Abstract

The purpose of this article is to analyze the contributions of Mouffe and Laclau from post-Marxism, agonist democracy, and populist logic that innovated the ways of building collective identities and political viability. The potency of these theories for the micropolitical development of health management was investigated. The theoretical contributions indicate passion as the driving force of politics; they propose to sublimate conflicts into action via institutional channels, establish hegemonic practices as the capacity to articulate heterogeneous demands, and explain the capacity to configure a collective identity with a contingent leadership. The particularities of health work such as the hands-on approach, the margins of autonomy, the micropolitical exercise for its development and the organization as a professional bureaucracy, enable the proposals to be put into practice. We point out that the experience of building identities within the organization from an affective bond and the vehiculation of unmet demands reduces the discomfort in the services and promotes a stance of transformation.

Keywords:
Health Policy; Health Services Administration; Health Personnel; Sociology, Medical; Politics

Introduction

Management in public institutions can be seen as the ramification of state policies, which Oszlack and O’Donnell (1984OSZLACK, O.; O’DONNELL, G. Estado y políticas estatales en América Latina: hacia una estrategia de investigación. Buenos Aires: CLACSO, 1984. p. 99-128. (Documento CEDES, n. 4).) define as the position taken by the state that involves a set of actions and omissions manifested from a socially problematized issue, i.e., one that attracts the attention, interest, or mobilization of other actors in civil society. This perspective sheds light on three elements: (1) The acknowledgement that policies are carried out by the State, made up of the three branches of government and their respective jurisdictions, as opposed to a reduced view of government; (2) That a policy is not always a positive action, but the definite absence of it also triggers processes in a given space; and (3) That a policy only addresses issues that were previously problematized so that they can be placed on the agenda, and that this only occurs jointly with different actors.

The last point is where the role of management comes into place, especially because it focuses on building viability so that the object of interest is recognized as such, requiring coordination with different political subjects. In the field of collective health, many authors have reflected on this and gave rise to perspectives and proposals for health management, mainly depending on the power of health teams to transform their realities (Campos, 2021CAMPOS, G. W. de S. Gestión en salud: en defensa de la vida. Buenos Aires: EDUNLa, 2021. ; Franco; Merhy, 2016FRANCO, T.; MERHY, E. Trabajo, producción del cuidado y subjetividad en salud. Buenos Aires: EDUNLa , 2016.; Onocko Campos, 2023ONOCKO CAMPOS, R. La planificación en el laberinto: un viaje hermenéutico. Buenos Aires: EDUNLa , 2023.; Spinelli, 2022SPINELLI, H. Sentirjugarhacerpensar: la acción en el campo de la salud. Buenos Aires: EDUNLa , 2022.). These referents find desire as the power of the work process; they recognize the health team’s capacity for action, highlight the playful dimension of work, promote commission-based and matrix management to articulate knowledge and skills, and promote spaces for reflection and debate to review and change practices in order to reorganize work processes or even the organization itself, without needing the support of managers.

This paper intends to contribute to this body of work by approaching the contributions of post-Marxism to health management, specifically the works by Chantal Mouffe and Ernesto Laclau. To this end, the proposals on the radicalization of democracy and populist logic are developed in order to analyze how they can promote new paths for the construction of collectives in health and for the vehiculation of demands. These theoretical approaches have been useful for studying the construction of political parties or large social movements, but their translation into the health sector is still incipient. In this regard, one can find in the texts by Speed and Mannion (2020SPEED, E.; MANNION, R. Populism and health policy: three international case studies of right‐wing populist policy frames. Sociology of Health & Illness, Hoboken, v. 42, n. 8, p. 1967-1981, 2020.) and Pavolini et al. (2018PAVOLINI, E. et al. Healthcare governance, professions and populism: Is there a relationship? An explorative comparison of five European countries. Health Policy, Amsterdam, v. 122, n. 10, p. 1140-1148, 2018.) interesting reviews on the media construction of right-wing populist governments in Europe and the United States to justify health system reforms that led to a reduction in coverage. The strategy is a discursive construction by which they manage to define those who are legitimate citizens (not encompassing the whole society), who are harmed by outsiders, i.e., by migrants and ethnic minorities who do not contribute financially to the health system but use it “too much,” thus generating a funding crisis.

