ABSTRACT

The objective of this article is to present a panorama of the health ombudsman offices in the 27 Brazilian states - registered at the General Ombudsman Department of the Unified Health System of the Ministry of Health - detecting the alignment of principles. A qualitative study was designed and a questionnaire was administered to the ombudsmen, drawing on an Ombudsman Strength-Idea that guides the department's structure and performance. The findings provide information to subsidize public policies directed to social control and participation. The ombudsman's performance is discussed considering its keyrole in the construction of socio-political participation.

KEYWORDS:
Patient advocacy. Social participation. Social control; formal

Introduction

Hearing is a sense and it is also one of the most basic and elementary human actions in communication. This action has great importance and relevance when one thinks in terms of responsiveness and accountability in the sphere of public management. Siamese sister and counter-face of vocalization, a component of the population's empowerment, hearing by the public administration to citizens' needs and demands is a crucial activity when seeking permanent qualification of services provided and improvement of public service functioning, and it assumes a strategic characteristic in the design, implementation and operation of policies.

For this purpose, worldwide and in Brazil as well, institutions have been created under the name of 'ombudsman', both in the private and the public sectors, in various administrative levels, consisting in bodies whose responsibility is to receive claims, complaints, denounces, praises, criticism and suggestions from citizens - named 'manifestations' - regarding products, services and attendance provided by a given body or by officials or civil servants (BRASIL, 2014A______. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Ouvidoria-Geral do SUS. Guia de orientações básicas para implantação de ouvidorias do SUS. Brasília, DF: Ministério da Saúde, 2014a.).

In Brazil, it is a well-known fact there that is a need for continuing and permanent control, regulation, analysis, assessment, and improvement and innovation of public policies and actions in the management of the health area (BOLZAN ., 2012BOLZAN, L. C. et al. Ouvidoria Ativa: A inovação das pesquisas de satisfação na ouvidoria-geral do SUS. In: CONGRESSO CONSAD de Gestão Pública, 5., 2012, Brasília, DF. Anais... Brasília, DF, 2012. Disponível em: <http://www.sgc.goias.gov.br/upload/arquivos/2013-03/ouvidoria-ativa-a-inovacao-das-pesquisas-de-satisfacao-na-ouvidoria-geral-do-sus.pdf>. Acesso em: 25 nov. 2016.
http://www.sgc.goias.gov.br/upload/arqui... ; NONATO, 2016; PIRES; VAZ, 2012PIRES, R.; VAZ, A. Participação Social como método de governo? Um mapeamento das "Interfaces Socioestatais" nos programas federais: Efetividade das instituições participativas no Brasil. Brasília, DF: Ipea, 2012. (Texto para Discussão 1707). Disponível em: <http://www.ipea.gov.br/participacao/images/pdfs/td_1707.pdf>. Acesso em: 24 nov. 2016.
http://www.ipea.gov.br/participacao/imag... ; FERNANDES ., 2016FERNANDES, F. M. B. et al. Inovação em ouvidorias do SUS - reflexões e potencialidades. Ciência & Saúde Coletiva, Rio de Janeiro, n. 8, p. 2547-2554, 2016. Disponível em: <http://www.scielo.br/pdf/csc/v21n8/1413-8123-csc-21-08-2547.pdf>. Acesso em: 24 nov. 2016.
http://www.scielo.br/pdf/csc/v21n8/1413-... ; PEIXOTO 2013PEIXOTO, S. F. et al. Atribuições de uma ouvidoria: opinião de usuários e funcionários. Saúde soc., São Paulo, v. 22, n. 3, p. 785-794, 2013. Disponível em: <http://www.scielo.br/pdf/sausoc/v22n3/12.pdf>. Acesso em: 24 nov. 2016.
http://www.scielo.br/pdf/sausoc/v22n3/12... ; SILVA , 2014SILVA, R. C. C. et al. Ouvidorias públicas de saúde: estudo de caso em ouvidoria municipal de saúde. Rev. Saúde Públ., São Paulo, v. 48, n. 1, p. 134-141, 2014. Disponível em: <http://www.scielo.br/pdf/rsp/v48n1/0034-8910-rsp-48-01-0134.pdf>. Acesso em: 24 nov. 2016.
http://www.scielo.br/pdf/rsp/v48n1/0034-... ). There is a political and democratic urgency to respond to demands expressed by citizens who are users of the Unified Health System (SUS) and it translates into operational, managerial, administrative, and executive challenges.

