Abstract

The State Policy for Integrative and Complementary Practices of Rio Grande do Sul (PEPIC/RS) was implemented in 2013 to institutionalize health practices based on the principle of integrality. This study aimed to investigate the potentialities, resistances, and peculiarities underlying PEPIC/RS elaboration and publication. Three managers involved in the PEPIC/RS formulation commission were interviewed about the important aspects of the early stages of the policy process. This study was conducted from June to November 2018 using an oral history methodological approach. Collected data were analyzed based on thematic content. Two categories were emphasized: “PEPIC/RS: agenda setting, formulation, and decision-making,” which investigated the policy path until its publication and “PICS: policy potentialities and resistance,” approaching the incentives and antagonisms around PICS consolidation as a public policy. The protagonism of actors that joined efforts to institutionalize access to the PICS in the context of Rio Grande do Sul public health triggered the formulation of a state policy.

Keywords:
Complementary Therapies; Integrality in Health; Public Policy

Introduction

The legitimization of Integrative and Complementary Practices in Health (PICS) in Brazil began in the 1980s, especially after the creation of the Unified Health System (SUS). In 2006, the National Policy of Integrative and Complementary Practices (PNPIC - Brasil, 2006BRASIL. Ministério da Saúde. Portaria nº 971, de 3 de maio de 2006. Aprova a Política Nacional de Práticas Integrativas e Complementares (PNPIC) no Sistema Único de Saúde. Diário Oficial da União: Brasília, DF, 4 maio 2006. Disponível em: <Disponível em: https://bit.ly/2PEJp8J >. Acesso em: 13 maio 2020.
https://bit.ly/2PEJp8J... ) was formulated in response to the social demands for PICS, evinced in several Health Conferences (Brazil, 2006BRASIL. Ministério da Saúde. Portaria nº 971, de 3 de maio de 2006. Aprova a Política Nacional de Práticas Integrativas e Complementares (PNPIC) no Sistema Único de Saúde. Diário Oficial da União: Brasília, DF, 4 maio 2006. Disponível em: <Disponível em: https://bit.ly/2PEJp8J >. Acesso em: 13 maio 2020.
https://bit.ly/2PEJp8J... ; Rio Grande do Sul, 2013RIO GRANDE DO SUL. Resolução CIB-RS nº 695, de 20 de dezembro de 2013. Política Estadual de Práticas Integrativas Complementares do Rio Grande do Sul. Diário Oficial do Estado: Porto Alegre, 20 dez. 2013.). Aligned with the national model, the State Policy of Integrative and Complementary Practices of Rio Grande do Sul (PEPIC/RS) was instituted in 2013, establishing comprehensive health practices that recognize the right to therapeutic option (Rio Grande do Sul, 2013RIO GRANDE DO SUL. Resolução CIB-RS nº 695, de 20 de dezembro de 2013. Política Estadual de Práticas Integrativas Complementares do Rio Grande do Sul. Diário Oficial do Estado: Porto Alegre, 20 dez. 2013.). With the publication of ordinances no. 849/2017 and 702/2018, new practices were included in the PNPIC, strengthening PICS institutionalization toward the integrality of care provided for users of the SUS (Brasil, 2017BRASIL. Ministério da Saúde. Portaria nº 849, de 27 de março de 2017. Inclui a arteterapia, ayurveda, biodança, dança circular, meditação, musicoterapia, naturopatia, osteopatia, quiropraxia, reflexoterapia, reiki, shantala, terapia comunitária integrativa e yoga à Política Nacional de Práticas Integrativas e Complementares. Diário Oficial da União , Brasília, DF, 28 mar. 2017. Disponível em: <Disponível em: https://bit.ly/3wwtXft >. Acesso em: 13 maio 2020.
https://bit.ly/3wwtXft... , ²⁰¹⁸BRASIL. Ministério da Saúde. Portaria nº 702, de 21 de março de 2018. Altera a Portaria de Consolidação nº 2/GM/MS, de 28 de setembro de 2017, para incluir novas práticas na Política Nacional de Práticas Integrativas e Complementares - PNPIC. Diário Oficial da União: Brasília, DF, 22 mar. 2018. Disponível em: <Disponível em: https://bit.ly/3fI4Gcv >. Acesso em: 13 maio 2020.
https://bit.ly/3fI4Gcv... ).

