso em: 25 jun. 2019.
https://bit.ly/2KEUrHg... ).

The initiative to mobilize social movements and entities to participate in free conferences, without the formality of being a health adviser, involved a pluralistic part of society. With that, the 15th Conference presented, in its institutional design, a strong participatory dynamic, broadening the representation of minority groups, as shown in the speech of Interviewee 9:

The realization of free conferences, while fulfilling the role of mobilizing social actors beyond those already involved with the health councils network, was also considered by the counselors as a mechanism capable of conferring greater legitimacy to the Conference, insofar as it provided the plural participation of various entities and social movements. The following report is a good illustration of this aspect:

Although free conferences are an innovative strategy for broadening the social base of the Conference, the mark of the 15th CNS was still the bureaucratic format, so that entities and social movements mobilized during the municipal and state stages and that were to Brasilia could not participate in debates at the national level, as they were not delegates, invitees or participants. It was also not allowed to bring new proposals and guidelines at the national stage, as this would reduce the time for debate and could affect the legitimacy of the upward voting process of the demands. Both aspects have given rise to debates in some National Council meetings - however, this configuration ended up prevailing in the conference regiment (Brasil, 2014fBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Ata da ducentésima sexagésima quarta reunião ordinária do Conselho Nacional de Saúde - CNS. Brasília, DF, 2014f. Disponível em: <Disponível em: https://bit.ly/2RyOeNA >. Acesso em: 25 jun. 2019.
https://bit.ly/2RyOeNA... , ^2015aBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Ata da ducentésima sexagésima quinta reunião ordinária do Conselho Nacional de Saúde - CNS. Brasília, DF, 2015a. Disponível em: <Disponível em: https://bit.ly/2J65FRM >. Acesso em: 25 jun. 2019.
https://bit.ly/2J65FRM... , ^2015cBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Ata da ducentésima sexagésima nona reunião ordinária do Conselho Nacional de Saúde - CNS. Brasília, DF, 2015c. Disponível em: <Disponível em: https://bit.ly/2INxY8o >. Acesso em: 25 jun. 2019.
https://bit.ly/2INxY8o... , ^2015fBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Resolução nº 500, de 12 de fevereiro de 2015. Aprova o Regimento da 15ª Conferência Nacional de Saúde. Diário Oficial da União, Brasília, DF, 6 out 2015f. Disponível em: <Disponível em: https://bit.ly/2KEUrHg >. Acesso em: 25 jun. 2019.
https://bit.ly/2KEUrHg... ). The speech of some delegate-counselors at the post-Conference indicates this format was a limiting factor of the event, as can be seen in these lines:

The gradual manner in which the process of opening up this channel of participation is taking place reflects the internal tensions of the National Health Council. Some advisers are concerned that this may favor the agglutination of actors opposed to the strengthening of SUS within the conference (Brasil, 2015aBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Ata da ducentésima sexagésima quinta reunião ordinária do Conselho Nacional de Saúde - CNS. Brasília, DF, 2015a. Disponível em: <Disponível em: https://bit.ly/2J65FRM >. Acesso em: 25 jun. 2019.
https://bit.ly/2J65FRM... ) or, in fact, weaken the council network and the Health Conference, in terms of its representative dynamics. Thus, the broad discussion in the National Council plenary on the inclusion of new participatory profiles at the conferences resulted in some changes in participatory dynamics, such as free conferences, but did not reflect on the representative dynamics of events.

Such partial opening of this space to non-counselors or delegates did not ensure their effective participation in the debates, inducing a sterile participation that can generate negative repercussions on the participatory process. The expansion of society participation is regarded as a profitable strategy to democratize the institutionalized participation, while also giving greater legitimacy to the participatory process. For Gadelha (2015GADELHA, P. Conferência Nacional de Saúde: desafios para o país. Cadernos de Saúde Pública, Rio de Janeiro, v. 31, n. 10, p. 2047-2072, 2015.), extending the health agenda to the Brazilian population consists of, above all, facing one of the challenges that accompanies the construction of SUS, which is about its social roots.