Demands from citizens in the form of manifestations constitute indicators that something can and/or should be adopted, maintained, modified, improved, and/or abolished within health services and systems. Recent experiences with collecting manifestations have been implemented and expanded, reaching variable degrees of effectively fulfilled expectations (BRASIL, 2010______. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Ouvidoria-Geral do SUS. Falando de Ouvidoria:experiências e reflexões. Brasília, DF: Ministério da Saúde, 2010. (Série B. Textos Básicos de Saúde).).

The ombudsman functions in the sphere of SUS were nationwide institutionalized in 2003 with the creation of the General Ombudsman Department, of the Secretariat of Strategic and Participative Management of the Ministry of Health (Departamento de Ouvidoria-Geral do SUS, da Secretaria de Gestão Estratégica e Participativa do Ministério da Saúde - Doges/SGEP/MS), through Decree Nr. 4,726/03 (BRASIL, 2003BRASIL. Decreto nº 4.726, de 09 de junho de 2003. Aprova a Estrutura Regimental e o Quadro Demonstrativo dos Cargos em Comissão e das Funções Gratificadas do Ministério da Saúde, e dá outras providências. Diário Oficial [da] União. Brasília, DF, 09 de jun. 2003. Disponível em: <http://www.planalto.gov.br/ccivil_03/decreto/2003/D4726.htm>. Acesso em: 24 nov. 2016. Acesso em: 24 nov. 2016.
http://www.planalto.gov.br/ccivil_03/dec... ). This legislation defined several responsibilities, such as: (a) propose, coordinate, and implement the National Policy for Health Service Ombudsman (Política Nacional de Ouvidoria em Saúde) within SUS, seeking to integrate and stimulate practices that widen users' access to SUS assessment process; (b) stimulate and give support to the creation of decentralized structures of health service ombudsman; (c) implement policies to stimulate the participation of users and civil society entities in the process of assessment of services provided by SUS; among others.

Due to those responsibilities, by offering SUS users various means of communication, according to what is expressed on its website (http://portalsaude.saude.gov.br/index.php/o-ministerio/principal/secretarias/872-sgep-raiz/DOGES-raiz/ouvidoria-geral-do-sus/l1-ouvidoria-g-sus/12221-conheca-a-ouvidoria-geral-do-sus), Doges works on: collection of demands sent by SUS users; systematization and analysis of those manifestations; dissemination of information related to services delivered to the population; and forwarding proposals to the competent management areas of SUS.

Doges is a strategic institutional communication channel between users and the health policy; it has received 1,048,575 contacts on the databank of health call service 136 (serviço 136 Disque-Saúde) in the period from 2002 to 2013, year with full information immediately previous to the year of the research reported in this article. This demonstrates the potential contribution of this governmental initiative to the improvement of SUS management.

In this sense, improving the decentralization of ombudsman's functions represents a crucial action to widen civil society participation channels in the process of shared management of SUS, which strengthens the constitutional directive of health policy democratization in Brazilian municipalities and states. Therefore, establishing decentralized ombudsman structures is an essential mechanism to potentiate the federative characteristics of SUS, according to the National Policy for Strategic and Participative Management of SUS (Política Nacional de Gestão Estratégica e Participativa do SUS - ParticipaSUS) (BRASIL, 2007______. Ministério da Saúde. Gabinete do Ministro. Portaria nº 3.027, de 26 de novembro de 2007. Aprova a Política Nacional de Gestão Estratégica e Participativa no SUS - ParticipaSUS, que vislumbra a implantação de ouvidorias como uma das formas de fortalecer a gestão estratégica e participativa no SUS. Diário Oficial [da] União. Brasília, DF, 26 nov. 2007. Disponível em: <http://bvsms.saude.gov.br/bvs/saudelegis/gm/2007/prt3027_26_11_2007.html>. Acesso em: 24 nov. 2016.
http://bvsms.saude.gov.br/bvs/saudelegis... ).