However, there is a lack of knowledge on how the matrix of post-Marxism can contribute to the micro-social examination of political dynamics, particularly in health services, which stimulates to face this challenge. To do so, this text presents the bases of post-Marxism and the works by Mouffe and Laclau, and then points out the characteristics of health work that would allow its applicability. The results describe the theoretical contributions that place passions as the driving force of politics; propose to sublimate conflicts into action through institutional channels; establish hegemonic practices as the capacity to articulate heterogeneous demands; and explain the capacity to configure a collective identity with a contingent leadership. In addition, it is described how the particularities of health work such as hands-on approach, margins of autonomy, micropolitical exercise for its development, and the organization as a professional bureaucracy enable the proposals to be put into practice. Finally, we reflect on whether the experience of constructing identities within the organization from an affective bond and the vehiculation of unmet demands invites to reduce the discomfort in the services and to promote a position of transformation.

The beginnings of post-Marxism

Laclau and Mouffe (2002LACLAU, E.; MOUFFE, C. Hegemonía y estrategia socialista. Buenos Aires: FCE , 2002.) with their 1985 work Hegemonía y estrategia socialista present the foundations of a trend that will later acquire the name “post-Marxist.” The dimension of “post” refers to the fact that it is a proposal that criticizes and surpasses the Marxism of that time, but the dimension of “Marxist” means that it sustains elements of the theory, above all, the materialist condition; it is thus a critique and proposal based on Marxism to transcend it.

Their work reflects on the historical path of left-wing movements full of setbacks, especially the conclusion of armed struggles and the rise of social democratic governments in different Latin American countries with the arrival of dictatorial governments directed by the United States’ Condor Plan in the 1970s. Not only did it lead to a state terrorism aimed at “doing away with leftist insurgents,” but it also consisted of the deployment of the new neoliberal socio-state model. Neoliberalism entails a different mode of production: the financial, and the consolidation of the third sector of services, resulting in the restructuring of the productive forces and labor reforms that will reduce the power of the working classes.

Hegemonía y estrategia socialista (Laclau; Mouffe, 2002LACLAU, E.; MOUFFE, C. Hegemonía y estrategia socialista. Buenos Aires: FCE , 2002.) presents a theoretical-practical revision of Marxist theory, outlining a set of challenges to be overcome. Firstly, they observe that it is no longer possible to think of the economic determinism of class, despite different authors already recognizing the weight of the superstructure, without conceiving it as a mere expression of the mode of production but the conformation of social classes in its function continued. Secondly, the existence of transformative actors other than a social class was obturated; instead, other social antagonisms appear, shaping identities to be highlighted and articulated, such as feminist, the LGBTTIQ+, anti-racism, and the environmental movements. Thirdly, it was no longer possible to think of a class essentialism, whereby class membership determines political subjectivity in an a priori way.

This analysis leads to a reformulation of the socialist project towards a radicalization of an agonistic and plural democracy. The authors carry out this development from a theoretical eclecticism taking elements from psychoanalysis and post-structuralism. Their contributions will be a warping of the central categories of structuralism that elucidates a new materiality. Language is no longer an instrument, but is identified as an institution, as a collective social practice; a discourse that is not produced by but rather a consequence of the subject. Laclau and Mouffe (2002LACLAU, E.; MOUFFE, C. Hegemonía y estrategia socialista. Buenos Aires: FCE , 2002.) start by converting Saussure’s radical differential relation between signs into the radical social difference that transform society into multiple social subjects. The subject is thus constructed within specific discourses that correspond to the multiplicity of social relations in which it is inscribed.

