Abstract

Our study analyzes the dynamics of the social control exercise in a Brazilian municipality in an international frontier region, based on the records in the minutes of the Municipal Health Council (CMS), referring to specific health policies for the location. The technique of document analysis was used, aided by an instrument designed to identify the participation of counselors in meetings, activities and topics related to health policy on the border area from 2006 to 2018, a period related to the inclusion in the Integrated Border Health System (SIS Fronteiras). The results indicate that the CMS discussed health policy without contextualizing it sufficiently for the specific border territory. Therefore, training mechanisms are recommended to improve action and organization, anchored on the theme health in border regions, supporting the social control exercise oriented to the needs of the local reality of Brazilian border cities.

Keywords:
Unified Health System; Social Control; Health in Border regions

Introduction

Brazil has a frontier shared with 10 other South American countries. There are 588 border cities distributed in 11 states, and 139 are located in the state of Paraná. Border territories are complex and must be understood, beyond the formal legal sphere, in the everyday life of spaces/boundaries, since elements of integration and conflict coexist. These elements must be considered in the social determination of the health-disease process and, therefore, in the health policies and programs.

The territory can be interpreted as a social space historically produced and organized, permeated by power relations, networks and identities in constant transformation, organized mainly by the capital and the State. The frontier constitutes an analytical and spatial part of several political, economic and cultural realities that involve the problems of capital volatility and relations of production in the territory. The frontier is also the space of cross-cultural and identity conflicts that carries in their history the concern for national security and the lack of public policies for cross-border cooperation, which would promote an integrated economic development. (Souza, 2013SOUZA, E. B. C. Por uma cooperação transfronteiriça: algumas contribuições para as dinâmicas territoriais da fronteira Brasil-Paraguai. Revista GeoPantanal, Campo Grande, v. 8, n. 15, p. 63-78, 2013.).

Health policies for border regions must consider the geopolitical situation marked by asymmetries and inequalities demonstrated by sociodemographic and health indicators of the population living in these areas. Health management planning must also consider the peculiarities of the territory as an instrument to understand these regions’ typical difficulties and needs (Azevedo, 2015AZEVEDO, S. T. s percepções sobre a saúde na fronteira Brasil e Paraguai: os transfronteriços e o atendimento pelo SUS. 2015. In: ENCONTRO NACIONAL DA ANPEGE, v. 11, 2015, Presidente Prudente. Anais [...]. Presidente Prudente: ANPEGE, 2015.).

The Brazilian National Health System (SUS) is organized nationally in a decentralized manner, observing the demographic and socioeconomic differences of the vast Brazilian territory, respecting the principles of access universality and assistance integrality. The Decree n. 7.508/2011 aims to regulate the roles of federative entities in regions and health networks, clarifying the responsibilities and attributions, financial resources, actions and health services to guarantee the effective right to health in the territory. Then, the decree defines as a health region the “continuous geographic space constituted by groupings of bordering cities, delimited based on shared cultural identities, economic, social, communication networks, and transport infrastructure, aiming to integrate the organization, planning and execution of actions and health services”²2Our translation. (Brasil, 2011BRASIL. Decreto nº 7.508, de 28 de junho de 2011. Regulamenta a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a organização do Sistema Único de Saúde (SUS), o planejamento da saúde, a assistência à saúde e a articulação interfederativa, e dá outras providências. Diário Oficial da União, Brasília, DF, 29 jun. 2011. Disponível em: <Disponível em: https://bit.ly/3aecgYS >. Acesso em: 15 set. 2020.
https://bit.ly/3aecgYS... ).

Aiming to mobilize healthcare managers and expand the operational capacity of 121 bordering cities, in 2005, the federal government proposed the Integrated Frontier Health System (SIS Fronteiras), implementing a system of network cooperation, integrating the actions and health services in the frontier regions (LEMÕES et al., 2019LEMÕES, M. A. M. et al. Mais médicos no programa de fronteira: gestão da saúde nas cidades gêmeas entre Brasil e Uruguai. Revista Uruguaia de Enfermagem, Montevidéu, v. 14, n. 1, p. 38-48, 2019. DOI: rue2019v14n1a44
https://doi.org/rue2019v14n1a44... ). Through international collaboration between border countries, it aimed to promote integrated and transformative practices to strengthen systems bilaterally in the health sector.