Decree Nr. 8,065/13 (BRASIL, 2013______. Decreto nº 8.065, de 07 de agosto de 2013. Aprova a Estrutura Regimental e o Quadro Demonstrativo dos Cargos em Comissão e das Funções Gratificadas do Ministério da Saúde e remaneja cargos em comissão. Diário Oficial [da] União. Brasília, DF, 7 ago. 2013. Disponível em: <http://www.planalto.gov.br/ccivil_03/_Ato2011-2014/2013/Decreto/D8065.htm>. Acesso em: 24 nov. 2016.
http://www.planalto.gov.br/ccivil_03/_At... ) established for Doges the responsibility to carry out researches required by the cabinet of the Ministry of Health, by the Secretariats of the Ministry of Health, and also by demands of the General Ombudsman, in association with other bodies, or not. Furthermore, Doges has the mission to widen and consolidate the SUS National Ombudsman System (Sistema Nacional de Ouvidorias - SNO) by creating an ombudsman network that shares the same conception of efficacious, efficient, effective, and humanized work, thus contributing to the improvement of SUS (BRASIL, 2014A______. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Ouvidoria-Geral do SUS. Guia de orientações básicas para implantação de ouvidorias do SUS. Brasília, DF: Ministério da Saúde, 2014a.).

At the end of 2013, aware of the importance of promoting a debate to qualify its actions and thus improve its performance in providing subsidies for SUS management, Doges established a partnership with a research team of the Social Sciences Department of the Sergio Arouca National School of Public Health (DCS/Ensp/Fiocruz)

The partnership was established with a work routine in a Reflective Work Group (RWG) to produce studies on the theme of citizens' social participation through health service ombudsman and to develop possibilities of follow-up, monitoring, assessment, and qualification of the performance of the ombudsman offices that constitute SNO.

The objective of this article is to present one of the products of this partnership, namely the design and administration of a tool to the health ombudsman offices in Brazilian states belonging to SNO, drawing on the debate on the role, aim, structure, and operation of the ombudsman offices, their potentialities, limits, and challenges in subsidizing SUS management, as well as their performance as participative bodies.

The aim of the creation of RWG was to debate the concepts 'Ombudsman', 'Governability', 'Autonomy', 'Responsiveness', 'Resoluteness', 'Information Management', 'Innovation', and 'Networking', among others, to provide theoretical-practical subsidies for SNO strengthening. These concepts were discussed drawing on the concerning literature, and generated other products - focusing on the work of municipal health ombudsman offices, information management, and innovation in health ombudsman - that are not within the scope of this article and will be developed elsewhere. An article on the theme Innovation related to the work of SUS ombudsman offices has already been published (FERNANDES ., 2016FERNANDES, F. M. B. et al. Inovação em ouvidorias do SUS - reflexões e potencialidades. Ciência & Saúde Coletiva, Rio de Janeiro, n. 8, p. 2547-2554, 2016. Disponível em: <http://www.scielo.br/pdf/csc/v21n8/1413-8123-csc-21-08-2547.pdf>. Acesso em: 24 nov. 2016.
http://www.scielo.br/pdf/csc/v21n8/1413-... ).

From the evolution of the debates held by RWG, two strategic needs stood out as priorities: 1) Establish an ombudsman concept to guide Doges in the understanding of its responsibilities and possibilities of improvement, and 2) Draw a panorama of the Brazilian municipal and state health ombudsman offices registered at Doges, detecting to what extent they were aligned with the principles it advocates.