Therefore, the process of building the 15th CNS was marked by efforts of the National Council members to review the Health Conference format. Discussions in the Council plenary on the 15th Conference had an impact on the change in its design, especially on the issue of including new actors, expanding its social base from the free plenary sessions, and about the rationalization of the number of proposals approved for final conference documents since, for example, at the 13th Conference 857 proposals were approved, while the 15th resulted in 560.

Concomitant with the strategy of change in the format of the Conference, the National Council also made efforts to politicize and qualify the elaboration of the event guidelines. Thus, the guiding document to support the debates of the 15th CNS, prepared and disseminated by the national counselors in state and municipal councils and in virtual channels of communication of some entities of the national collegiate, was launched. Still aiming to strengthen the political debate, entities and universities, such as the Brazilian Center for Health Studies (Cebes) and the ISC-UFBA, promoted discussions with entities and social movements, enriched the proposals of the aforementioned guiding document, and reverberated their theses in texts published in free and municipal conferences, favoring the critical construction of proposals (Cebes, 2015CEBES - CENTRO BRASILEIRO DE ESTUDOS DE SAÚDE. Cebes divulga tese para a 15a Conferência Nacional de Saúde. Conselho Nacional de Saúde, Brasília, DF, 5 ago. 2015. Disponível em: <Disponível em: http://bit.ly/2Xf3Ojm >. Acesso em: 28 maio 2019.
http://bit.ly/2Xf3Ojm... ; UFBA, 2015UFBA - UNIVERSIDADE FEDERAL DA BAHIA. Rumo à 15ª Conferência Nacional de Saúde: documento produzido pelo Instituto de Saúde Coletiva (ISC) da UFBA. Análise Política em Saúde, Salvador, 25 jul. 2015. Disponível em: <Disponível em: http://bit.ly/2VYL5Hg >. Acesso em: 28 maio 2019.
http://bit.ly/2VYL5Hg... ).

The politicization of the Conference presupposes considering the historical-political context in which the guidelines would be elaborated, based on a specific concrete reality. Such dimension of the Conference was pointed out by the delegate-counselors as a central element to make it more effective, so to influence the construction of health policy, as shown by the following statements:

Amidst the economic and political crisis and several threats to SUS, the 15th CNS was convened by then President of the Republic, Dilma Rousseff, in December 2014, with the theme “Quality public health to take care of people: a right of the Brazilian people” (Müller Neto, 2015MÜLLER NETO, J. S. A 15a Conferência Nacional de Saúde ouvirá os clamores do povo? Cadernos de Saúde Pública, Rio de Janeiro, v. 31, n. 10, p. 2047-2072, 2015.). Thousands of people were mobilized for the 15th CNS in 4,706 municipal health conferences, 26 state conferences, the district conference and the national event, as presented in Table 1. The regions with the highest percentages of municipal conferences held were the Central-West and the Northeast, with 91.86% and 91.14%, respectively. The Southeast region was the one with the lowest percentage of municipal conferences, with 76.14%, Minas Gerais being the Brazilian state with the lowest percentage of municipalities that held conferences (64.48%).

The fact that 14 states of the Federation held conferences in 100% of their municipalities and 84.49% of Brazilian municipalities hold their respective health conferences demonstrates that in 2015 there was an intense mobilization around the theme of health throughout the country. In this process, new social actors were mobilized for the national public scene, as pointed out in the following speech:

Proposals presented and discussed at the 15^th Conference

At the 15th Conference, there was a limit of proposals to be sent to the national stage. Thus, according to the methodological guidelines, it was foreseen that each state of the Federation could send a guideline for each of the eight axes and five proposals by guideline (Brasil, 2015gBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Resolução nº 501, de 7 de maio de 2015. Diário Oficial da União, Brasília, DF, 15 jun. 2015g. Disponível em: <Disponível em: http://bit.ly/2VXlSNw >. Acesso em: 28 maio 2019.
http://bit.ly/2VXlSNw... ) to the national stage. Although state conferences took place in all states, Pernambuco was unable to vote on the 40 priority proposals and sent 372 proposals to Brasilia. Faced with the impasse and without consensus to vote in the National Council plenary, the national organizing committee of the 15th CNS decided that only the axis discussed and with fewer proposals (35) from that state be appreciated at the National Conference, since the legitimacy to decide which ones would be prioritized and part of the national consolidation of the state stage is not up to the commission but to the delegates elected at conferences (Brasil, 2015dBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Ata da ducentésima septuagésima quinta reunião ordinária do Conselho Nacional de Saúde - CNS. Brasília, DF, 2015d. Disponível em: <Disponível em: https://bit.ly/2YehITj >. Acesso em: 25 jun. 2019.
https://bit.ly/2YehITj... ).

Thus, 208 guidelines and 1,040 proposals from 25 state conferences were sent, in addition to the district, from which the national rapporteurship committee consolidated 36 directives and 541 proposals that were part of the list of proposals available for voting in the working groups and in the final plenary session of the 15th CNS, plus another guideline and 35 proposals from Pernambuco, which came late to be included in the national consolidation of state conferences, but were appreciated in the national stage of the 15th CNS. Finally, at the National Conference, 37 guidelines and 560 proposals published in Resolution No. 507 of the National Health Council were approved in March 2016 (Brasil, 2016bBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Resolução nº 507, de 16 de março de 2016. Diário Oficial da União, Brasília, DF, 5 maio 2016b. Disponível em: <http://bit.ly/2W960fZ>. Acesso em: 28 maio 2019.); until June 2019, its final report was not published.

In an attempt to indicate priority proposals and guidelines, the organizing committee decided to record in the final document of the 15th Conference the percentage of approval obtained by the proposals and guidelines in the voting held in the final plenary or in the working groups of the national stage. This data was organized, in Table 2, into three accepted acceptance ranges: (1) 50% to 70% of approval, (2) 71% to 89% of approval, and (3) 90% or more approval. Thus, 201 (35.9%) proposals and 15 (40.6%) guidelines had approval equal to or greater than 90%.

Axes that obtained proposals accepted with the least amount of approval in the interval 3 were the cross-section of democratic and popular reforms of the State and the one of SUS financing and public-private relationship. Thus, only 5.1% of the accepted proposals in the area of democratic reforms obtained approval equal to or higher than 90%, and only 22% of proposals accepted in the financing axis showed 90% or more approval. The highest number of proposals in interval 3 was the right to health, guaranteed access and quality care, with 53.7% of their proposals accepted with approval equal to or greater than 90%, and SUS management and health care models, with 48%, as presented in Table 2. As for the guidelines, the axes that did not have any of their guidelines with approval equal to or greater than 90% were those of democratic reforms, financing and social participation.

The preference for certain demands, far from being a disinterested process, reflects the game of interests of the set of actors that participate in the Conference. Thus, although a proposal achieves a high percentage of approval, this does not necessarily mean that it is prioritized by the delegates. This may effectively mean that the dispute between interest groups about an axis was more consensual. This explains why the axes of democratic and financing reforms have fewer proposals with an approval percentage equal to or above 90%, given the politicization of the debates and the fierce dispute that may have taken place around these issues. Thus, the percentage of approval of proposals is not a good indicator of priority.