In health management, the social control has an important role in consolidation SUS principles, exercised formally in the instances of councils and conferences, constituting a space for debates, agreements and deliberations, in which the civil society can interfere in the definition of health policies, considering collective interests and local health needs.

The Municipal Health Councils (CMS), while instruments of civil society participation, can contribute in the organization of a more effective local health network. They can regard the population’s health problems in this territory and collaborate in the elaboration of regional public interest topics, emerging as a democratic space for social participation. In this sense, this study aims to analyze the dynamics of social control in a Brazilian border city.

Methodology

This is a descriptive study with a qualitative approach, based on the documental analysis of the minutes of the Municipal Health Council meetings in Foz do Iguaçu (COMUSFOZ). It started from 2006, which is the implantation period of SIS Fronteiras. This period was chosen intentionally, because the SIS Fronteiras was an important and specific public policy for border cities, which enabled or intensified the debate about issues related to border territory and its health policies. The documental research was made with material that has not yet received an analytical treatment regarding a particular object of study (Cechinel et al., 2016CECHINEL, A. et al. Estudo/análise documental: uma revisão teórica e metodológica. Criar Educação, Criciúma, v. 5, n. 1, 2016. DOI: 10.18616/ce.v5i1.2446
https://doi.org/10.18616/ce.v5i1.2446... ).

The COMUSFOZ was created by the City Law n. 1.507/1990. It is integrated by three social segments and with a parity representation of 50% representatives of patients entities, 25% health service workers, 12,5% managers of public health agencies, and 12,5% health service clerks. In total, it had 32 full member and 32 alternate members, indicated by entities/bodies elected in the Municipal Health Conference (Foz do Iguaçu, 2012FOZ DO IGUAÇU. Regimento Interno do Conselho Municipal de Saúde no município de Foz do Iguaçu-PR. Foz do Iguaçu: Secretaria Municipal de Saúde, 2012.).

The SIS Fronteiras was a proposal made by the Brazilian government, aiming to minimize current administrative asymmetries and strengthen health services in the 121 borders cities. In this context, according to Hortelan et al. (2019HORTELAN, M. S. et al. Papel do gestor de saúde pública em região de fronteira: scoping review. Acta Paulista de Enfermagem, São Paulo, v. 32, n. 2, p. 229-236, 2019. DOI: 10.1590/1982-0194201900031
https://doi.org/10.1590/1982-01942019000... ), “binational agreements, citizenship of foreigners, and leading programs/policies on cross-border care [...]” (p. 235) potentiate health services and conduct public health managers’ planning and actions. Therefore, this program was used as a discussion maker for the specific health policies for border region in the CMS studied.

282 minutes were analyzed and 77 were selected. The minutes selected were those that mentioned “health and frontier”, “border health policies” and/or “SIS Fronteiras”, including participation of advisors in events or training related to border health. Figure 1 presents the data analysis procedure to extract the analytical categories and the thematic units approached in the results.

An instrument was designed for data collection and systematization. Bardin’s referential (2016) was used for content analysis, which deals with raw information in reproductions that aid the access, consultation and referencing of the documents, followed by the pre-analysis stages, material exploration, and data treatment. The organized analytical categories were intended to identify the participation of advisors in meetings, as well as activities and discussions related to border health policy in the period of adherence to SIS Fronteiras. The following themes operate as analytical categories: (1) border health policies, (2) SIS Fronteiras, and (3) participation of advisors in trainings about the theme of health in border areas (Figure 01). The following thematic units were analyzed: (1.1) health care for the population at the border, (2.1) accountability of SIS Fronteiras funding, (2.2) actions financed by SIS Fronteiras, (2.3) operational plan, and (2.4) local health commission of SIS Fronteiras. These were the most expressive units according to this study’s aim.