The development the theoretical-conceptual debate produced an Ombudsman Typological Matrix, drawing on Historical-Conceptual Charts elaborated by the research team by means of bibliography search. By refining the discussion on this matrix, the group arrived at an Ombudsman Strength-Idea, original in the country, expressed as follows:

Ombudsman as a 'processing body' of individual or collective manifestation about a service, process, or product provided by a given public or private institution. It is, thus, a 'mediation body' with the objective of producing adequate responses to the manifestation. (MOREIRA; FERNANDES, 2015MOREIRA, M. R.; FERNANDES, F. M. B. Análise da Implantação Descentralizada do Sistema Nacional de Ouvidorias do SUS - Uma Tipologia para as Ouvidorias. Relatório de Pesquisa. 2015. Mimeo.. P. 7. EMPHASIS ADDED).

This Strength-Idea has been suggested by the RWG to Doges for the assessment of the state of the art and the degree of convergence/divergence of health service ombudsman offices integrating SNO, regarding the concepts with which the Group has work out the Typological Matrix.

The proposal was to build a baseline that in the medium and long terms would enable the use of the Strength-Idea as a guiding concept for the constitution of ombudsman as a participative body, to be incorporated in SNO, always taking into consideration the needs of adjustments indicated by the results from the data collection.

Therefore, based on the Strength-Idea, a research tool was designed with the aim of collecting information to provide subsidies for the formulation, implementation, and improvement of public policies directed to social control and social participation in the sphere of SUS ombudsman offices.

Methodological considerations

The Strength-Idea constructed by the research group was employed to assess the ombudsman offices as participative bodies. Thus, it was assumed that the more convergent with the Strength-Idea were the ombudsman offices, the more participative they would be.

The research tool was composed of eighteen closed questions, offering two options for answers, driven by the logic of convergence or divergence with the Strength-Idea. Five of the questions of the tool admitted multiple answers. Among these questions, three were formulated in a way that the answer to be considered as convergent would fulfill exclusively one or two of the options; and two questions due to their multiple natures (means of contact made available to the user and type of manifestation received by the ombudsman office).

The questions in the research tool were distributed in four blocks, preceded by a section Identification of the Ombudsman Office, with the usual information. Each block represented a group of concepts worked in 'dimensions', directly co-related to the Strength-Idea.

In the first block, questions were related to dimension 'Bodies - Ombudsman Offices'; in block II, questions related to dimension 'Processing - Reception', 'Treatment', 'Feedback' and 'Assessment'; in block III, questions related to dimension 'Manifestation - Demand'; and in block IV, questions related to dimension 'Mediation - Performance'.

The research team administered the tool by telephone to the ombudsmen integrating SNO, in the period from August to November 2014. The ombudsman offices of all the 27 states of the country answered the research tool, including the Federal District.

Results and discussion

Firstly, for the work of the group in the elaboration of the research tool and also for the research team in the analysis of the collected information, it was necessary to establish what defines the nature and the competences of the bodies under study, i.e., define what is the function of the health ombudsman offices, in this case, those allocated within the structure of the state health secretariats.

According to Ordinance Nr. 2,416/14 (BRASIL, 2014A______. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Ouvidoria-Geral do SUS. Guia de orientações básicas para implantação de ouvidorias do SUS. Brasília, DF: Ministério da Saúde, 2014a.), Article 5, it is the competence of SUS ombudsman services in the sphere of each the Federation's member-states:

1. analyze, in a permanent way, the needs and interests of SUS users, received by means of suggestions, denounces, praises, and complaints referring to health actions and services delivered by SUS;

2. detect, by means of ombudsman procedures, the complaints, suggestions, praises, and denounces, to subsidize the assessment of health actions and services by the competent bodies;

3. forward the denounces to bodies and units of the Secretariat of Health or equivalent body for the necessary measures;

4. perform administrative mediation with the body's administrative units for proper, objective, and agile instruction of the demands presented by citizens, and its conclusion and reply to demanders in the established term;

5. inform, sensitize, and give guidance to citizens for participation and social control of public services of health;

6. inform about the rights and duties of SUS users; and

7. prepare reports with subsidies contributing for SUS managers to find solutions that minimize and resolve SUS deficiencies identified and pointed by citizens. (BRASIL, 2014A______. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Ouvidoria-Geral do SUS. Guia de orientações básicas para implantação de ouvidorias do SUS. Brasília, DF: Ministério da Saúde, 2014a., P. 1).