Integrality of care denotes a form of treatment different from those specialized in a single body part, fragmenting it. In this sense, integrality approaches the concept of holism, which conveys the idea of non-reductionism, of the individual as a whole person - a central concept to several PICS (Toniol, 2015TONIOL, R. Do espírito na saúde: oferta e uso de terapias alternativas/complementares nos serviços de saúde pública no Brasil. 2015. Tese (Doutorado em Antropologia Social) - Universidade Federal do Rio Grande do Sul, Porto Alegre, 2015.). These practices contemplate complex healthcare systems and therapeutic resources that stimulate the use of natural mechanisms of low-density technologies for treating and preventing diseases. Many PICS promote receptive listening, encourage self-care, and broaden the spectrum of the health-disease process, playing a key role both in health promotion and in the prevention and treatment of diseases (Brasil, 2006BRASIL. Ministério da Saúde. Portaria nº 971, de 3 de maio de 2006. Aprova a Política Nacional de Práticas Integrativas e Complementares (PNPIC) no Sistema Único de Saúde. Diário Oficial da União: Brasília, DF, 4 maio 2006. Disponível em: <Disponível em: https://bit.ly/2PEJp8J >. Acesso em: 13 maio 2020.
https://bit.ly/2PEJp8J... ). Both the older and more modern practices stimulate individualized care through autochthonous treatment, assimilating a positive notion of health (Tesser, 2009TESSER, C. D. Práticas complementares, racionalidades médicas e promoção da saúde: contribuições poucos exploradas. Cadernos de Saúde Pública, Rio de Janeiro, v. 25, n. 8, p. 1732-1742, 2009. DOI: 10.1590/S0102-311X2009000800009
https://doi.org/10.1590/S0102-311X200900... ).

Research and evidence on PICS and their impact on health, especially on public health, strengthened these practices while clinical treatment and public policy. Meditation, a millenary practice of Eastern origin, confer many benefits to health, such as reducing stress and depression, controlling anxiety, and improving quality of life (Khoury et al., 2017KHOURY, B. et al. Effectiveness of traditional meditation retreats: a systematic review and meta-analysis. Journal of Psychosomatic Research, Amsterdam, v. 92, p. 16-25, 2017. DOI: 10.1016/j.jpsychores.2016.11.006
https://doi.org/10.1016/j.jpsychores.201... ). Likewise, auriculotherapy have showed to be effective for smoking cessation when combined to other treatments (Lee, 2019LEE, E. J. Auricular acupressure and positive group psychotherapy with motivational interviewing for smoking cessation. Holistic Nursing Practice, Philadelphia, v. 33, n. 4, p. 214-221, 2019. DOI: 10.1097/HNP.0000000000000333
https://doi.org/10.1097/HNP.000000000000... ). A study conducted with patients affected by rheumatoid arthritis and knee osteoarthritis found that regular yoga practice may help reduce symptoms and improve general wellbeing (Wang et al., 2018WANG, Y. et al. Integrative effect of yoga practice in patients with knee arthritis: a prisma-compliant meta-analysis. Medicine, Baltimore, v. 97, n. 31, art. e11742, 2018. DOI: 10.1097/MD.0000000000011742
https://doi.org/10.1097/MD.0000000000011... ). Phytotherapy integrate consumers with nature, traditional knowledge, and scientific knowledge, besides offering therapeutic possibilities that enrich the types of care provided in primary healthcare (Antonio; Tesser; Moretti-Pires, 2013ANTONIO, G. D.; TESSER, C. D.; MORETTI-PIRES, R. O. Contribuições das plantas medicinais para o cuidado e a promoção da saúde na atenção primária. Interface, Botucatu, v. 17, n. 46, p. 615-633, 2013. DOI: 10.1590/S1414-32832013005000014
https://doi.org/10.1590/S1414-3283201300... ).

Implementing PICS into the SUS requires a solid and sustainable process democratically discussed among all parties involved and a methodological script that enables the development and maintenance of actions over time. Thus, institutionally legitimizing PICS depend upon regulation (Santos; Tesser, 2012SANTOS, M. C.; TESSER, C. D. Um método para a implantação e promoção de acesso às Práticas Integrativas e Complementares na Atenção Primária à Saúde. Ciência & Saúde Coletiva , Rio de Janeiro, v. 17, n. 11, p. 3011-3024, 2012. DOI: 10.1590/S1413-81232012001100018
https://doi.org/10.1590/S1413-8123201200... ).