The ethical aspects of the research follow what is proposed by the Resolution n. 510/2016 of the National Health Council (CNS). The project was approved by the Human Research Ethics Committee under decision n. 2.982.939/2018.

Results

The spaces for debate in the CMS have fundamental importance for social control, inspecting health policies and influencing regional development. Chart 1 presents the documental analysis results obtained from the COMUSFOZ minutes, trying to understand how this entity approached the theme of health in border region.

Health policies in the frontier

There are registers of health policies in the border in 47 minutes (Table 1). 20 of them highlighted the thematic unit health care for the border population. On the agenda of the meeting n. 339/2006, in which the day theme refers to the current assistance situation in the city:

In 2008, Minute n. 418 presented registers of an attendance in the Santa Casa Monsenhor Guilherme, when the advisors questioned the population attended in the city regarding the number of beds available. In addition to the resident population of the city, they also questioned the attendance of nonresidents, highlighting the “brasiguaios” (Brazilians who reside in Paraguay) and interrogated about the federal funding for health in the city that did not benefit the cross-border population in the transfer of funds.

In the meeting records that intend to deliberate about the Municipal Health Department budget, it was identified that representatives of the city management also questioned the assistance to non-resident population in the city’s health services.

The recognition of distinction of public budgets destinated to local system of health in border counties is a concern of municipal health managers recurrently expresses in minutes due to non-accounting of floating population in data for financial transfers. In meeting registered in Minute n. 355/2006 to treat of Management and Budget Pact 2007 of Municipal Health Department, the theme frontier appears as part of presentation of municipal manager who says:

Yet, in this meeting, the manager explains the objective of the Management Agreement, besides explaining the functions of the management collegiate and the priorities of each federative entity regarding health policies, reinforcing the compromise with system management in aspects of decentralization, regionalization, financing, planning, integrated agreement programming, regulation, social participation, and work management related to health. Concerning the frontier regions, the ministerial resolution includes health care in border cities, promoting articulation between countries and the institutions involved.

Despite this meeting, registered in Minute n. 355/2006, treating in its agenda the management agreement, there were no records of effective participation of municipal health advisors, questioning or arguing the pact and the bilateral agreements that could be negotiated in the regional management collegiate. Also, there were no other minutes with meeting records, appointments or events promoted by this collegiate to deal with health care in border areas. This theme was not present in the minutes of the following years until 2018.

SIS Fronteiras

In the COMUSFOZ, 21 minutes presented registers about SIS Fronteiras (Table 1). The first discussion about the program was in Minute n. 340 of the 09/03/2006 meeting. The meeting agenda was the indication of advisors for the local health commission of SIS Fronteiras:

In the meeting mentioned, the manager presented the program aims, the three phases of execution, exhibiting the values of the financial transfers and the institution of a commission. According to the minute, the program institutes SIS Fronteiras in its first article, directed to integrate actions and health services in the border regions with the following goals:

It was also stated in the minute that the city would receive from the federal budget the sum of R$ 6.5 million, provided by the Project of Training and Enhancement of the Health care Network Quality (QualiSUS), for the development of SIS Fronteiras. The program would be developed in three phases: diagnosis and operational planning, implantation of services for border regions, and training of managers for strategic areas. The manager reported that one of the demands made by the Ministry of Health was the institution of a Permanent Committee for the Implementation and Monitoring of SIS Fronteiras Actions, which in COMUSFOZ was constituted by representants of national and foreign entities:

According to the Minute n. 340/2006, the main goal of this meeting was the institution of a permanent committee, which should be immediately decided even after the presentation of the program structure, as explained by the manager.

By reading the minutes based on the tag “border”, discussions regarding the accountability of SIS Fronteiras resources were found in 9 minutes, the actions financed by SIS Fronteiras in 5, the operational plan in 2, and the Local Health Commission of SIS Fronteiras in 3.

The operational plan was evaluated by the city advisors in the meeting of Minute n. 358/2006.