The document 'Basic guidance for the implementation of SUS ombudsman offices' prepared by Doges (BRASIL, 2014B______. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Ouvidoria Ativa do SUS: ampliando a escuta e o acesso à informação do cidadão. Brasília, DF: Editora do Ministério da Saúde, 2014b., P. 8-9) presents:

In this context, SUS ombudsman offices are strategic instruments for the promotion of citizenship in health, organizing and interpreting the information received from the civil society by means of conducts that inspire credibility, ethics, and respect for citizens [...]. Hearing citizens is an individual process, but the ombudsman office is responsible for systematizing the demands that it receives, as to enable the preparation of broad indicators that can be used as strategic support for decision-making in the field of health management.

Those should be, thus, the responsibilities and competences of the state health ombudsman offices. However, when searching the bibliography referring to ombudsman offices, deeper studies and analysis on the specificities of those state bodies are scarce.

According to search on the platform Scientific Electronic Library Online (SciELO) for the group work, and later updated when preparing this article, it was verified that the amount of works published in the country in recent years involving the ombudsman theme still presents little increase. Themes that have been explored are, for instance, the relationship between ombudsman and democratic governance; between ombudsman and monitoring, control, and accountability; and between reactive and proactive ombudsman (BOLZAN , 2012BOLZAN, L. C. et al. Ouvidoria Ativa: A inovação das pesquisas de satisfação na ouvidoria-geral do SUS. In: CONGRESSO CONSAD de Gestão Pública, 5., 2012, Brasília, DF. Anais... Brasília, DF, 2012. Disponível em: <http://www.sgc.goias.gov.br/upload/arquivos/2013-03/ouvidoria-ativa-a-inovacao-das-pesquisas-de-satisfacao-na-ouvidoria-geral-do-sus.pdf>. Acesso em: 25 nov. 2016.
http://www.sgc.goias.gov.br/upload/arqui... ; NONATO, 2016; PIRES; VAZ, 2012PIRES, R.; VAZ, A. Participação Social como método de governo? Um mapeamento das "Interfaces Socioestatais" nos programas federais: Efetividade das instituições participativas no Brasil. Brasília, DF: Ipea, 2012. (Texto para Discussão 1707). Disponível em: <http://www.ipea.gov.br/participacao/images/pdfs/td_1707.pdf>. Acesso em: 24 nov. 2016.
http://www.ipea.gov.br/participacao/imag... ; RITO CARDOSO ., 2011RITO CARDOSO, A. S. et al.Introdução: ouvidoria pública e governança democrática. In: INSTITUTO DE PESQUISA ECONÔMICA APLICADA (IPEA). Boletim de Análise Político-Institucional. Brasília, DF: Ipea, 2011. p. 51-57. Disponível em: <http://www.ipea.gov.br/ouvidoria/images/stories/2013/PDF/12-04-2013boletim_analisepolitico.pdf>. Acesso em: 24 nov. 2016.
http://www.ipea.gov.br/ouvidoria/images/... ; PÓ; ABRUCIO, 2006).

