ABSTRACT

The study aimed to analyze the relationship between the National Health Conferences and the planning process of the Ministry of Health. A qualitative research was conducted based on comparative documentary analysis of the four National Health Plans with the reports of the corresponding Conferences (12th to 15th), identifying references to their influence in the planning process. It was verified that the Conferences mention planning, but, with little prominence. The Plans, in general, do not cite the Conferences as a base, except for the 12th Conference, anticipated to subsidize the 2004-2007 Plan. In order for the Conferences to be more effective, they must indicate priorities and effectively guide the management.

KEYWORDS
Unified Health System; Social participation; Health conferences; Health planning; Participative planning

Introduction

In Brazil, health is constitutionally established as a right of all and a duty of the State. This right is the result of a process of struggle for redemocratization that took place in the Country after a long dictatorial period and the actions of the Brazilian Health Reform movement, which resulted in the establishment of the Unified Health System (SUS), in the Federal Constitution of 1988, also called Citizen Constitution (PAIM ., 2011PAIM, J. et al. The Brazilian health system: history, advances, and challenges. The Lancet, Londres, v. 377, n. 9779, p. 1778-1797, 2011. Disponível em: <https://www.ncbi.nlm.nih.gov/pubmed/21561655>. Acesso em: 2 fev. 2017.
https://www.ncbi.nlm.nih.gov/pubmed/2156... ).

The participation of the community is one of the guidelines of the SUS and was regulated by Law nº 8.142/1990, considered a complement to the Organic Law of SUS (Law nº 8.080/1990), since the part referring to participation had been vetoed by then-President Fernando Collor de Melo. The Law nº 8.142 defines two collegiate instances of community participation, the Conferences and the Health Councils, which must be instituted in each of the three spheres of government - municipal, state and federal (BRASIL, 1990BRASIL. Lei nº 8.142, de 28 de dezembro de 1990. Dispõe sobre a participação da comunidade na gestão do Sistema Único de Saúde (SUS) e sobre as transferências intergovernamentais de recursos financeiros na área da saúde e dá outras providências. Diário Oficial [da] República Federativa do Brasil, Brasília, DF, 28 dez. 1990. Disponível em: <http://www.planalto.gov.br/ccivil_03/leis/L8142.htm>. Acesso em: 5 jun. 2016.
http://www.planalto.gov.br/ccivil_03/lei... ).

Despite having as a reference mark of social participation in health, Law nº 8.142/1990, the National Health Conferences predate the SUS itself, having occurred for the first time in 1941. However, only from 1986, with the 8th Conference, is that they are no longer restricted to a federal management summit and have expanded their participation in different segments (GUIZARDI 2004GUIZARDI, F. L. et al. Participação da Comunidade em Espaços Públicos de Saúde: uma Análise das Conferências. Physis, Rio de Janeiro, v. 14, n. 1, p. 15-39, 2004. Disponível em: <http://www.scielosp.org/pdf/physis/v14n1/v14n1a03.pdf>. Acesso em: 2 fev. 2017.
http://www.scielosp.org/pdf/physis/v14n1... ).

The Health Conferences aim to assess the health situation and propose the guidelines for the formulation of the health sector policy. Summoned by the Executive Power or, extraordinarily, by another Conference or by the Health Council, they must occur maximally every four years and be represented by the various social segments (BRASIL, 1990BRASIL. Lei nº 8.142, de 28 de dezembro de 1990. Dispõe sobre a participação da comunidade na gestão do Sistema Único de Saúde (SUS) e sobre as transferências intergovernamentais de recursos financeiros na área da saúde e dá outras providências. Diário Oficial [da] República Federativa do Brasil, Brasília, DF, 28 dez. 1990. Disponível em: <http://www.planalto.gov.br/ccivil_03/leis/L8142.htm>. Acesso em: 5 jun. 2016.
http://www.planalto.gov.br/ccivil_03/lei... ).

It is recognized the relevance of the Health Conferences for the strengthening of the democratic process of social participation and for the formulation of a health policy that meets, actually, the needs of the population (MÜLLER NETO; ARTMANN, 2014MÜLLER NETO, J. S.; ARTMANN, E. Discursos sobre o papel e a representatividade de conferências municipais de saúde. Cadernos de Saúde Pública, Rio de Janeiro, v. 30, n. 1, p. 68-78, 2014.). Together with other instruments of community participation in SUS management, they represent a real reform for the democratization of the health policy of the State, expanding the relations between representative democracy and direct participatory democracy, above all because of its ascending nature, which aims at participation from the analysis of the local health situation until the definition of priorities and the formulation of public policy (TOFANI; CARPINTÉRO, 2012TOFANI, L. F. N.; CARPINTÉRO, M. C. C. 3ª Conferência Municipal de Saúde de Várzea Paulista: a participação da sociedade no processo de priorização e compromisso político. Saúde e Sociedade, São Paulo, v. 21, p. 244-252, 2012. Disponível em: <http://www.scielosp.org/pdf/sausoc/v21s1/21.pdf>. Acesso em: 2 fev. 2017.
http://www.scielosp.org/pdf/sausoc/v21s1... ).