During this meeting, the manager explained how the study was performed to reach the city diagnosis by the Universidade Federal do Paraná.

According to the records, the research conducted to define the local diagnosis would also present data regarding the nationality of patients who sought for health services and the profile of the assistance provided for them during the period studied.

The minute also reports the results found by the research that diagnosed the local health system regarding access (if the help of a third person was needed) and the satisfaction level:

Regarding financial resources, the minute reports that the values would be provided by the Ministry of Health, which would also determine where they should be used:

The operational plan permits the city to receive funds from the Ministry of Health. After being presented by the Health Secretariat, it was evaluated and approved by the city’s health advisors. The phase I of SIS Fronteiras was approved through the Ordinance n. 160/2007, which states:

This meeting constituted the moment with higher discussion about SIS Fronteiras among advisors. Other registers related to the program appear punctually on the accountability: few talks questioned the delay in the transfer of funds to build the health units contemplated in the plan, and only one appointment in a requesting minute is made by the health secretariat for the evaluation of alterations in the funds application plan.

The last minute related to the program occurred in 2011 (Chart 2), regarding financial transfers for the building of two health units. It is noticed that from 2006, when the program was implanted in the city, until 2011, when the subject appears for the last time, the discussion about SIS Fronteiras was restricted to financial matters. There are no records regarding the elaboration of health policies in the border, considering that the program goal is to promote the integration between actions and health services in the region, as stated by Ordinance n. 1.188/2006. There is also no record of other necessities predicted, such as the evaluation of coordinated actions regarding health in the border, the development of an information system to support a cooperation system, and the mobilization of managers in border areas to define and implement a network cooperation system (Brasil, 2006BRASIL. Ministério da Saúde. Portaria nº 1.188, de 05 de junho de 2006. Dá nova redação a Portaria nº 1.120/GM, que instituiu o Sistema Integrado de Saúde das Fronteiras - SIS FRONTEIRAS. Diário Oficial da União, Brasília, DF, 6 jun. 2006. Disponível em: <Disponível em: https://bit.ly/32iRyCr >. Acesso em: 4 dez. 2019.
https://bit.ly/32iRyCr... ).

Even after the city’s adhesion to SIS Fronteiras, considering that it is a program that propels the discussion about health system in border areas and the moment of higher discussion on the subject in the city council, further records did not reveal the consolidation of this debate in the COMUSFOZ.

Participation of advisors in training courses with the subject of health in border areas

The Policy of Permanent Health Training (PEPS), reformulated in 2007 with the participation of CNS, deliberated the guidelines for the PEPS function in SUS Social Control. It aimed to expand institutions’ existing initiatives and stimulate states and cities in the training of their advisors (Brasil, 2007aBRASIL. Política Nacional de Educação Permanente para o controle social no Sistema Único de Saúde - SUS. Brasília, DF: Ministério da Saúde, 2007a.).

The participation of COMUSFOZ advisors in training activities was identified in the register of internal activities in 9 minutes promoted by CMS management board. External activities were based on invitations mainly from higher education institutions and the GT-SAUDE¹⁶16Work group for the integration of health services in Itaipu’s influence area, created in 2003, with the aim of building a democratic workspace and health debates in the Triple Frontier (Brazil-Paraguay-Argentina). It promotes cooperation and integration between the countries, respecting the guidelines of each national health system, emphasizing basic health care. Itaipu receives funds for GT Saúde administrative activities, using a participative methodology, involving health professionals from the three countries (PERON, 2017). to participate in courses, seminars, forums, and lectures.

The tag “health in the border area” appears in 9 minutes. In these meetings, training activities with advisors’ participation are mentioned:

Concerning the SIS Fronteiras, part of the funds from the program provided training courses for the city’s public servers, but not for advisors, in the following format:

Registers about QUALIFOZ were found, which is a training course promoted by COMUSFOZ, aiming to contemplate the policy of permanent training for health social control in Foz do Iguaçu. The course follows the structure of QUALICONSELHOS with certificates emitted by the Escola Nacional de Saúde Pública Sérgio Arouca (Fundação Oswaldo Cruz). It offers each year courses for city advisors with a studyload of 100 hours, approaching themes related to local and Brazilian public health policies, such as funding, main programs and services, and other local policies as well. However, until now, the course does not comprise the theme health in the border. The minute consulted stated that it: “[...] Informed that it had two groups of Qualifoz-2018, with classes until the end of November, with more than 60 students enrolled this year”¹⁹19Our translation. (Foz do Iguaçu, 2018).