The 15th Conference was an effectively political phenomenon and the cross-cutting axis of democratic and popular reforms contributed to this by mobilizing into the conference the political debate about structural changes around policies that are strategic for health. This axis included proposals for economic social justice, such as the following proposal: to carry out public debt audits and tax reform (Brasil, 2016bBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Resolução nº 507, de 16 de março de 2016. Diário Oficial da União, Brasília, DF, 5 maio 2016b. Disponível em: <http://bit.ly/2W960fZ>. Acesso em: 28 maio 2019.). The following report illustrates this political-ideological character:

The 37 guidelines and 560 proposals approved in the national phase of the 15th Conference were classified in this study, as to their form, into administrative and legislative proposals. Administrative proposals refer to those presenting demands directed to the Executive Branch, i.e., proposals that require Executive Branch action for their execution. An example of an administrative proposal may be the one that provides “to implement, guarantee and effect the National Humanization Policy in all health services” (Brasil, 2016bBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Resolução nº 507, de 16 de março de 2016. Diário Oficial da União, Brasília, DF, 5 maio 2016b. Disponível em: <http://bit.ly/2W960fZ>. Acesso em: 28 maio 2019.). Legislative proposals, however, require the Legislative Branch to comply with them. Thus, an example of a legislative proposal approved in the final document of the 15th CNS in “to revise the Fiscal Responsibility Law (LRF) to differentiate and expand the limit of expenses with personnel under SUS”, or to recommend the “end the Unbundling of Union Revenue (DRU) and the Unbundling of State Revenues (DRE) for the social security budget”(Brasil, 2016bBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Resolução nº 507, de 16 de março de 2016. Diário Oficial da União, Brasília, DF, 5 maio 2016b. Disponível em: <http://bit.ly/2W960fZ>. Acesso em: 28 maio 2019.).

Regarding the nature of the demands, in addition to the proposals and guidelines for policy formulation (19.1%) - the main purpose of the conferences, there were still those demanding the implementation of an existing policy, program or law (36.5%) and improvement of a policy or service (20.3%), as well as guidelines for a general public policy that exceeds the scope of the health sector (12.6%), as presented in Table 3.

Thus, one can see that most (80.5%) demands approved in the 15th CNS were directed to the Executive Branch, with a view to implementing an existing policy. On the other hand, the proposals that demanded Legislative competence occurred especially to improve an existing policy or service and to structure public policies that affect the health sector in some way.

Among the proposals that depend on the competence of the Executive Branch for their execution, there are those that are shared or exclusive responsibility of sectors other than health. There are still those that, even if they are located in this sector and need the Executive Branch to be induced, for their concretion they depend fundamentally on the distribution of power within the institutions and the forms of organization of the work process in health services. Thus, there are proposals in the final report that, due to various factors, will hardly be implemented, especially in a four-year period, which favors the repetition of proposals in subsequent Conferences. The counselors highlight this perspective in the following sections:

In considering the cycle of health policy, Pinto, Vieira-da-Silva and Baptista (2014PINTO, I. C. M.; VIEIRA-DA-SILVA, L. M.; BAPTISTA, T. V. F. Ciclo de uma política pública de saúde: problematização, construção da agenda, institucionalização, formulação, implementação e avaliação. In: PAIM, J. S.; ALMEIDA FILHO, N. (Org.). Saúde coletiva: teoria e prática. Rio de Janeiro: Medbook, 2014. p. 69-81.) affirm the implementation of a policy involves a set of aspects ranging from technical, political, economic, and social conditions to the diversity of agents and their degrees of involvement in the process. Within this range, there are several elements that make it difficult to implement a policy, such as formulators’ commitment to their viability, the low degree of coordination between formulators and implementers, the understanding of the policy by the agents responsible for its execution, and the amount of changes required for implement it.

Also noteworthy are the programmatic constraints, the difficulties in adjusting the technical and political times, and the legal or budgetary impediments that are placed as limiting factors so that the demands of the conferences can be institutionalized, implemented or improved in a health policy. In addition, another equally shocking element that involves the process of constructing a health policy consists in the political dimension of this process, expressed in the correlation of forces within the state apparatuses and in the pressure mechanisms of society. Thus, the CNS is a political phenomenon inserted in a broader political and institutional arrangement, being one of the alternatives to express the interests in dispute of the social actors in the definition of health policy (Souza et al., 2013SOUZA, C. H. L. et al. Conferências típicas e atípicas: um esforço de caracterização do fenômeno político. In: AVRITZER, L.; SOUZA, C. H. L. (Org.). Conferências nacionais: atores, dinâmicas participativas e efetividades. Brasília, DF: Instituto de Pesquisa Econômica Aplicada, 2013. p. 25-52.).