The National Health Conferences are organized in stages, which start in the municipalities (which may be preceded by local stages to further democratize access and participation), go to the state and advance to the national level. The discussions of the municipal and state Conferences are systematized and subsidize the national stage, whose main product, besides the mobilization, is the Final Report, which brings the deliberations, in the form of guidelines, proposals and motions, seeking to subsidize the management and favor the monitoring by the population (GUIZARDI , 2004GUIZARDI, F. L. et al. Participação da Comunidade em Espaços Públicos de Saúde: uma Análise das Conferências. Physis, Rio de Janeiro, v. 14, n. 1, p. 15-39, 2004. Disponível em: <http://www.scielosp.org/pdf/physis/v14n1/v14n1a03.pdf>. Acesso em: 2 fev. 2017.
http://www.scielosp.org/pdf/physis/v14n1... ). However, increasingly, it is discussed the effectiveness of the spaces of participation and the possibilities of potentializing them. One of the aspects to be considered is that, to meet their objectives, the Health Conferences should guide the planning of the SUS management, directly influencing the decision-making processes of the managers. And this aspect has, often, received insufficient attention from management, the participants of the Conferences, social control and even the academy.

According to Matus (1997)MATUS, C. Política, planejamento e governo. 3. ed. Brasília, DF: IPEA, 1997., planning is to try to submit to the will itself the chained course of everyday events, which determine a direction and a speed for change that, inevitably, a country experiences. It is the systematic situational calculation that relates the present to the future and knowledge to action.

In the SUS, there are some expected instruments that should be used at the federal scope for planning the management: the National Health Plan (NHP), the Annual Health Program and the Annual Management Report. In addition, beyond the health sector, the government elaborates the Pluriannual Plan (PPA), the Budgetary Guidelines Law (LDO) and the Annual Budgetary Law (LOA). Although foreseen in the Organic Laws of Health and the requirement of elaboration by the entities of Municipal and State Plans, the National Health Plan, a great instrument guiding the national health policy, was only elaborated and published as of 2004.

Despite the historical and political relevance of the Health Conferences, there are still few studies related to them, and the existing ones, in general, are more focused on analyzing the profile of participants or the way some specific themes have been presented over the years, based on the Final Reports (GUIZARDI 2004GUIZARDI, F. L. et al. Participação da Comunidade em Espaços Públicos de Saúde: uma Análise das Conferências. Physis, Rio de Janeiro, v. 14, n. 1, p. 15-39, 2004. Disponível em: <http://www.scielosp.org/pdf/physis/v14n1/v14n1a03.pdf>. Acesso em: 2 fev. 2017.
http://www.scielosp.org/pdf/physis/v14n1... ; MÜLLER NETO; ARTMANN, 2014MÜLLER NETO, J. S.; ARTMANN, E. Discursos sobre o papel e a representatividade de conferências municipais de saúde. Cadernos de Saúde Pública, Rio de Janeiro, v. 30, n. 1, p. 68-78, 2014.). However, little research has been done on the effectiveness of these spaces (LOBATO; MARTICH; PEREIRA, 2016LOBATO, L. V. C.; MARTICH, E.; PEREIRA, I. D. F. Prefeitos eleitos, descentralização na saúde e os compromissos com o SUS. Saúde em Debate, Rio de Janeiro, v. 40, n. 108, p. 74-85, 2016. Disponível em: <http://www.scielo.br/pdf/sdeb/v40n108/0103-1104-sdeb-40-108-00074.pdf >. Acesso em: 2 fev. 2017.
http://www.scielo.br/pdf/sdeb/v40n108/01... ; MÜLLER NETO 2006MÜLLER NETO, J. S. et al. Conferências de saúde e formulação de políticas em 16 municípios de Mato Grosso, 2003-2005. Saúde em Debate, Rio de Janeiro, v. 30, n. 73-74, p. 248-274, 2006. Disponível em: <http://www.redalyc.org/pdf/4063/406345309010.pdf>. Acesso em: 2 fev. 2017.
http://www.redalyc.org/pdf/4063/40634530... ), and there are no scientific investigations directly relating the National Health Conferences to the planning process in federal management, although the purpose of these is the proposal of guidelines for Health Policy, which is made explicit, mainly, in the National Health Plan and in the Pluriannual Plan.