Among the training actions promoted by COMUSFOZ and offered for city advisors, there were no records of the theme health in the border. Other institutions also treat the theme marginally; institutions that invite city advisors and propitiate their punctual participation.

Discussion

The construction of a territory expresses the appropriation and the social relations that occur in a geographical space, involving power. Therefore, territory is a geographical space socially constructed and historically transformed by the societies occupying it. Each territory has an identity that characterizes it and implies the territoriality feeling among the citizens. Brazilian border territories are a singular space that must be analyzed differently from the territorial organization in the center of the Capitalist territorial order with crucial influence in transborder areas (Souza; Gemelli, 2011SOUZA, E. B. C.; GEMELLI, V. Território, região e fronteira: análise geográfica integrada da fronteira Brasil-Paraguai. Revista Brasileira de Estudos Urbanos e Regionais, São Paulo, v. 13, n. 2, p. 101-116, 2011. DOI: 10.22296/2317-1529.2011v13n2p101
https://doi.org/10.22296/2317-1529.2011v... ). Borders are privileged and specific spaces with marked components since their occupation until their (dis)encounter with the “Other”. The consequences of these relations can be expressed in disputes and ethnic or social conflicts. Without conflict, the borders would also disappear because, at the same time that they are a separation line, they are fluid and porous enough to attend the demands of their subjects (KLEINSCHMITT, S. C.; AZEVEDO, P. R.; CARDIN, E. G. A tríplice fronteira internacional entre Brasil, Paraguai e Argentina: contexto histórico, econômico e social de um espaço conhecido pela violência e pelas práticas ilegais. Revista Perspectiva Geográfica, Cascavel, v. 8, n. 9, 2013.).

A study with city health managers in a border area highlights the funding of health activities and services as a crucial factor to expand or restrict the access of foreigners. It also suggests extra funding for each procedure conducted with a foreign patient, a Piso de Atenção Básica (PAB) [Minimum wage for Basic Care] especially for the population not counted, registers, the creation of an information system for foreigners’ health care, and structuring of management and funding (Aikes; Rizzotto, 2018AIKES, S.; RIZZOTTO, M. L. F. Integração regional em cidades gêmeas do Paraná, Brasil, no âmbito da saúde. Cadernos de Saúde Pública, Rio de Janeiro, v. 34, n. 8, p. e00182117, 2018. DOI: 10.1590/0102-311x00182117
https://doi.org/10.1590/0102-311x0018211... ).

SUS is hierarchically and regionally organized, conceding to city advisors the institution of intercity consortiums for joint actions and health services. The alliance for health in the dimension of a management alliance promoted an advancement by contemplating border areas in its regionalizing plan. Thus, it granted universal and equal access to health services, expanding city managers’ governability (Santos-Melo et al., 2020SANTOS-MELO, G. Z. et al. Integração em saúde: cooperação na tríplice fronteira internacional amazônica. Revista de Saúde Pública, São Paulo, v. 54, p. 5, 2020. DOI: 10.11606/s1518-8787.2020054001306
https://doi.org/10.11606/s1518-8787.2020... ).

The management alliance determines a set of institutional reforms, agreed between the three federative entities, aiming to renovate management methods and tools, strengthening health care, guaranteeing universal and equal access. Changes in SUS effectuation are highlighted, among them: “[the] solidary and cooperative regionalizing as a structural axis of the decentralizing process; integration of many federal funding manners; and unification of agreements already established”²⁰20Our translation. (Preuss, 2018PREUSS, L. T. A gestão do Sistema Único de Saúde no Brasil e as regiões de fronteira em pauta. Revista Katálysis, Florianópolis, v. 21, n. 2, p. 324-335, 2018. DOI: 10.1590/1982-02592018v21n2p324
https://doi.org/10.1590/1982-02592018v21... , p. 329).