For analytical purposes, public policy consists of a multi-stage cycle that involves political themes and governmental decisions. The first stage, agenda setting, concerns appointing a problem to gain government attention. The second stage concerns policy formulation, whereby involved actors propose a course of action. The third stage comprises the decision-making process, whereby government bodies choose to adopt or not a certain action. In the fourth stage, implementation, the policy is given an effective course. The fifth and final stage concerns policy evaluation, whereby government bodies define, based on the achieved results, whether the public policy will remain effective or undergo changes (Howlett; Ramesh; Perl, 2013HOWLETT, M.; RAMESH, M.; PERL, A. Política Pública: seus ciclos e subsistemas: uma abordagem integradora. Tradução: Francisco G. Heidemann. Rio de Janeiro: Elsevier, 2013.).

The PEPIC/RS formulation commission was composed of public servants and political agents of the State Department of Health (SES). Based on PNPIC guidelines, the participants sought to contemplate recommendations issued by Health Conferences, including structuring and strengthening care in PICS within the SUS, developing qualification strategies for professionals, and referencing traditional and scientific knowledge in the field (Brazil, 2006BRASIL. Ministério da Saúde. Portaria nº 971, de 3 de maio de 2006. Aprova a Política Nacional de Práticas Integrativas e Complementares (PNPIC) no Sistema Único de Saúde. Diário Oficial da União: Brasília, DF, 4 maio 2006. Disponível em: <Disponível em: https://bit.ly/2PEJp8J >. Acesso em: 13 maio 2020.
https://bit.ly/2PEJp8J... ; Rio Grande do Sul, 2013RIO GRANDE DO SUL. Resolução CIB-RS nº 695, de 20 de dezembro de 2013. Política Estadual de Práticas Integrativas Complementares do Rio Grande do Sul. Diário Oficial do Estado: Porto Alegre, 20 dez. 2013.).

This study aimed to investigate the potentialities, resistances, and peculiarities underlying PEPIC/RS elaboration and publication as a public policy. For that, we sought to understand important aspects of the early stages of PEPIC/RS cycle, especially that of formulation, by conducting interviews with members of the policy formulation commission.

Methodology

To understand the history beyond PEPIC/RS cycle origins, we opted by a qualitative approach with an oral history methodology. As this study investigates a specific theme, we used the thematic oral history genre according to Meihy and Holland (2017MEIHY, J. C. S. B.; HOLANDA, F. História oral: como fazer, como pensar. 2. ed. São Paulo: Contexto, 2017.), which involves collecting people’s narratives with their unique perspectives on a given theme and passing them from oral into written form. Data were collected through semi-structured interviews, which were recorded and later transcribed.

Oral history incorporates fundamental concepts, namely: target community, which refers to a collectivity with common destinies, forming a collective memory of affective affinities; colony, which represents a share of people from the same target community, and thus a representative fraction of it; and network, representing the colony subdivision (Meihy; Netherlands, 2017MEIHY, J. C. S. B.; HOLANDA, F. História oral: como fazer, como pensar. 2. ed. São Paulo: Contexto, 2017.). In our study, the participants of PEPIC/RS formulation commission are considered the target community and the network was formed by the three interviewed health professionals actuating in some level of state management, here referred to as “managers.”

As per Meihy and Holland (2017MEIHY, J. C. S. B.; HOLANDA, F. História oral: como fazer, como pensar. 2. ed. São Paulo: Contexto, 2017.), ground zero determines the origin of the network, which should preferably be created by derivation - that is, the interviewed participant indicates someone to be the next interviewee. The ground zero of our study network was the proposer of PEPIC/RS formulation; this manager indicated the next interviewee, who indicated the third and last interviewee. With these three interviews, we obtained enough data to achieve the research objectives.

Participation in the study was optional. After the due clarifications regarding the study purpose, objectives, and methods, the participants signed an informed consent form, as well as the interview authorization letter at the end of each interview. This study was conducted within the scope of the State Department of Health of Rio Grande do Sul and the Coordination of PEPIC/RS, located in the Department of Health Actions at the Administrative Center Fernando Ferrari, in Porto Alegre/RS. Each interview lasted from 45 to 70 minutes, and their content was recorded using a digital audio recorder and later transcribed. The interviewers also used a field notebook for annotations. After transcribed, the material was sent to each interviewee for conference. The principal researcher will be responsible for the material for a 5-year period, after which it will be destroyed.