Therefore, the results of health policy conferences depend not only on their format, but on a set of factors, including the sensitivity of the manager to the issues of society participation in the democratization of policies. The following statements allude to the political weight of the CNS for managers:

Health conferences play a key role in conferring legitimacy on health policies, as well as on government action in the health sector. A concrete example of this political role of the Conference is the reformulation of the National Basic Attention Policy (PNAB). This was one of the proposals of the 15th Conference. However, the changes made by the Tripartite Inter-agency Committee and, say, the National Council of Health Secretaries (Conass), the Ministry of Health and the Conasems in this policy did not please the social societal entities that are part of the National Health Council, provoking a strong reaction contrary to the proposed reformulation, to the point the draft of this policy was approved by then Minister Ricardo Barros without the proper appreciation and approval of the largest body of social control in the country (Brasil, 2016aBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Ata da ducentésima octogésima sétima reunião ordinária do Conselho Nacional de Saúde - CNS. Brasília, DF, 2016a. Disponível em: <Disponível em: http://bit.ly/2VVjabl >. Acesso em: 28 maio 2019.
http://bit.ly/2VVjabl... , ^2017aBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Ata da ducentésima nonagésima quinta reunião ordinária do Conselho Nacional de Saúde - CNS. Brasília, DF, 2017a. Disponível em: <Disponível em: http://bit.ly/2HFIWfD >. Acesso em: 28 maio 2019.
http://bit.ly/2HFIWfD... , ^2017bBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Ata da ducentésima nonagésima oitava reunião ordinária do Conselho Nacional de Saúde - CNS. Brasília, DF, 2017b. Disponível em: <Disponível em: http://bit.ly/2XbLAPP >. Acesso em: 28 maio 2019.
http://bit.ly/2XbLAPP... ; Parlamentares…, 2017PARLAMENTARES formalizam projeto de decreto que diz não à nova PNAB. #susconecta, [s. l.], 3 out. 2017. Disponível em: <Disponível em: http://bit.ly/2HXki9e >. Acesso em: 28 maio 2019.
http://bit.ly/2HXki9e... ; Projeto…, 2017PROJETO de decreto que barra nova PNAB é pauta da 298ª reunião ordinária do CNS. #susconecta, [s. l.], 4 out. 2017. Disponível em: <Disponível em: http://bit.ly/2HIPJWg >. Acesso em: 28 maio 2019.
http://bit.ly/2HIPJWg... ). Although the reformulation of the PNAB differs from that envisaged by the social actors of the 15th Conference, the representatives of the management affirm the change in this policy consists of a legitimate demand of the society, made with social participation, since it comes from the CNS.

Importance and political significance of the 15^th Conference in the context of 2015