The current sanitary legislation, after the institution of SUS, observes intraterritorial differences in Brazil and seeks to develop legal apparatuses to aid managers’ action and the social control in order to incorporate such characteristics in health policies planning. Thus, the Ordinance n. 7.508/2011, when establishing SUS organizational structure, proposes health planning and assistance, and articulation between federal entities, seeking to expand access to the right to health in the whole country. Nevertheless, some hindrances still impede the full achievement of SUS goals (Oliveira et al., 2019OLIVEIRA, R. A. D. de et al. Barreiras de acesso aos serviços em cinco Regiões de Saúde do Brasil: percepção de gestores e profissionais do Sistema Único de Saúde. Cadernos de Saúde Pública, Rio de Janeiro, v. 35, n. 11, p. e00120718, 2019. DOI: 10.1590/0102-311x00120718.
https://doi.org/10.1590/0102-311x0012071... ).

To ensure universal and integral health services access to citizens, health regions were instituted, considering in their definitions the daily life of individuals, where they live and transit, involving the three federative entities in their negotiation (Preuss, 2018PREUSS, L. T. A gestão do Sistema Único de Saúde no Brasil e as regiões de fronteira em pauta. Revista Katálysis, Florianópolis, v. 21, n. 2, p. 324-335, 2018. DOI: 10.1590/1982-02592018v21n2p324
https://doi.org/10.1590/1982-02592018v21... ). This device aims to expand the operation of city advisors regarding universal and integral health access for foreigners (Nogueira; Fagundes, 2014NOGUEIRA, V. M. R.; FAGUNDES, H. S. A implementação do SIS Fronteiras-Perspectivas para a ampliação do direito à saúde na fronteira arco sul. Serviço Social e Saúde, Campinas, v. 13, n. 2, p. 245-260, 2014. DOI: 10.20396/sss.v13i2.8634903
https://doi.org/10.20396/sss.v13i2.86349... ).

The absence of records in the minutes from 2012 onwards express the deactivation of SIS Fronteiras. By means of the Ordinance n. 622/2014, the Ministry of Health demanded the gradual closure of the actions foreseen in the Operational Plans in all cities benefited with SIS Fronteiras. That means that, as the actions were conducted, the program was gradually deactivated in border towns (Brasil, 2014BRASIL. Ministério da Saúde. Portaria nº 622, de 23 de abril de 2014. Dispõe sobre os prazos para conclusão da implementação das ações previstas no Sistema Integrado de Saúde das Fronteiras (SIS Fronteiras) e sobre o repasse de incentivo financeiro. Diário Oficial da União, Brasília, DF: 28 abr. 2014. Disponível em: <Disponível em: https://bit.ly/3uYJRxP >. Acesso em: 13 abr. 2020.
https://bit.ly/3uYJRxP... ). After the actions and acquisitions were conducted, this policy was deactivated and the cities were again destitute of a health policy specific for border areas (Fabriz, 2019FABRIZ, L. A. Sistema Integrado de Saúde nas fronteiras entre o Brasil e o Paraguai, no estado do Paraná: um estudo avaliativo. 2019. Tese (Doutorado em Enfermagem em Saúde Pública) - Universidade de São Paulo, Ribeirão Preto, 2019., p. 46).

With SIS Fronteiras funding, the city of Foz do Iguaçu built a Basic Health Unit and renovated other, promoted management training and partially funded the Centro Materno Infantil (Foz do Iguaçu, 2010FOZ DO IGUAÇU. Plano Municipal de Saúde: 2010/2013. Foz do Iguaçu: Secretaria Municipal de Saúde, 2010.). Discussions about these services were not found in the minutes.