Another characteristic of the approach is the analogy between the laws of social space and the laws of the unconscious, insofar as they are structured as a language; the unconscious thus assumes a centrality, a framework. Notably, the materiality of class structuring and production relations is replaced by one constituted by relations of power and force. Economic categories are replaced by the syntax of language, desire, and power; and the new economy is the libidinal one (Tonkonoff, 2021TONKONOFF, S. Teoría más allá de la theoría. El movimiento posestructuralista. Enfoques, Entre Ríos, v. 33, n. 2, p. 33-58, 2021.). Change comes from “discursive practices” understood as meaningful practices composed of meaning and action, linguistic and affective components, which summarize words, affects, and actions (Mouffe, 2018MOUFFE, C. Por un populismo de izquierda. Buenos Aires: Siglo XXI Editores, 2018.).

The radicalization of democracy

Chantal Mouffe is the author behind the reformulation of socialism toward a radicalized democracy. In En torno a lo político (²⁰⁰⁹MOUFFE, C. En torno a lo político. Buenos Aires: Fondo de Cultura Económica, 2009.) she criticizes the dominant rationalist and liberal approach by which political issues become only technical matters entrusted to experts, denying the inherently antagonistic character of politics. She understands that the individualism it engenders prevents us from seeing the nature of collective identities and, if it is recognized, it takes pluralism from a harmonious perspective whose differences are resolved through rationality and consensus.

Mouffe’s proposal is based on a redefinition of what politics is; she distinguishes three dimensions: “politics” as the procedural dimension, the dynamic political processes marked by the conflict of objectives, content and decisions; “polity” as the institutional dimension, the legal system and the institutional structure of the political-administrative system; and “policy” as the material dimension, the configuration of political programs and the material content of political decisions. However, in Ibero-America there is no such classification, and these levels are often confused. In order to understand reality, she points out the distinction between two terms: “the political” as the ontological dimension of antagonisms constitutive of human societies; and “politics” as the ontic set of practices and institutions through which a certain order is created, organizing human coexistence in the context of the conflicts ensuing from the political.

In this way, she introduces the core axis of her theorization: the inherent condition of antagonisms in society. She recalls Carl Schmitt (2007SCHMITT, C. The concept of the political: expanded edition. Chicago: University of Chicago Press, 2007.) and his logic of “friend/enemy” to indicate that all collective identity rests on the structuring of an “us” versus “them”; all identity is therefore relational because it implies a link with a constitutive exteriority. There is also a latent condition of threat and enmity, which derives in two principles: conflict cannot be eradicated; and all consensus implies exclusion, there is no rational consensus that is totally inclusive.

This concludes by perceiving a contradiction between pluralism and democracy because a demos is assumed to be homogeneous. She, thus, locates three ways of dealing with differences within the demos. First, from an “aggregative paradigm” whereby politics is the establishment of compromises between conflicting forces in search of the maximization of individual interests. Secondly, “the deliberative paradigm” from which it is hoped to reach a rational moral consensus through free discussion. And, thirdly, there is the “agonist paradigm” of dispute and radicalization of democracy. For Mouffe (2009MOUFFE, C. En torno a lo político. Buenos Aires: Fondo de Cultura Económica, 2009., ²⁰¹⁸MOUFFE, C. Por un populismo de izquierda. Buenos Aires: Siglo XXI Editores, 2018.), if conflict is inevitable, it should be legitimized without breaking the political association, it should be domesticated in order to transform the antagonistic into “agonistic.” If antagonism implies an “us-them” relationship without any common ground, the opponent becomes the object of eradication. Agonism, in turn, legitimizes the opponent because it is recognized as part of the same political association, of a symbolic common space where the conflict is unleashed; the “enemy” becomes “adversary.” This is the role of democracy: to be constituted as the terrain of agonistic struggles, of struggles between hegemonic projects in dispute, but sublimated in institutionally accepted political channels.

Struggle emerges from the passions. Far from the economistic political subject, it is the affective forces that are at the origin of the collective forms of identification; passions, thus, become the main driving force. Politics rather than an interest becomes an identity, a self-image that can be valued, a libidinal investment in a “we.” Mouffe (2009MOUFFE, C. En torno a lo político. Buenos Aires: Fondo de Cultura Económica, 2009., ²⁰¹⁸MOUFFE, C. Por un populismo de izquierda. Buenos Aires: Siglo XXI Editores, 2018.) warns that not understanding the political aspect limits the ability to think about it, and hides that all social order implies hegemony, i.e., that the social is the sedimentation of hegemonic practices product of political struggle. Hegemonic practices are defined as articulatory practices through which a certain contingent order is established.