The June 2013 mobilizations, which led thousands of Brazilians to the streets throughout the country, despite being marked by spontaneity, nonpartisanism and the heterogeneity of diffuse demands, had, in addition to criticism of representative democracy, health as one of the main concerns, being named by 45% of Brazilians as the main problem of the country (Alencar, 2013ALENCAR, C. A rua, a nação e o sonho: uma reflexão para as novas gerações. Rio de Janeiro: Mar de Ideias, 2013.; Gohn, 2015GOHN, M. G. Vozes que gritam e vozes silenciadas na América Latina. Civitas, Porto Alegre, v. 15, n. 3, p. 491-509, 2015.; Leite, 2014LEITE, M. Datafolha aponta saúde como principal problema dos brasileiros. Folha de S. Paulo, São Paulo, 29 mar. 2014. Disponível em: <Disponível em: http://bit.ly/2EF8XKt >. Acesso em: 28 maio 2019.
http://bit.ly/2EF8XKt... ; Magno, 2015MAGNO, L. Dos clamores das ruas aos rumores no congresso: uma análise da conjuntura recente da saúde no Brasil. 2015. Dissertação (Mestrado em Saúde Coletiva) - Universidade Federal da Bahia, Salvador, 2015.). These manifestations are not dissociated from the success of the National Movement in Defense of Public Health in collecting more than 2.2 million signatures. Known as “Health + 10”, this movement was created in 2012 and gave rise to Bill 321/2013 -Popular Initiative Bill - which provided for the effective and full repayment of 10% of current gross revenues gross of the Union for health (Brasil, 2013BRASIL. PLP nº 321/2013. Altera dispositivos da Lei Complementar nº 141, de 13 de janeiro de 2012, e dá outras providências. Câmara dos Deputados, Brasília, DF, 29 ago. 2013. Disponível em: <Disponível em: http://bit.ly/2QvOBIj >. Acesso em: 28 maio 2019.
http://bit.ly/2QvOBIj... ).

The Health + 10 movement, headed by titular entities in the National Health Council, had PL 321/2013 modified, appended and finally shelved by the Chamber of Deputies (Brasil, 2014bBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Ata da ducentésima quinquagésima sexta reunião ordinária do Conselho Nacional de Saúde - CNS. Brasília, DF, 2014b. Disponível em: <Disponível em: http://bit.ly/2I2A7f2 >. Acesso em: 29 maio 2019.
http://bit.ly/2I2A7f2... , ^2015bBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Ata da ducentésima sexagésima sexta reunião ordinária do Conselho Nacional de Saúde - CNS. Brasília, DF, 2015b. Disponível em: <Disponível em: https://bit.ly/2Xtnbsr >. Acesso em: 25 jun. 2019.
https://bit.ly/2Xtnbsr... ). In 2015, this project was unshelved - however, in four months it was again filed. In its place, EC No. 86/2015, the Tax Revenue Law, was approved, which, contrary to the provisions of the Popular Initiative Bill, requires that up to 1.2% of the net current revenue of the previous year be destined to parliamentary amendments, and half of this resource needs to be invested in health and this amount must be deducted from the Federal Government budget allocated to the Ministry of Health. This amendment also repealed the legal provision that established the allocation of 25% of the resources acquired through the exploitation of the pre-salt to health, as well as staggering in five years the reach of the 15% percentage of the resources of the Union, beginning with an application of 13.2% from 2016 (Brasil, 2015eBRASIL. Emenda Constitucional nº 86, de 17 de março de 2015. Altera os arts. 165, 166 e 198 da Constituição Federal, para tornar obrigatória a execução da programação orçamentária que específica. Diário Oficial da União, Brasília, DF, 18 mar. 2015e. Disponível em: <Disponível em: http://bit.ly/2VXhmi2 >. Acesso em: 29 out. 2016.
http://bit.ly/2VXhmi2... ; Golpe… , 2014GOLPE contra controle social e iniciativa popular. Conselho Nacional de Saúde, Brasília, DF, 9 maio 2014. Disponível em: <Disponível em: http://bit.ly/2WdxpNN >. Acesso em: 28 maio 2019.
http://bit.ly/2WdxpNN... ).

The accumulation of political forces around the issue of public health financing was channeled into the 15th Conference. Thus, in the process of building the 15th CNS, there was a deliberate attempt by the National Health Council to unify all its segments around the demand for health financing, in order to make it the main agenda of the Conference. There was even a movement within the Federal Government, articulated to entities, social movements and the National Health Council, to secure more financing for health.