Aiming to understand how the National Health Conferences have guided the planning processes of the Ministry of Health, the study sought to analyze the National Health Plans, relating them to the Final Reports of the National Health Conferences held in the same period (12th to 15th), in order to identify their correlations and their estrangements.

Methods

It is a qualitative research of a historical nature, based on documentary analysis. Documentary research is a method of researching social reality, in which already existing texts are considered as research data. It resembles bibliographical research, but, in documentary research, information is sought in documents that have not received any scientific treatment - such as reports, official documents, news -, characterizing themselves as original data from primary sources (OLIVEIRA, 2007OLIVEIRA, M. M. Como fazer pesquisa qualitativa. Petrópolis: Vozes, 2007.).

To carry out a more in-depth analysis of the impact of the Conferences on the planning of the Ministry of Health based on a more consolidated instrument and the main reference for health policy - the National Health Plan -, a comparative analysis of the Plans with the Final Reports of the National Health Conferences was conducted occurred in the corresponding administrations.

After the materials were gathered in electronic format, initially, a first reading of the material was carried out, seeking to extract general characteristics and the main elements of each of them. Then, a more in-depth analysis was performed, with a survey of the main mentions to the planning process made in the final reports, as well as references to the Conferences in the National Health Plans. It was also verified how the role and referrals of the conferences themselves to management were set out in the Final Reports.

This article is part of the doctoral study of the Postgraduate Program in Collective Health of the University of Brasília, which was submitted and approved by the Research Ethics Committee with Human Beings of the Faculty of Health Sciences, of the University of Brasília, under the opinion nº 1.311.854.

Results

Considering the period of the study, four Final Reports of National Health Conferences were analyzed (12th, 13th, 14th and 15th) (BRASIL, 2004______. Ministério da Saúde. Conselho Nacional de Saúde. Consolidado dos relatórios das conferências estaduais de saúde. Brasília, DF: Ministério da Saúde, 2004., ^2008A______. Ministério da Saúde. Conselho Nacional de Saúde. Relatório Final da 13ª Conferência Nacional de Saúde: Saúde e qualidade de vida: políticas de Estado e desenvolvimento. Brasília, DF: Ministério da Saúde, 2008a., ²⁰¹²______. Ministério da Saúde. Conselho Nacional de Saúde. Relatório Final da 14ª Conferência Nacional de Saúde: todos usam o SUS: SUS na seguridade social: Política pública, patrimônio do povo brasileiro. Brasília, DF: Ministério da Saúde, 2012., ^2016A______. Ministério da Saúde. Plano Nacional de Saúde: PNS 2016-2019. Brasília, DF: Ministério da Saúde, 2016a.) and the four existing National Health Plans (2004-2007, 2008-2011, 2012-2015 and 2016-2019) (BRASIL, 2005______. Ministério da Saúde. Plano Nacional de Saúde: um Pacto pela Saúde no Brasil. Brasília, DF: Ministério da Saúde, 2005., ^2008B______. Ministério da Saúde. Secretaria-Executiva. Mais Saúde: Direito de Todos: 2008-2011. 2. ed. Brasília, DF: Ministério da Saúde, 2008b., ²⁰¹¹______. Ministério da Saúde. Secretaria-Executiva. Subsecretaria de Planejamento e Orçamento. Plano Nacional de Saúde - PNS: 2012-2015. Brasília, DF: Ministério da Saúde, 2011., ^2016A______. Ministério da Saúde. Plano Nacional de Saúde: PNS 2016-2019. Brasília, DF: Ministério da Saúde, 2016a.), described in chart 1.

As can be observed, there is variation in both the quantitative and thematic approach format and structuring of conferences and health plans. The 12th Conference is structured in 10 very detailed axes, including the large number of approved proposals (total = 723), highlighting the quantitative guidelines regarding the organization of health care and health work. The issue of attention models was a priority topic of discussion in this context of management change, as well as the need to structure and integrate a health care network. Health work had been highlighted, especially since the Basic Operational Standard for Human Resources, published in the previous year and also important for planning, and shows, furthermore, the weight of the participation of workers in the Conference. The NHP 2004-2007, published the following year, presents 5 axes, in which the guidelines, goals and targets are divided, with emphasis on health conditions and health care lines.