To continue with the analysis, the following main ideas are highlighted: the distinction between the political and politics; the driving force of passions in collective identification; the sublimation of conflict through institutionalized channels; and hegemony as the contingent articulation of political actors.

The populist logic

Ernesto Laclau (2005LACLAU, E. La razón populista. Buenos Aires: FCE, 2005.) undertakes the challenge of building a theory on populism as a valid way of building the political, as opposed to the academic assessments that identify it as a deviation from the “correct” democracy (Biglieri; Perelló, 2007BIGLIERI, P.; PERELLÓ, G. En el nombre del pueblo: el populismo kirchnerista y el retorno del nacionalismo. Buenos Aires: UNSAM, 2007.). The question that structures his work is how collective identities and transforming historical actors are constructed. His answer is populism, not as a regime or movement, but as a political logic that allows the constitution of a “people.”

The author goes through the typologies of populism, its revisions, and a theoretical reconfiguration of the elements from post-structuralism, to then give rise to his elaboration of a populist construction (Figure 1). This configuration departs from a heterogeneous social space composed of unsatisfied, differential, and isolated social demands called “democratic”; a name that comes from the bourgeois-democratic revolutions that confront the status quo with egalitarian presumptions. In this context, the key purpose is to achieve an articulation between these demands, to identify in those singularities a totality that crosses them to give rise to a “popular” demand, i.e., a demand that constitutes a broader social subjectivity and enables the constitution of a people, of a potential historical actor. The first clarification in this process is that, for Laclau, the minimum unit is not social groups, but demands, because up to that moment there is no collective identity. Demands can be institutionally channeled by a logic of difference (individually) or by a logic of equivalence (the articulation of a set of demands that share a common element). However, neither option will be a natural process insofar as demands contain a property of catachresis, i.e., a figure of speech by which a metaphorical name is assigned to a reality that lacks a specific name (e.g., the “wing” of an airplane). Thus, a demand acquires a name that cannot represent it in its literalness, that cannot be entirely made visible, and will sustain hidden elements that continue to operate from dissatisfaction.

The question is how to identify a universality, an equivalence, within differential demands that form a totality. The first answer is that they are all equally unsatisfied, but that is not enough. The proposal is to find a limit to that totality that delimits an “us,” an element that differentiates them from themselves, a differential element to which all isolated demands are opposed. That is to say, the first step to articulate democratic demands is to identify an internal border based on an “antagonistic otherness” that brings them together into a collective. Therefore, it will be the antagonism that they all keep inside, the universality that crosses them. The consequence of the frontier is the dichotomous division of society between an incipient “people” and a “power” that does not satisfy the demands, that makes the people experience a shortage that harms them. The quest is not to eliminate the adversary, but to transform the correlation of forces that is presented up to that moment, a transformation of the positions of power.

However, they are not yet articulated, and, for that, a symbolic unification is necessary. The plurality of demands to become a people must be condensed into a popular identity, a common denominator should be identified, which can only be found within the established chain. One of the demands will acquire a certain centrality, as a primus inter pares, and will assume a hegemonic condition, i.e., a particularity that acquires a universal significance that transcends the entire chain of equivalences. To achieve this, a series of disputes of different contents will be unleashed, depending on the case, a struggle of hegemonic projects that will shape a contingent social order, i.e., an order to be sustained by the correlation of forces between the demands, and feasible to be modified. Whoever triumphs will be able to occupy that place legitimately.

The people, as a unit, crystallizes when the demands acquire a consistency of their own, so that the equivalential bond acquires greater leadership than the original demands. A radical inversion occurs, in which the consequence of the demands begins to behave as their foundation. The people manage to condense into a popular identity, into a united people, despite the constant tension. Heterogeneity within the people is a sine qua non condition, otherwise it would be a homogeneous “mass.” However, the more extensive the chain, the more likely it is that the particularities of the original demands are less linked to the identity. The chain becomes fuller because of its extension and, at the same time, poorer because it must abandon particular contents to contain the heterogeneity of the demands.