The legitimacy of the Federal Government among the legislators was already showing signs of wear and tear at the end of Dilma’s term (2011-2014), signaling a major shudder in Executive-Legislative relations. In May 2014, the National Social Participation Policy (PNPS) was sanctioned, through Presidential Decree no. 8243, whose objective was to strengthen the spaces of participation and social control - and, therefore, participatory democracy - through the presence of these institutions of public policy and management in a more articulated and systemic way. Although it did not bring substantial changes to the participatory institutions, especially those with a solid trajectory in public policy such as health, the PNPS was interpreted by the Federal Legislative Branch as a threat to the Brazilian representative system, because, according to the critics of the Parliament, it was about the creation of another Power in the Republic, eliminating the Legislative from the discussions of public policies. This proposal was barred by the National Congress (Alencar; Ribeiro, 2014ALENCAR, J. L. O.; RIBEIRO, U. C. O decreto sobre a participação social no governo federal e a “polêmica bendita”. Boletim de Análise Político-Institucional, Brasília, DF, n. 6, p. 23-27, 2014.; Gadelha, 2015GADELHA, P. Conferência Nacional de Saúde: desafios para o país. Cadernos de Saúde Pública, Rio de Janeiro, v. 31, n. 10, p. 2047-2072, 2015.), demonstrating a change in the correlation of forces between the Executive and Legislative Branches, in the direction of a weak Executive and a strong Legislative. Based on the ordinary meeting of the National Health Council, the plenary approved a motion to support the policy and endorsed the manifesto in defense of the Presidential Decree, launched by the 1st Inter-council Forum of the PNPS (Fórum…, 2014FÓRUM Interconselhos divulga manifesto em favor da Política Nacional de Participação Social. Conselho Nacional de Saúde, Brasília, DF, 7 jul. 2014. Disponível em: <Disponível em: http://bit.ly/2KaA9nG >. Acesso em: 28 maio 2019.
http://bit.ly/2KaA9nG... ; Brasil, 2014dBRASIL. Ministério da Saúde. Conselho Nacional de Saúde. Ata da ducentésima quinquagésima nona reunião ordinária do Conselho Nacional de Saúde - CNS. Brasília, DF, 2014d. Disponível em: <Disponível em: https://bit.ly/2YebmDB >. Acesso em: 25 jun. 2019.
https://bit.ly/2YebmDB... ). The following speech alludes to the impasse surrounding this policy:

From the economic crisis and the political crisis that marked the history of Brazil, especially from 2014, and culminated with the impeachment of President Dilma in 2016, the political conjuncture became a central issue in the national stage of the 15th CNS. The imminence of the parliamentary coup, whose consummation represented a threat to Brazilian democracy itself (Domingues, 2017DOMINGUES, J. M. Crise da República e possibilidades de futuro. Ciência & Saúde Coletiva, Rio de Janeiro, v. 22, n. 6, p. 1747-1758, 2017.), made the Conference an area of political expression in defense of the president’s mandate and the democracy. The public financing of health remained a priority issue of the event, but under an unfavorable situation. Health came to be the target of the conservative attack of the National Congress with the “bomb-schedules,” materialized, for example, by PEC 451, of December 2014, by deputy Eduardo Cunha, which intended to make health plans mandatory for all workers. The following statements demonstrate this dynamic:

In this way, the Brazilian conjuncture of 2014 and 2015 reflected in the 15th CNS, being in line with the concern of the National Health Council to make it more politicized, to bring elements of the Brazilian conjuncture into the event, so that the Conference was not detached from reality. The national stage was initiated in the midst of a march in defense of the SUS, a political act followed by several other demonstrations during the four days of the conference (Costal; Conceição, 2016COSTAL, I.; CONCEIÇÃO, P. Entrevista do mês de janeiro: Antônio José Costa. Observatório de Análise Política em Saúde, Salvador, 8 jan. 2016. Disponível em: <Disponível em: http://bit.ly/30KQLsd >. Acesso em: 28 maio 2019.
http://bit.ly/30KQLsd... ). The acceptance of the request to open the process of impeachment of the President of the Republic by the Federal Chamber reverberated in the plenary of the 15th Conference, provoking in the delegates a reaction to defend the democratic regime.