The 13th Conference, unlike the previous one, was not structured in several themes, encompassing only three general axes, with emphasis on public policies for health and quality of life: the SUS in social security and the Pact for Health. The Pact had been published in the year prior to the conference and was of great importance for the management, planning and organization of health care and services. This was the conference with the highest number of Resolutions (total = 857) and a singularity, with the division, in the report, between unprecedented deliberations (almost 40%) and those coming from the discussions of the municipalities and states. The NHP 2008-2011, similarly to the previous plan, was divided into guidelines, measures and goals and had a greater emphasis on health care, but brought different themes, such as the Industrial Health Complex - valued in a development context of the Country, also the conference - and also brought an axis of international cooperation.

The 14th was the Conference with more axes, in this case, presented as guidelines (14), as well as the Plan 2011-2015 (14), which had two transversal directives of the federal government. The axes of both documents present a great inter-relation, possibly, among other factors, because the Minister presided over the Health Council in the period. In all, the 14th resulted in a smaller number of proposals (total = 343) than the 12th and 13th Conferences. The health plan, above all, presents the peculiarity of this moment in which management starts to prioritize the organization of care in health care networks.

In the 15th, the themes were distributed in eight axes, seven of them directly referring to health policy and one transversal axis, on democratic and popular reforms of the State, presented as an innovation in the Conferences, in the context of the beginning of a major political crisis in the Country. There was, also, considerable emphasis on access issues with quality and valorization of work and health education, and there was great mobilization around the theme of financing, which had been reduced shortly before the Conference. In total, 15th resulted in 560 approved proposals. The NHP 2016-2019 does not present important innovations, having great similarity with the axes of the previous Plan, but, apparently, with less evidence of integration to the federal government planning beyond the health sector.

Next, the results referring to the theme of the planning itself and the role of the Conferences are detailed, derived from the documentary analysis of each Conference report, in comparison with the respective National Health Plan.

12th National Conference on Health and NHP 2004-2007

The 12th National Health Conference brought the theme 'Health: A Right of All and Duty of the State - The Health We Have, the SUS We Want' and was held at the end of 2003. It had the participation of more than 4.000 people in the national stage and more than 100 thousand people in the municipal stages (carried out in 3.640 municipalities) and state stages (in all the states).

This Conference had some very important innovations, which, as pointed out in the Final Report, have caused successes and some frustrations. There was a decision to anticipate the Conference for the first year of its management, so that it could have more impact and generate necessary changes for the management of the SUS, since, until then, the Conferences had taken place, in general, in the second year of federal administration. Reference documents were also elaborated by the Ministry of Health and the National Health Council, distributed after the municipal stages, and an intensive use of information technology was made, with the creation of a system for feeding, indexing and grouping the proposals of state conferences, working groups and plenary amendments of the national stage. This made it possible, for the first time, to systematize the state reports in a proposal book, giving more importance to the municipal and state stages, but, also had an impact in the significant increase in the number of proposals approved at a national stage.

An important difficulty in the process was the finalization of the vote on the proposals. With the large amount, the vote was not completed in the Conference Plenary. Thus, the National Health Council carried out a review of the deliberations, separating the proposals considered controversial and pending voting and sending them to both male and female delegates of the Conference. This home vote, held for the first time, reached 58.3% of the delegates and returned to the plenary session of the Council, where the motions were voted on. The report was completed with 723 proposals, from 10 different axes.

In the report of the 12th, planning is mentioned since the presentation of the rapporteurs - who contextualize the anticipation of the Conference to subsidize the elaboration of the National Health Plan - to the guidelines themselves.

Axis 4 is what most addresses this issue, since it deals with the management of the SUS and the role of the three management spheres. It begins with the re-discussion directive by the society of federative pact for the formulation of the National Health Plan and for the approval of the Social Responsibility Law, and it is also proposed the establishment of teams of tripartite representation among SUS managers to elaborate the National Health Plan, in an ascending process, submitted to health councils and updated annually. In addition to the NHP, the following are highlighted: Agreed and Integrated Programming (PPI) and the PPA, with proposals for integration between the instruments; the democratization of instruments of agreement and evaluation; elaboration based on health needs; and the annual review of the PPA of the three spheres, with the participation of society and the adequacy of contents for the feasibility of Plans and Goal Chart.