This leads to the question of representativeness. The new hegemony is the incarnation of an always incommensurable universality, of an impossible object or a failed totality, which can only be achieved by assuming an identity of the order of the “empty signifier.” To understand this, it is necessary to return to Saussure, who explains that the linguistic sign can be divided into two elements: signifier and signified. The first element is the form of the sign given by the mental trace that one has from the sound with which this referent should be associated; the second is the content, it is the concept or the idea that one wishes to convey. An empty signifier means that different contents/meanings can be attributed to the same form/signifier-in this case, the nomination of the popular identity. The empty signifier can operate as a point of identification because it represents the equivalent chain and, therefore, cannot be passive, but should add a new qualitative dimension so that it can constitute the totality. Thus, the nomination of the equivalential chain, of the people, constitutes a nodal point: it is the social productivity of the name that can sustain its unity. The signifier is the symbolic synthesis of the chain that must exert an irresistible attraction on any unsatisfied demand, whose capacity to give unity to a heterogeneous whole also translates into an inability to determine what kind of demands fall under its head count. The importance of the empty signifier is that the attribution of meaning assigned to it by each actor may vary, i.e., an empty signifier may gather several differential meanings that it links to specific demands, resulting in ideological ambiguity. For the nomination to occur, a radical investment must take place, containing and producing an affective dimension. It should be the product of the overdetermination of demands. Investments implies turning an object into the incarnation of a mythical fullness, its essence being enjoyment.

In spite of the constituted identity, a tension persists between the particularity of each demand and the universality that crosses them. The empty signifier cannot become totally autonomous from the chain it represents, but neither can it lose that particularity that allowed its hegemony. Equivalence weakens the differences between the concatenated demands but does not void them. Thus, there is a tension between the subordination of the demands to the people or their autonomization. Integrating a demand is a double-edged sword: On the one hand, inscription gives the demand a corporeality it would not otherwise have; on the other hand, the chain acquires its own strategies of movement and may come to sacrifice or compromise the contents implied in particular demands. Belonging to an equivalential chain gives it solidity and stability, but also restricts its autonomy. In any case, not all demands have the same power in the chain; the weaker it is, the more it depends on its insertion into the chain. If one or more demands manage to become autonomous and be satisfied in an individual/differential manner, the people are diluted because the internal border has been crossed. It is worth clarifying that the equivalential chain is composed of heterogeneous demands, not opposed in their unique objectives. Therefore, people must renounce the aspiration to represent all the demands of the social space.

A second axis of tensions in the chain is the possibility of a displacement of signifier. As aforementioned, the order achieved is contingent and may fluctuate due to power disputes between hegemonic projects. Other identities in the social field may attempt to break the equivalential chain and propose a new internal border that also absorbs some of the concatenated demands. These signifiers that remain undecided between alternative equivalential chains are called “floaters.” Figure 2 shows how this displacement, which can weaken or even dilute the previous equivalential chain, is plotted.

The last question to be presented is who can build “the people,” if there can be left and right-wing populisms. Laclau and Mouffe (2002LACLAU, E.; MOUFFE, C. Hegemonía y estrategia socialista. Buenos Aires: FCE , 2002.) will say that yes, it is a political logic that can develop beyond ideology. Other authors disagree with this position that places populism as a technique without its own ontology. Biglieri and Cadahia (2021BIGLIERI, P.; CADAHIA, L. Siete ensayos sobre el populismo: hacia una perspectiva teórica renovada. Buenos Aires: Herder, 2021.), for example, point out that populism has an emancipatory matrix and a pretension to incorporate all possible demands with a status of equality, although maintaining its differences from an articulating principle. On the other hand, the right-wing’s proposal is an explicit exclusion of sectors of society, which pretends a homogeneous people from an imposed canon to reach a singular people. While left-wing populism delimits a field between “above” and “below,” right-wing populism does so between “inside” and “outside.” On the other hand, Biglieri and Perelló (2020BIGLIERI, P.; PERELLÓ, G. Anti-populismo en la Argentina del siglo XXI o cuando el odio se vuelve un factor político estructurante. RevCom, Buenos Aires, v. 10, n. e031, 2020.) find in the right-wing a type of “anti-populist” political conformation. In this case, hatred is the motif that unites the equivalential chain of demands and structures the identificatory bond. Its empty signifier upholds values of neutrality and apolitical in pursuit of the defense of rationality, good practices, consensus, and respect for the rules.