Dilma Rousseff attended the last day of the Conference, marking the 15th as the Conference that was attended by the President of the Republic itself. She was greeted by the plenary, despite arid restrictions and criticism against aspects of her economic, social and even health policy. But there were also attempts at booing with her arrival at the 15th Conference. At that time, the Chamber of Deputies authorized to initiate the process of impeachment of the President of the Republic (Campos, 2016CAMPOS, G. W. S. XV Conferência Nacional de Saúde: o que comemorar e o que criticar? Trabalho, Educação e Saúde, Rio de Janeiro, v. 14, n. 1, p. 5-10, 2016.).

Final remarks

Some limitations were identified in the 15th CNS. From the point of view of its institutional design, despite having mobilized both the network of councils and social movements that were not part of the social control, becoming a Conference with relevant participatory dynamics, a bureaucratic format still prevailed since the partial opening for the company’s participation (not adviser) in the event was regulated and limited. It is necessary to radicalize the democratization of health conferences in the country and make strategic use of this participatory channel to further strengthen the social base of the SUS. Another weakness is the holding of the Conference outside the appropriate period to interfere in the preparation of the PPA. In addition, although its guidelines are part of the PNS, it was drafted and approved belatedly in relation to the PPA and the Budgetary Law of 2016.

On the other hand, the effort to improve the elaboration of the guidelines by politicizing the debates and limiting the number of proposals and guidelines sent for appreciation in the final stage of the 15th CNS is recognized. Thus, from the perspective of the current legislation, the 15th Conference fulfilled the role of assessing the health situation, since much of its guidelines go towards proposing the improvement of existing health policies and calling for the implementation of policies previously formulated. The 15th Conference also maintained the lead in proposing guidelines for new health policies, and was also a source of political pressure to address one of the SUS bottlenecks, which is the historical public underfunding of health. In addition, this event was the scene of the defense of democracy at the crucial moment of the parliamentary coup of 2015-2016, since the strengthening of the SUS presupposes a democratic political system.

However, it should be noted that there is an expectation that the CNS will do more. Just as the guidelines of the 8th Conference guided the National Constituent Assembly, 30 years ago, and became constitutional articles in the chapter on social security (health section), defining the directions of the Brazilian health system, there are those who expect, at each Conference, that its impact is equivalent to that of the 8th. The historical and political conjuncture, the social, political and market actors, the situation of the health system and, therefore, the challenges are different. Today, SUS is a reality and has positive impacts on the health of Brazilians, although it presents relevant fragilities (Paim et al., 2011PAIM, J. et al. The Brazilian health system: history, advances, and challenges. The Lancet, London, v. 377, n. 9779, p. 1778-1797, 2011.; Viacava et al., 2018VIACAVA, F. et al. SUS: oferta, acesso e utilização de serviços de saúde nos últimos 30 anos. Ciência & Saúde Coletiva, Rio de Janeiro, v. 23, n. 6, p. 1751-1762, 2018.). The alignment of the Conference debate with this concrete reality of the health system is a necessary but not sufficient condition for its effectiveness - that is, for the CNS guidelines to actually be implemented. The results of this article demonstrate that the 15th Conference expressed this alignment.

However, the politicization of the Conference debates, innovations in participatory dynamics and the temporal alignment with the planning and management instruments do not guarantee that its guidelines will guide the construction of health policies. Returning to the initial question of this study, it is not enough to rethink the Health Conferences themselves. In addition, one must reflect on mechanisms that make decision-makers more permeable to the demands of society expressed in these events, beyond the political pressure of social movements and the work of the Health Council. One of the ways may be to democratize, in fact, the planning process and health management. This would contribute to strengthening the role of the Conference in the dispute with the other actors around the definition of health policy.

References

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