The content of recorded and transcribed data were processed using the three-stage thematic content analysis (Minayo, 2014MINAYO, M. C. S. O desafio do conhecimento: pesquisa qualitativa em saúde. 14. ed. São Paulo: Hucitec, 2014.). The first stage concerns pre-analysis, whereby documents are selected for analysis based on floating reading, exploring the material and building the documentary corpus. The next stage comprises corpus investigation, whereby the material is classified to identify the content comprehension core within categories. These categories are identified by meaningful words or expressions to encode and separate speeches content. The final stage concerns data processing and interpretation through inferences based on the theoretical framework (Minayo, 2014MINAYO, M. C. S. O desafio do conhecimento: pesquisa qualitativa em saúde. 14. ed. São Paulo: Hucitec, 2014.).

For thematic analysis of data obtained from interviews transcription, representative statements were discussed based on a theoretical framework and divided into two components: “PEPIC/RS: agenda setting, formulation, and decision-making” and “PICS: policy potentialities and resistance.”

Recorded and transcribed statements were identified with the names of Hindu deities to protect interviewees’ identity. Considering the Eastern origins and ancient tradition of many PICS, as well as the characteristics of the three interviewees - women who strive for new care paradigms in public health, - the following deities were chosen: Saraswati, the goddess of wisdom and arts, who protects those who seek knowledge; Lakshmi, the goddess who symbolizes feminine power, generosity, and love; and Durga, a warrior goddess who inspires ethics and conscience and protects humanity from evil and diseases (Recine; Guimarães; Rodrigues, 2005RECINE, E.; GUIMARÃES, K.; RODRIGUES, N. Deusas orientais. In: DONATELLI, M. (Coord.). O livro das deusas. São Paulo: Publifolha, 2005. p. 18-33.).

This research project was approved by the Ethics Committee on Health Research of the School of Public Health, under opinion no. 2,691,921, according to CNS Resolutions no. 466/2012 and 510/2016. The study was conducted from June to November 2018.

Results and discussion

PEPIC/RS: agenda setting, formulation, and decision-making

The public policy cycle is a complex phenomenon that involves decisions of actors and groups inside and outside the government. For analytical purposes, the policy cycle can be divided into five interconnected stages, without necessarily presenting a linear progression (Howlett; Ramesh; Perl, 2013HOWLETT, M.; RAMESH, M.; PERL, A. Política Pública: seus ciclos e subsistemas: uma abordagem integradora. Tradução: Francisco G. Heidemann. Rio de Janeiro: Elsevier, 2013.). The first three stages refer to agenda setting, when a problem becomes the object of government attention; policy formulation, when courses of action for the given problem are identified; and decision-making, the inherently political moment when government bodies approve the official course of action (Kingdon , 2003KINGDON, J. W. Agendas, alternatives, and public policies. 2. ed. New York: Longman, 2003.).

PEPIC/RS formulation commission was established in 2012 (Rio Grande do Sul, 2012RIO GRANDE DO SUL. Portaria nº 201, de 23 de maio de 2012. Comissão de Formulação da Pepic/RS. Diário Oficial do Estado: Porto Alegre, 25 maio 2012.), six years after the implementation of the National Policy on Medicinal Plants and Herbal Medicine and the Intersectoral Policy of Medicinal Plants and Herbal Medicines of Rio Grande do Sul, in 2006. The connection with medicinal plant policies played a central role in the agenda-setting and formulation stages of PEPIC/RS, which is evinced by Saraswati’s speech below.

Inserting medicinal and herbal plants within the SUS stimulated PICS institutionalization in the Rio Grande do Sul public health system. According to Santos and Tesser (2012SANTOS, M. C.; TESSER, C. D. Um método para a implantação e promoção de acesso às Práticas Integrativas e Complementares na Atenção Primária à Saúde. Ciência & Saúde Coletiva , Rio de Janeiro, v. 17, n. 11, p. 3011-3024, 2012. DOI: 10.1590/S1413-81232012001100018
https://doi.org/10.1590/S1413-8123201200... ), the traditionality underlying the popular use of medicinal plants makes it the first integrative practice recognized for use in the public health field.