Beyond these speeches, it can be said that the people is not an ideological expression, but a real relationship between social actors, a way of constituting the unity of the group. The axis of the configuration of a transforming subject is the hegemonic articulation of specific demands. This requires a plurality of demands unified in an equivalential chain; the identification of an internal border that divides society in a dichotomous manner; and the consolidation of the equivalential chain through the construction of a popular identity that is qualitatively something more than the sum of the equivalential ties.

Transforming work into health

Laclau (2005LACLAU, E. La razón populista. Buenos Aires: FCE, 2005., p. 155) points out that “any institution or social level can operate as a surface of equivalential inscription” (free translation). The notion of populism is not the determination of a rigid object assignable to certain objects, but the establishment of an area of variations in which a plurality of phenomena can be inscribed. Public health institutions may fall within this arc due to the unique characteristics that constitute the work processes.

The purpose of health work is considered to be the construction of therapeutic projects based on specific needs, desires, and possibilities of each patient. It demands an active construction between both parties and within the health team, in which subjective positioning and inter-relational configuration operate. These processes are marked by moralities, life histories, the effects of the composition of work teams or different groups, encounters with the population of a territory and its history, the political-religious convictions of each one, and by the daily encounter with patients and their contexts, among others (Merhy et al., 2019MERHY, E. E. et al. Rede básica, campo de forças e micropolítica: implicações para a gestão e cuidado em saúde. Saúde em Debate, Rio de Janeiro, v. 43, n. spe6, p. 70-83, 2019.). Hence, health work acquires a hands-on approach (Spinelli, 2022SPINELLI, H. Sentirjugarhacerpensar: la acción en el campo de la salud. Buenos Aires: EDUNLa , 2022.). The ability to achieve its purpose requires margins of autonomy to be able to articulate between people and to manage the required projects. In this sense, health practices are a living work in action because production and consumption occur at the same time, they are acts of production, of transformation of a state of affairs identified as a health problem. The work, then, demands the micropolitical exercise because everyone governs in some way by having the ability to interfere, create, and dispute certain values and productions (Merhy et al., 2019MERHY, E. E. et al. Rede básica, campo de forças e micropolítica: implicações para a gestão e cuidado em saúde. Saúde em Debate, Rio de Janeiro, v. 43, n. spe6, p. 70-83, 2019.).

The autonomy of workers is also explained by the structural configuration of health organizations, characterized by Mintzberg (2001MINTZBERG, H. Diseño de organizaciones eficientes. Buenos Aires: El Ateneo, 2001.) as a “professional bureaucracy.” For the author, the uncertainty regarding everyday demands can only be answered with margins of freedom within the team, whose main coordination mechanism is mutual adjustment, i.e., monitoring and accountability of work among peers. The multiplicity of professions and occupations that make up the work, the specialization of technical knowledge, and the complexity of care also reduce the capacity of control by superiors. Thus, the power of the “strategic summit” is transferred to the “operational core,” i.e., the pyramid that usually represents organizations, in this case, is inverted. Given these characteristics, governance and the implementation of health policies within the institutions are not linear; on the contrary, the health teams tend to put tension on them and have the autonomy to decide how much to put into practice. The relationships between managers, workers, and patients creates fields of dispute where each order achieved is the product of each one’s agency capacity (Merhy et al., 2019MERHY, E. E. et al. Rede básica, campo de forças e micropolítica: implicações para a gestão e cuidado em saúde. Saúde em Debate, Rio de Janeiro, v. 43, n. spe6, p. 70-83, 2019.). Therefore, Spinelli (2022SPINELLI, H. Sentirjugarhacerpensar: la acción en el campo de la salud. Buenos Aires: EDUNLa , 2022.) proposes that changes in these organizations should not be produced at government level, but at work level, i.e., from the bottom up, from the teams to the top.