In the international literature, there are texts analyzing themes related to Latin-American bodies of state-civil society interface homologue and analogue to Brazilian ombudsman offices beyond the health area, highlighting common themes such as: the role of the ombudsman or person responsible for the body doing the hearing of citizens' demands; systems of protection of rights; and self-regulation of institutions, among which stand out corporative media, corporations, and private and public services, namely in the health area (PEIXOTO 2013PEIXOTO, S. F. et al. Atribuições de uma ouvidoria: opinião de usuários e funcionários. Saúde soc., São Paulo, v. 22, n. 3, p. 785-794, 2013. Disponível em: <http://www.scielo.br/pdf/sausoc/v22n3/12.pdf>. Acesso em: 24 nov. 2016.
http://www.scielo.br/pdf/sausoc/v22n3/12... ; CARVALHO 2009CARVALHO, D. B. et al. Humanização e controle social: o psicólogo como ouvidor hospitalar. Psicologia Ciência e Profissão, Brasília, DF, 29, n. 1, p. 172-183, 2009. Disponível em: <http://www.scielo.br/pdf/pcp/v29n1/v29n1a14.pdf>. Acesso em: 24 nov. 2016.
http://www.scielo.br/pdf/pcp/v29n1/v29n1... ; MACIA-BARBER, 2009MACIA-BARBER, C. La autorregulación extrínseca en la empresa periodística: La experiencia del Grupo 16. Palabra Clave, Madri, v.12, n. 2, p. 269-286, 2009. Disponível em: <http://www.scielo.org.co/pdf/pacla/v12n2/v12n2a07.pdf>. Acesso em: 24 nov. 2016.
http://www.scielo.org.co/pdf/pacla/v12n2... ; SAGASTEGUIM, 2010SAGASTEGUIM, F. Supervisando la seguridad vial en el Perú. Rev. peru. med. exp. salud pública (Impr), Lima v. 27, n. 2, p. 255-259, 2010. Disponível em: <http://www.scielo.org.pe/pdf/rins/v27n2/a15v27n2.pdf>. Acesso em: 24 nov. 2016.
http://www.scielo.org.pe/pdf/rins/v27n2/... ; GONZALEZ PEREZ, 2011GONZALEZ PEREZ, L. R. El sistema no-jurisdiccional de protección de los derechos humanos en México. Rev. IUS, Puebla, v. 5, n. 28, 99-122, 2011. Disponível em: <http://www.scielo.org.mx/pdf/rius/v5n28/v5n28a6.pdf>. Acesso em: 8 dez. 2016.
http://www.scielo.org.mx/pdf/rius/v5n28/... ; PEREZ ORTIZ; POLO ROSERO, 2012PEREZ ORTIZ, V.; POLO ROSERO, M. El Defensor del Pueblo y su intervención em los juicios de constitucionalidade concentrados em Colombia: ¿Planteamiento de um debate? Vniversitas, Bogotá, n. 125, p. 257-286 2012. Disponível em: <http://www.scielo.org.co/pdf/vniv/n125/n125a09.pdf>. Acesso em: 24 nov. 2016.
http://www.scielo.org.co/pdf/vniv/n125/n... ; SPADONI, 2013SPADONI, E. The role of the ombudsman in environmental conflicts: the case of the Matanza Riachuelo Basin. Ambiente e Sociedade, São Paulo, v. 16, n. 2, p. 47-62, 2013. Disponível em: <http://www.scielo.br/pdf/asoc/v16n2/en_04.pdf>. Acesso em: 24 nov. 2016.
http://www.scielo.br/pdf/asoc/v16n2/en_0... ; MELO, 2014MELO, M. P. P. Governo da população: relação médico-paciente na perícia médica da previdência social. Interface (Botucatu), Botucatu, v. 18, n. 48, p. 23-36, 2014. Disponível em: <http://www.scielo.br/pdf/icse/v18n48/1807-5762-icse-18-48-0023.pdf>. Acesso em: 24 nov. 2016.
http://www.scielo.br/pdf/icse/v18n48/180... ).