With the publication of the PNPIC in 2006, containing five PICS (Brazil, 2006BRASIL. Ministério da Saúde. Portaria nº 971, de 3 de maio de 2006. Aprova a Política Nacional de Práticas Integrativas e Complementares (PNPIC) no Sistema Único de Saúde. Diário Oficial da União: Brasília, DF, 4 maio 2006. Disponível em: <Disponível em: https://bit.ly/2PEJp8J >. Acesso em: 13 maio 2020.
https://bit.ly/2PEJp8J... ), the advance of practices other than phytotherapy were leveraged at national level. Moreover, the 2011 regime change in the state government enabled PEPIC/RS agenda setting, as Saraswati reports:

According to Kingdon (2003KINGDON, J. W. Agendas, alternatives, and public policies. 2. ed. New York: Longman, 2003.), political entrepreneurs are actors from inside and outside the government who present characteristics such as persistence in defending their positions and ability to negotiate and perceive political opportunities beneficial to their interests. Political entrepreneurs are key actors in the agenda setting process, bridging the gap between solutions, political challenges, and opportunities (Howlett; Ramesh; Perl, 2013HOWLETT, M.; RAMESH, M.; PERL, A. Política Pública: seus ciclos e subsistemas: uma abordagem integradora. Tradução: Francisco G. Heidemann. Rio de Janeiro: Elsevier, 2013.).

The PEPIC/RS agenda was set in a favorable context of increasing demand for practices, where the manager offered a viable solution to the deputy secretary, who in turn was open to the proposal and supported the policy formulation process. Actors involved in the public policy cycle - whether political or social actors and public servants - propose actions to the government agenda. In this scenario, the State is an actor with decisive resources for the process viability (Czermainski, 2009CZERMAINSKI, S. B. C. A Política Nacional de Plantas Medicinais e Fitoterápicos: um estudo a partir da análise de políticas públicas. 2009. Dissertação (Mestrado em Ciências Farmacêuticas) - Universidade Federal do Rio Grande do Sul, Porto Alegre, 2009.). Regarding the structure of the formulation commission, Lakshmi remarks:

The qualification of healthcare personnel must embody critical reflections on real practices of real professionals, whose resulting learning may help transforming work practices and processes by associating technical and institutional contents with reality (Vendruscolo et al., 2016VENDRUSCOLO, C. et al. Integração ensino-serviço e sua interface no contexto da reorientação da formação na saúde. Interface, Botucatu, v. 20, n. 59, p. 1015-1025, 2016. DOI: 10.1590/1807-57622015.0768
https://doi.org/10.1590/1807-57622015.07... ). During PEPIC/RS formulation, professionals associated to organized bodies who worked with PICS were invited to talk about their work. According to Lakshmi:

The narratives allow us to understand that social engagement with PEPIC/RS formulation represented an effort to democratize the process, relying on the participation of professionals associated to organized bodies, besides seeking to value popular knowledge. A PhD student also participated in the commission, contributing to the discussions with bibliographic reviews and important scientific research.

According to Santos et al. (2015SANTOS, F. A. et al. A definição de prioridade de investimento em saúde: uma análise a partir da participação dos atores na tomada de decisão. Physis, Rio de Janeiro, v. 25, n. 4, p. 1079-1094, 2015. DOI: 10.1590/S0103-73312015000400003
https://doi.org/10.1590/S0103-7331201500... ), the Brazilian electoral system, with state elections being held every four years, exerts considerable political-electoral influence on priorities setting due to the short-term management and the lack of solid ideological bases, compromising even actions with strong technical support and social endorsement. On this regard, Saraswati comments:

The power of the various actors involved and their often conflicting interests interferes with decision-making on policy setting (Santos et al., 2015SANTOS, F. A. et al. A definição de prioridade de investimento em saúde: uma análise a partir da participação dos atores na tomada de decisão. Physis, Rio de Janeiro, v. 25, n. 4, p. 1079-1094, 2015. DOI: 10.1590/S0103-73312015000400003
https://doi.org/10.1590/S0103-7331201500... ). According to Howlett, Ramesh, and Perl (2013HOWLETT, M.; RAMESH, M.; PERL, A. Política Pública: seus ciclos e subsistemas: uma abordagem integradora. Tradução: Francisco G. Heidemann. Rio de Janeiro: Elsevier, 2013.), the number of actors tend to decrease at the decision-making stage, when the offered options can be officially approved by government authorities. At this stage, the power of the political actor who participated in the commission was decisive for PEPIC/RS approval before transition.