Regarding health policies, the CMS configurate spaces that permit the population participation in the formulation and control of public health policies, representing the civil Society intervention on SUS management. Freitas & Souza, Ferreira & Oliveira (2019FREITAS e SOUZA, M.; FERREIRA, T. F.; OLIVEIRA, Ronally Dart. Crise do capital e dos desafios para o controle social da saúde. Revista Direitos, Trabalho e Política Social, Cuiabá, v. 5, n. 8, p. 57-77, 2019., p. 519) present the importance of training programs for public health managers. The authors state that “there is a high percentage of advisors developing activities in CMS with no training in the area, and the Community itself is not well oriented about their right to opine and inspect health actions in their surroundings”²¹21Our translation.. Santos-Melo et al. (2020SANTOS-MELO, G. Z. et al. Integração em saúde: cooperação na tríplice fronteira internacional amazônica. Revista de Saúde Pública, São Paulo, v. 54, p. 5, 2020. DOI: 10.11606/s1518-8787.2020054001306
https://doi.org/10.11606/s1518-8787.2020... ) conclude that the lack of knowledge by local managers of agreements between federal entities is a limiting factor for the main health cooperation strategies. These authors’ study had the participation of a CMS president in the triple frontier Brazil-Colombia-Peru.

PEPS presupposes the effective modification of the health sector daily life to incorporate learning and teaching in daily functions, using active learning-teaching methods (Fakhouri; Francischetti; Vieira, 2017FAKHOURI, A. P.; FRANCISCHETTI, I.; VIEIRA, C. M. Proposta de educação permanente para conselheiros municipais de saúde: relato de experiência. Revista Baiana de Saúde Pública, Salvador, v. 40, n. 4, p. 1029-1040, 2017. DOI: 10.1590/1983- 1447.2017.01.58779
https://doi.org/10.1590/1983- 1447.2017.... ). It can be directed to workers, managers, and patients of SUS with the aim of stimulating effective social control over health policies.

Dealing with the importance of permanent training, Gomes et al. (2018GOMES, A. M. et al. Reflexões e produção coletiva sobre o “ser” conselheiro municipal de saúde. Revista Brasileira de Enfermagem, Brasília, DF, v. 71, p. 538-547, 2018. Supl. 1. DOI: 10.1590/0034-7167-2017-0369
https://doi.org/10.1590/0034-7167-2017-0... ) state that the improvement of social control over city health advisors contributes to the enhancement of public policies adjusted to local realities, as well as the principles and guidelines of SUS.

Final Considerations

The analyzes of COMUSFOZ minutes from 2006 to 2018 indicate that specificities concerning health in border areas received little attention from agents of health social control in Foz do Iguaçu. Even with the adhesion to SIS Fronteiras by the local manager and the approval of the operational plan by CMS, the structuring of public policies for health in border areas is not a reality yet.

It is worth mentioning that, besides SIS Fronteiras was used as a “object-marker” for a social control policy in the frontier, it was identified that this program did not establish a permanent debate among city health advisors. There was a lack of training during the period for COMUSFOZ to exert an effective control over SIS Fronteiras, beyond the program homologation.

It is highlighted that COMUSFOZ adopts QUALIFOZ dynamics, a course designed by QUALICONSELHOS. However, it also does not include in its program the theme health in the border area. Thus, advisors must be trained for this attribution, i.e., they must know SUS basic principles, the life and work conditions in the region, which impact in the sanitary profile and the advisor’s functions. Knowing the local reality is a fundamental component to exert social control. By being a border town in an international triple frontier, knowledge about international treaties, bilateral agreements, and health integration relations between countries collaborates with the social control regarding border areas’ necessities.

In order to expand this population capacity to exercise health social control in border areas, we suggest the inclusion of contents related to health policies in border areas in the training of city health advisors. Activities, such as those developed by the Fundação Oswaldo Cruz, which recently made available a distance education course, deal with health in border areas with an interdisciplinary approach, considering current issues in health and the connection with the international scenario. They may also contribute to expand the critical and participative view on border areas’ health policies, supporting the action of city health advisors for these territories’ specific necessities.

References

Publication Dates

History