Regarding the municipal level, although some production is being carried out on health ombudsman offices (FERNANDES , 2016FERNANDES, F. M. B. et al. Inovação em ouvidorias do SUS - reflexões e potencialidades. Ciência & Saúde Coletiva, Rio de Janeiro, n. 8, p. 2547-2554, 2016. Disponível em: <http://www.scielo.br/pdf/csc/v21n8/1413-8123-csc-21-08-2547.pdf>. Acesso em: 24 nov. 2016.
http://www.scielo.br/pdf/csc/v21n8/1413-... ; SILVA , 2014SILVA, R. C. C. et al. Ouvidorias públicas de saúde: estudo de caso em ouvidoria municipal de saúde. Rev. Saúde Públ., São Paulo, v. 48, n. 1, p. 134-141, 2014. Disponível em: <http://www.scielo.br/pdf/rsp/v48n1/0034-8910-rsp-48-01-0134.pdf>. Acesso em: 24 nov. 2016.
http://www.scielo.br/pdf/rsp/v48n1/0034-... ; GUIMARÃES , 2011GUIMARÃES, M. B. L. et al. Os impasses da pobreza absoluta: a experiência da Ouvidoria Coletiva na região da Leopoldina, Rio de Janeiro (RJ, Brasil). Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, n.1, p. 291-300, 2011. Disponível em: <http://www.scielo.br/pdf/csc/v16n1/v16n1a31.pdf>. Acesso em: 24 nov. 2016.
http://www.scielo.br/pdf/csc/v16n1/v16n1... ; VASQUEZ ET AL., 2005; DE MARIO, 2006DE MARIO, C. G. Ouvidorias públicas municipais no Brasil. 2006. 141 f. Dissertação (Mestrado em Urbanismo) - Pontifícia Universidade Católica, Campinas. 2006. Disponível em: <http://tede.bibliotecadigital.puccampinas.edu.br:8080/jspui/bitstream/tede/28/1/Camila%20G%20de%20Mario.pdf>. Acesso em: 24 nov. 2016.
http://tede.bibliotecadigital.puccampina... ), it does not seem they are an issue of concern among authors who present higher frequency and greater volume of publications in national journals.

The finding by RWG that there was not much meaningful academic production on the issue of health ombudsman, either at state or municipal levels, besides representing a challenge for the construction of the Strength-Idea, also served to confirmed the importance of collecting data by means of the research tool.

Chart 1 presents a panorama of the results from the administration of the Tool referring to state health ombudsman offices.

From these results it can be affirmed that the state ombudsman offices present high convergence with the Strength-Idea that guides the research tool. From the 18 questions, convergence was higher than 59% in 14 questions; in four questions convergence was higher than 90%. The only question with 100% convergence was about the permission for unrestricted access by citizens. The four questions presenting convergence lower than 50% ranged between 22% and 41%.

The questions that admitted multiple answers received interesting remarks. The question referring to means of communication, the expectation had been that the totality of state ombudsman offices would offer all possibilities: telephone, e-mail, postal, in person, web form, and suggestion box. However, only the health ombudsman offices in six states (MT, PE, PI, RJ, RN and RO) were considered convergent, as shown on chart 2.

It is certainly necessary to relativize the importance of a state or even a municipal ombudsman office offering the totality of means of communication to citizens. Technological or more modern means, such as e-mail and internet, for instance, are not necessarily more efficacious, efficient, and effective that others considered 'traditional'. The relativization implied in this thought becomes clear when one observes municipalities with a low number of inhabitants, with shortage of resources, where the population has close contact with authorities and institutions, thus being able to have their demands successfully reaching those responsible for them - at least theoretically. This is the nucleus of the idea of municipalization.

On the other hand, in state ombudsman offices, which theoretically comprise more equipments and larger geographical area than municipal ombudsman offices, distance communication means tend to become more usable.

The ombudsman office in the state of Amapá (AP) was the only one to declare not having a telephone to receive complaints from citizens. The ombudsman office in the state of Paraná (PR) was the only one that did not make an e-mail available for citizens' demands. And the ombudsman office in the state of Santa Catarina (SC) was the only one that declared that communication in person was not made available to the population.