In 2013, when PEPIC/RS was first published, the policy contained some PICS modalities different from those of PNPIC, such as floral therapy, thus being considered innovative in relation to the national policy in force at the time. In 2017 and 2018, many of these practices were also added to the federal regulation (Brazil, 2006BRASIL. Ministério da Saúde. Portaria nº 971, de 3 de maio de 2006. Aprova a Política Nacional de Práticas Integrativas e Complementares (PNPIC) no Sistema Único de Saúde. Diário Oficial da União: Brasília, DF, 4 maio 2006. Disponível em: <Disponível em: https://bit.ly/2PEJp8J >. Acesso em: 13 maio 2020.
https://bit.ly/2PEJp8J... , ²⁰¹⁷BRASIL. Ministério da Saúde. Portaria nº 849, de 27 de março de 2017. Inclui a arteterapia, ayurveda, biodança, dança circular, meditação, musicoterapia, naturopatia, osteopatia, quiropraxia, reflexoterapia, reiki, shantala, terapia comunitária integrativa e yoga à Política Nacional de Práticas Integrativas e Complementares. Diário Oficial da União , Brasília, DF, 28 mar. 2017. Disponível em: <Disponível em: https://bit.ly/3wwtXft >. Acesso em: 13 maio 2020.
https://bit.ly/3wwtXft... , ²⁰¹⁸BRASIL. Ministério da Saúde. Portaria nº 702, de 21 de março de 2018. Altera a Portaria de Consolidação nº 2/GM/MS, de 28 de setembro de 2017, para incluir novas práticas na Política Nacional de Práticas Integrativas e Complementares - PNPIC. Diário Oficial da União: Brasília, DF, 22 mar. 2018. Disponível em: <Disponível em: https://bit.ly/3fI4Gcv >. Acesso em: 13 maio 2020.
https://bit.ly/3fI4Gcv... ; Rio Grande do Sul, 2013RIO GRANDE DO SUL. Resolução CIB-RS nº 695, de 20 de dezembro de 2013. Política Estadual de Práticas Integrativas Complementares do Rio Grande do Sul. Diário Oficial do Estado: Porto Alegre, 20 dez. 2013.). On this regard, Durga remarks:

Besides the five practices originally outlined in PNPIC, PEPIC/RS includes several others: floral therapy, Reiki, integrative body practices (Yoga, Tai Chi Chuan, Qi Gong), manual & manipulative therapy (massage therapy, osteopathy, and chiropractic), community therapy, dietotherapy, Ayurvedic medicine, meditation, chromotherapy, music therapy, aromatherapy, and geotherapy (Rio Grande do Sul, 2013RIO GRANDE DO SUL. Resolução CIB-RS nº 695, de 20 de dezembro de 2013. Política Estadual de Práticas Integrativas Complementares do Rio Grande do Sul. Diário Oficial do Estado: Porto Alegre, 20 dez. 2013.). Once approved by the CIB, PEPIC/RS was approved by the State Health Council in 2014 (Rio Grande do Sul, 2014RIO GRANDE DO SUL. Resolução CES/RS nº 14, de 13 de novembro de 2014. Aprova a proposta de Política Estadual de Prática Integrativas e Complementares encaminhada pela SES. Diário Oficial do Estado: Porto Alegre, 24 dez. 2014.). According to Saraswati:

The protagonism of social control over the State in the formulation process of public policies enables these to truly address real health needs (Shimizu; Moura, 2015SHIMIZU, H. E.; MOURA, L. M. As representações sociais do controle social em saúde: os avanços e entraves da participação social institucionalizada. Saúde e Sociedade, São Paulo, v. 24, n. 4, p. 1180-1192, 2015. DOI: 10.1590/S0104-12902015136180
https://doi.org/10.1590/S0104-1290201513... ). Although social control bodies did not participate in PEPIC/RS formulation process, the State Health Council evaluated and approved the text, ratifying the adequacy of the proposed policy to address the demand for PICS within the SUS.

PICS: policy potentialities and resistance

The narratives reported personal and professional experiences with the use of PICS, which led managers to participate in the PEPIC/RS formulation process. Saraswati describes her contact with the PICS, which was triggered by a family situation that influenced her professional performance:

The experience, combined with practitioners’ affinity towards the activities they perform, positively affects professional performance. Pleasure at work is associated with professional achievement, personal gratification, recognition, and freedom of expression (Maissiat et al., 2015MAISSIAT, G. S. et al. Contexto de trabalho, prazer e sofrimento na atenção básica em saúde. Revista Gaúcha de Enfermagem, Porto Alegre, v. 36, n. 2, p. 42-49, 2015. DOI: 10.1590/1983-1447.2015.02.51128
https://doi.org/10.1590/1983-1447.2015.0... ). Durga talks about her willingness toward the PICS:

With the tensioning of the biomedical, curative model, centered on biological issues, the demand for more humanized practices, as those proposed by many PICS, increased (Contatore et al., 2015CONTATORE, O. A. et al. Uso, cuidado e política das práticas integrativas e complementares na atenção primária à saúde. Ciência e Saúde Coletiva, Rio de Janeiro, v. 20, n. 10, p. 3263-3273, 2015. DOI: 10.1590/1413-812320152010.00312015
https://doi.org/10.1590/1413-81232015201... ). The questioning of the hegemonic medical model triggered various issues and evinced numerous gaps to which the PICS, representing the public policy flow, brought new perspectives not merely as a successor for biomedical practices, but for complementing and broadening therapeutic possibilities. The convergence between these aspects and the political flow created an opportunity for the PICS. According to Lakshmi, before the beginning of PEPIC/RS formulation process, the theme was already recurrent among managers:

For a sustained implementation and consolidation of PICS within the SUS, in view of services qualification and greater resolutiveness, one must secure the alignment between management, institutional policies, and professionals. Thus, PICS implementation may promote integrality of care - one of the principles of the SUS (Santos; Tesser, 2012SANTOS, M. C.; TESSER, C. D. Um método para a implantação e promoção de acesso às Práticas Integrativas e Complementares na Atenção Primária à Saúde. Ciência & Saúde Coletiva , Rio de Janeiro, v. 17, n. 11, p. 3011-3024, 2012. DOI: 10.1590/S1413-81232012001100018
https://doi.org/10.1590/S1413-8123201200... ). However, the practices must not be subverted to the medicalization logic (such as norms of conduct in health) and their complexity must not be simplified - given that many practices, such as traditional Chinese and Ayurvedic medicine, are millennials and require advanced professional training (Tesser; Barros, 2008TESSER, C. D.; BARROS, N. F. Medicalização social e medicina alternativa e complementar: pluralização terapêutica do Sistema Único de Saúde. Revista de Saúde Pública, São Paulo, v. 42, n. 5, p. 914-920, 2008. DOI: 10.1590/S0034-89102008000500018
https://doi.org/10.1590/S0034-8910200800... ). On PICS potentials, Lakshmi highlights:

According to Schveitzer and Zoboli (2014SCHVEITZER, M. C.; ZOBOLI, E. L. C. P. Papel das práticas complementares na compreensão dos profissionais da atenção básica: uma revisão sistemática. Revista da Escola de Enfermagem da USP, São Paulo, v. 48, p. 189-196, 2014. Número especial. DOI: 10.1590/S0080-623420140000500026
https://doi.org/10.1590/S0080-6234201400... ), PICS implementation represents a diversification strategy to improve the current care model rather than a competition to find the best type of care. Such improvement in healthcare provision may reconstruct work processes, motivate involved professionals, and even enhance the satisfaction of users regarding services singularities. The managers here interviewed recognize the practices as approaches with great potential for the public health system qualification. From the perspective of integrality of care, this perception motivated them to strive for PICS implementation within the SUS.

A study conducted by Galhardi, Barros, and Leite-Mor (2013GALHARDI, W. M. P.; BARROS, N. F.; LEITE-MOR, A. C. M. B. O conhecimento de gestores municipais de saúde sobre a Política Nacional de Prática Integrativa e Complementar e sua influência para a oferta de homeopatia no Sistema Único de Saúde local. Ciência e Saúde Coletiva, Rio de Janeiro, v. 18, n. 1, p. 213-220, 2013. DOI: 10.1590/S1413-81232013000100022
https://doi.org/10.1590/S1413-8123201300... ) found municipal health managers to consider PNPIC as trivial when compared to other policies, such as the National Primary Health Care Policy. Thus, formulating a state regulation such as PEPIC/RS strengths PICS consolidation. Regarding the difficulties of recognizing PICS such as homeopathy, Durga comments:

After agenda setting, policy formulation, and decision-making, the policy cycle reaches the stage concerning policy implementation, whereby government authorities will execute the action (Howlett; Ramesh; Perl, 2013HOWLETT, M.; RAMESH, M.; PERL, A. Política Pública: seus ciclos e subsistemas: uma abordagem integradora. Tradução: Francisco G. Heidemann. Rio de Janeiro: Elsevier, 2013.). According to Durga’s report, the resistance towards homeopathy decreased with its strengthening resulting from PEPIC/RS implementation.