It is important to point out that the neoliberal health reforms implemented from the 1980s-1990s, such as financialization, disinvestment, focalization, and outsourcing of services, implied a reorganization of health care that threatened the autonomy of workers due to the precarious working conditions. However, economic rationality does not succeed in completely subjugating the production of care because it is unable to subjugate living, subjective, intangible and hands-on work (Merhy; Franco, 2016MERHY, E.; FRANCO, T. Reestructuración productiva y transición tecnológica en salud: debate necesario para la comprensión del proceso de “financiarización” del mercado en la salud. In: MERHY, E.; FRANCO, T. Trabajo, producción del cuidado y subjetividad en salud . Buenos Aires: Lugar Editorial, 2016. p. 97-120.). This type of work engenders fissures of autonomy in a regime of economic-administrative control and should be maximized to transform health teams and organizations.

In this context, we are interested in locating populist logic as an option to make collective demands feasible. Demands in these institutions may emerge from specific services, from the sum of them or even from individual actors whose power is based on their specialized knowledge. Dissatisfaction may come not only from health teams, but also from patients. In the institutions, demands are often directed at the management or the superior authority that administers them. This will be mainly their antagonistic otherness, rallying against those they see as responsible for the deficiencies of the work processes. However, they could also build otherness of political models that transcend the organization, such as the historical examples of collectives that fought against the privatization and precariousness of health care, against psychiatric care, or against the criminalization of abortion.

Health institutions are diverse and the larger they are, the more conflicts and antagonisms they face. Some of the antagonisms may be the result of opposing values in models of care, in the hierarchization of tasks, in the use of space, in the modes of management, and in work performance, among other possibilities. Conflict is inevitable in these organizations and there is a constant perception of unsatisfied demands, which are generally seen from a zero-sum perspective. These are usually channeled through institutional means, although many of them are not formulated and remain in a plane of discomfort in teams.

The post-Marxist construction allows us to reflect on other ways of dealing with this scenario. The first premise that enables it is that health teams are workers of the word, the materiality they produce is through acts of speech (Spinelli, 2022SPINELLI, H. Sentirjugarhacerpensar: la acción en el campo de la salud. Buenos Aires: EDUNLa , 2022.), and this can be useful to develop hegemonic projects from the discourse. The proposal is to sublimate an initial discomfort in the work process into a greater construction that allows the demand to be conveyed for its satisfaction. This requires identifying which demands of other actors could be equivalent and contacting those who represent them. The encounter between unmet demands may be casual, as an event, or it may be promoted by one party to initiate a process of aggregation and articulation of demands. However, their articulation requires the mobilization of libidinal energy in order to be sustained; promoting a collective willingness implies inscribing the subjects in discursive practices that generate affective identifications. The possibility of configuring an empty and attractive signifier that represents the chain can be facilitated by the health field path in shaping symbolic syntheses that have acted as counter-hegemonic projects such as social medicine, collective health, health as a right, the sovereignty of bodies, the autonomy of people in their care processes, primary health care, etc. These constructions of articulation of heterogeneous actors under a symbolic identity have allowed the development of health policies in Argentina such as the Mental Health Law (2010), the Voluntary Interruption of Pregnancy (2020) and the Law for the Promotion of Healthy Meals (2022).