In the other question with multiple answers, which refers to types of manifestation, it was expected that the state ombudsman offices would accept the six types that had been established: complaint, suggestion, praise, demand, denounce, and Access to Information Law (AIL), as shown on chart 3.

The health ombudsman offices of 11 states (CE, DF, ES, GO, MA, MG, MT, PA, PB, PE, PI, PR, RO, RR, RS and SC) were considered convergent, and the remaining were not, for not having answered the option referring to AIL. This may be understood as an expression of the low capillarity of this legislation, thus representing a challenge for the consolidation of a participative culture and for assuring citizenship among users of SUS. The issue becomes even more interesting when it is observed that in this group there are ombudsman offices of highly populated and politically expressive states like São Paulo and Rio de Janeiro.

Conclusions

The work of Doges to improve the efficiency, efficacy, and effectiveness of SUS has various meanings that may, at times, be conflicting at first sight. On the one hand, it goes in the sense of decentralizing the actions of ombudsman offices, in order to strengthen the process of implementation of their services throughout the national territory.

The aims of this process is to consolidate the dissemination of ways, means, channels, and systems of communication between citizens and public administration in states and municipalities, in order to permanently examine the needs and interests of users and their evaluation of health actions and services. It also aims to foment the networking, turning into reality the integrality of SUS national ombudsman system, articulating databases in order to provide greater agility (i) for the resolution of issues of administration and of analysis management; (ii) for the interchange of information to be used in studies; and (iii) for the assertion of real possibilities of citizens' participation in the design of public policies for health.

It is evident that the path is not free from difficulties. In order that it actually becomes a national ombudsman system it is urgent to dynamize the implementation of those participative bodies, which are in operation in all states of the country but only in 582 municipalities, according to data provided by Doges to the research team when the tool was administered. Also strategic is the use of information technology so that municipal and state ombudsman offices may have their communication capability expanded, both with Doges and users, in order to reinforce citizenship.

In this process it is crucial to have extreme attention to and care with local-regional differences and asymmetries that the municipalities, states, and regions of a continental country like Brazil present. Important factors that require consideration are: the sociopolitical and sociocultural history of each locality; the fluctuation of political parties dominating public policies; the institutional capabilities to perform; the conjunctures and structures of socioeconomic development; and, specifically in the case of health, the capacity and installed coverage of actions and services.

The permanent effort to improve the actions of the ombudsman offices as participative bodies is also related to the awareness concerning the importance of intertwining and strengthening the coordination of actions, both intra-ministerial and extra-ministerial, with the involvement of the two other levels of public administration and also other spheres. Specifically regarding the academy, there are ample possibilities to enhance the production of knowledge on management and on the theme of participation concerning ombudsman, as well as on the understanding of the processes of decentralization, regionalization, and permanent critical advocacy and (re)construction of SUS.

In this process, the state health ombudsman offices can and, why not say, should be seen as important knots in the fabric of this network of sociopolitical participation, which is the meaning of the conciliation and interlocution promoted and stimulated by the ombudsman's work. As subnational partners of Doges, the work of the state health ombudsman offices is the basis for the organization and systematization of the work of the municipal ombudsman offices. The level and reach of this network shall be the more efficient, efficacious, and effective as will the efforts be for the conciliation and concordance of actions that the bodies involved are able to lead, according to the achieved potentialities of the arrangements made aiming at the safeguard of democracy.

Finally, it should be stressed that the collection of information carried out by the research, which is presented in this article, occurred during the second half of 2014, in a period previous to the change of administration in the state level. Therefore, it cannot be stated that the data presented here reflect the state of the art of the ombudsman offices in the states simultaneously to the period when this article was sent to publication, which means that conditions are open for updates.

It is expected that, not only with updates, but also by deepening the studies carried out, further contributions shall be made for the improvement of actions and decision-making in the bodies responsible for the ombudsman offices in all spheres of public administration.

References

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