The logic underlying medical rationalities such as homeopathy, centered on integrality and understanding healthcare as an unique process for each individual, differs from that of biomedical rationality, whose therapies emphasize cure and the biological aspect of diseases. In this sense, despite advances in studies approaching practices, their designs are often centered on pathologies and interventions effects, excluding many of the approaches included on PICS (Contatore et al., 2015CONTATORE, O. A. et al. Uso, cuidado e política das práticas integrativas e complementares na atenção primária à saúde. Ciência e Saúde Coletiva, Rio de Janeiro, v. 20, n. 10, p. 3263-3273, 2015. DOI: 10.1590/1413-812320152010.00312015
https://doi.org/10.1590/1413-81232015201... ). Regarding other resistances faced by the practices, Durga remarks:

Institutions whose interests differ from those of integrality and universality disqualify SUS in the eyes of the population - regardless of its accountability for 75% of the country healthcare despite being underfunded (Rizzotto, 2018RIZZOTTO, M. L. F. A reafirmação da democracia e do direito universal à saúde em tempos de ultraneoliberalismo. Ciência & Saúde Coletiva, Rio de Janeiro, v. 23, n. 6, p. 1717-1718, 2018. DOI: 10.1590/1413-81232018236.05682018
https://doi.org/10.1590/1413-81232018236... ). Before the pressure of groups with divergent interests and the importance of establishing public policies to legitimize health actions that are considered interesting for users (such as those of the PICS), the political context will influence the decision-making process. According to Lakshmi:

For Machado, Cotta, and Soares (2015MACHADO, J. C.; COTTA, R. M. M.; SOARES, J. B. Reflexões sobre o processo de municipalização das políticas de saúde: a questão da descontinuidade político-administrativa. Interface, Botucatu, v. 19, n. 52, p. 159-170, 2015. DOI: 10.1590/1807-57622013.1002
https://doi.org/10.1590/1807-57622013.10... ), the political-administrative discontinuity is related to filling positions of trust and political and partisan bias with each government change, and may interrupt programs, projects, and priorities without considering their merit and quality. Such discontinuity discourages teams, wastes public resources, and causes institutional memory loss.

As a way of opposing to hegemonic discourse, PEPIC/RS supports the right to therapeutic option based on an integral and humanized care, respecting individuals’ dimensions as biological, mental, emotional, spiritual, and social beings, and conceiving health as a holistic and unique process for each person (Rio Grande do Sul, 2013RIO GRANDE DO SUL. Resolução CIB-RS nº 695, de 20 de dezembro de 2013. Política Estadual de Práticas Integrativas Complementares do Rio Grande do Sul. Diário Oficial do Estado: Porto Alegre, 20 dez. 2013.). On this regard, Saraswati comments:

These practices provide greater capacity to address public health challenges, stimulating the protagonism of workers and users of the SUS (Telesi Júnior, 2016TELESI JÚNIOR, E. Práticas integrativas e complementares em saúde, uma nova eficácia para o SUS. Estudos Avançados, São Paulo, v. 30, n. 86, p. 99-112, 2016. DOI: 10.1590/S0103-40142016.00100007
https://doi.org/10.1590/S0103-40142016.0... ). The movement triggering the public policy formulation likewise owes to such demand for a more humanized care, which is proposed by the PICS.

Final considerations

In a context of valuing practices such as phytotherapy and integrative possibilities of counter-hegemonic care, a group of actors set the PEPIC/RS agenda based on a mutual interest: formulating a state public policy. Just as one of the managers’ performance was key for embracing the opportunity given to PICS, the presence of the political agent in the commission was decisive for the approval of the policy.

This study did not focus on evaluating the public policy cycle as a method for PEPIC/RS implementation; rather, it sought to reveal important elements of the process based on the narratives of involved actors. All managers mentioned aspects of the first four stages of the public policy cycle (namely, agenda setting, formulation, decision-making, and implementation) without a rigid linearity. The formulation stage had greater emphasis among reports, and managers made no relevant reference to the last stage - evaluation.

Our results allow us to conclude that PEPIC/RS implementation was a movement headed by healthcare management professionals with prior experience in PICS, either in the clinical or persona/family environment, who spotted a window of opportunity and sought to strengthen these practices by establishing a public policy with potential to qualify care in the public health system of Rio Grande do Sul.

References

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