However, this challenging process may be hindered by the same institutional members. A question to be reviewed is who is interested in carrying out this political articulation, and how many unmet demands can be integrated into the equivalence chain. The autonomy of the health teams’ work allows them to mobilize demands, but its downside, due to specialization and independence, is the potential to lead to atomization and isolation of people (Mintzberg, 2001MINTZBERG, H. Diseño de organizaciones eficientes. Buenos Aires: El Ateneo, 2001.). Often the discomfort is sheltered in the task and produces an affective disengagement with the organization. In general, their political participation is null or critical, their arguments come from anger and disappointment. It could be argued that their position is reactive, that their position is to demand how the institution should be, an expression of “hatred” brings them together as in anti-populism (Biglieri; Perelló, 2020BIGLIERI, P.; PERELLÓ, G. Anti-populismo en la Argentina del siglo XXI o cuando el odio se vuelve un factor político estructurante. RevCom, Buenos Aires, v. 10, n. e031, 2020.), but they are not mobilized by a political will to act, and are usually disintegrated. Mouffe (2018MOUFFE, C. Por un populismo de izquierda. Buenos Aires: Siglo XXI Editores, 2018.) adds that the neoliberal model established a moment of “post-politics” understood as an instance of possessive individualism and institutional disaffection that derives in abstention from political participation. They remain then in a plane of a social heterogeneity that lacks representation, whose dissatisfaction has not been formulated as specific demands, being a mere noise or complaint (Biglieri; Perelló, 2007BIGLIERI, P.; PERELLÓ, G. En el nombre del pueblo: el populismo kirchnerista y el retorno del nacionalismo. Buenos Aires: UNSAM, 2007.). However, Mouffe (2018)MOUFFE, C. Por un populismo de izquierda. Buenos Aires: Siglo XXI Editores, 2018. approaches a strategy in face of this context, mobilization begins with understanding where these people come from stand and how they feel, and offering them a vision of the future that produces hope to overcome the stagnation of complaint and promotes a binding constitution that triggers desire. In Spinoza’s terms, affections are the affections of the body by which the power to act is increased or decreased; therefore, to govern is to affect, it is to lead with affection (Lordon, 2018LORDON, F. La sociedad de los afectos. Por un estructuralismo de las pasiones. Buenos Aires: Adriana Hidalgo, 2018.).

To exemplify the proposal, Figure 3 presents the synthesis of political vehiculation in a hospital. The characteristics of the work process, such as the teams’ autonomy, embedded micropolitical exercise, discursive condition of practices, and the symbolic struggles in the history of health, can be nested in post-Marxist theory. This sheds light on a path to explore, a way to see the political construction in a different way, and an invitation to health teams to deploy their strategies. The proposal is also aimed at promoting democratic practices in the institutions not the search for horizontality, participation, co-management, or direct representation, but by the deployment of agonistic struggles channeled via institutional means toward a democratic radicalization of health organizations.

Final considerations

We start from a definition of policy that places, as a central dimension, the insertion of issues on the agenda so that it can be responded to by socially problematizing a situation from various political actors, which requires the capacity for political construction and viability. A way of doing this was proposed based on the contributions of Mouffe and Laclau to review how they can highlight the political vehicle at a micro level rather than in large social movements.

The potency of carrying out a post-Marxist construction in health institutions can be compiled in three axes. In the first place, the recognition of passions as a driving force promotes an affective relationship within health teams, with patients and with the organization. This dimension allows both to trigger the desired changes and to increase commitment and, according to Ayres (2008AYRES, J. R. de C. M. Para comprender el sentido práctico de las acciones de salud: contribuciones de la hermenéutica filosófica. Salud Colectiva, Lanús, v. 4, n. 2, p. 159-172, 2008.), the search for fulfilling projects at work. Secondly, the constructions of different “we” in an institution, beyond their antagonisms, reduce the tendency to atomization and generate collective identities that contain and mobilize their members. Finally, understanding political dynamics based on antagonistic differences and finding new ways to collectively energize demands can contribute to reducing the discomfort with the institution. On the other hand, we observed that the incorporation of certain actors who are not politically minded in the institutions is limited, although theory indicates that it is unnecessary to include everyone for transformation, considering that one part may be presented as the whole.

This article does not intend to present a formula, but rather to enable other ways of thinking about management. We follow Mouffe (2018MOUFFE, C. Por un populismo de izquierda. Buenos Aires: Siglo XXI Editores, 2018.), who recovers Gramsci, to indicate that the disputes to transform the State occur in all the apparatuses and public spaces that make it up, the purpose is not “to seize State power,” but the “to become the State.” The aim is to highlight that teams can begin to identify the unmet demands: to distinguish which of them could be equivalent, what otherness compels them, and what symbolic synthesis mobilizes and excites them. Health work enables this collective transformation.

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