There is also mention of planning in the axes related to intersectoriality, the organization of health care, financing, communication and science and technology. The guidelines that emphasize the need to strengthen intersectoriality in the elaboration of the annual and multi-annual plans of the three spheres are highlighted, with the compatibility of the sectoral plans; the need for prioritization of guidelines in the NHP, such as health research; the use of health plans and master plans as a basis for investment; the conduct of public opinion polls coordinated by the health councils for the reprogramming of the plans; and the integration of different planning instruments in the health sector. There is, also, reference to the Executive Plans of Regionalization (PDR) and Investments (PDI).

The report itself includes, also, proposals on the role of conferences in the planning, monitoring and implementation of resolutions, of which, are noteworthy the guidelines for ensuring compliance with the deliberations of the conferences by the managers, including the possibility of punishments; of altering the propositional character to deliberative; and the creation of forums to follow up conference resolutions.

The 2004-2007 National Health Plan, entitled 'A Pact for Health in Brazil', approved in December 2004 by Decree nº 2.607/2004, refers to the Conference from the introduction to the objectives and references. It is highlighted that the Plan was drawn up in the year following the Conference and was based on its deliberations. In addition to the Conference itself, the Health Project 2004 - contribution to the debates of the 12th Conference - was developed and a research was carried out with the participants of the Conference about their opinions and suggestions of priorities to be contemplated in the National Plan. Also, the PPA 2004-2007 is mentioned as the basis for the elaboration of the Plan, which was discussed in internal forums of the Ministry of Health, the Tripartite Interagency Commission and the National Health Council.

As a goal for the purpose of strengthening democratic management and improving participation processes and instances, the NHP 2004-2007 points to the 13th National Health Conference.

As described in the final report of the 12th, the outcome of the Conference is the basis of the National Health Policy to be implemented, which should often be revisited by policymakers, managers, users, social control agents, health professionals, legislators, analysts, by an expressive sample of brazilian society.

13th National Conference on Health and NHP 2008-2011

The 13th Conference took place from November 14 to 18, 2007, with the theme 'Health and Quality of Life: State Policies and Development'. The national stage counted on 4700 participants, among managers, workers, users, parliamentarians, teachers and foreign observers. Of the 5.564 Brazilian municipalities, 4.430 (77%) held their Municipal Conferences. 857 Resolutions and 157 Motions were approved.

The debates focused, mainly, on reflections and deliberations on intersectoriality, the reversal of the care model, the regulation of SUS funding, the restructuring and strengthening of the public network, the fight against precarious work and the establishment of positions of the SUS. For the first time, the general coordination of the Conference was made by the elected President of the National Health Council, of the category of professionals, giving much emphasis to the protagonism of the health councils. In its report, it is pointed out that

The report of the 13th Conference brings several deliberations regarding the planning process. Axis 2, which also deals with management, is the one that presents the greatest number of proposals on the theme, one of them appearing in a repeated way. It is pointed out the need for upward and strategic construction of health plans, involving the effective participation of public servants and local leaders in the processes of programming and evaluation of goals, ensuring a model in accordance with SUS principles.

Participatory planning and the implementation of instruments such as the PDR, the PDI and the PPI, as well as the Pact for Health, established after the 12th Conference, are also scheduled. It is emphasized the importance of management qualification regarding the achievement of health outcomes, with emphasis on regionalization.

The other axes also point to issues related to planning, retaking the issue of intersectoriality and integration of social policies, especially in the field of social security. They require, also, the need for the general planning instruments of the federal government (PPA, LDO and LOA) to be based on the reports of the Conferences, the health plans approved by the councils and the Pact for Health, as envisioned. A differentiated deliberation refers to the parliamentary amendments, in which it is defended the need for these to be in accordance with the priorities set forth in the Health Plan of the corresponding sphere and to be approved and controlled by the respective council.

In the context of deliberations in the Final Report on the Conferences themselves, as well as in 12th, 13th defended the need to establish a permanent commission composed of delegates and health advisers to monitor the implementation of the approved proposals and the holding of Conferences in the first year of the management, to be guidelines for health policy. In addition, it proposed the implementation of an information system for the detailed follow-up of the deliberations and indicated the need for wide dissemination of the reports of the conferences in the media, under the responsibility of the health councils, and the rendering of accounts by the management. Finally, it was approved, also, the need for a broad evaluation of participation and social control in the SUS, in the three spheres, as well as the revision and innovation of the methodology of the conference, which was also the subject of one of the approved motions.

On the other hand, the National Health Plan 2008-2011, entitled 'More Health - Everyone's Right', does not mention the 13th National Health Conference, because it was elaborated in the first year of its management, and was subsequently revised. It refers to the Conferences in the contextualization of Axis 6 - Participation and Social Control -, mentioning in general, from 8th to 12th, especially the latter, affirming the relevance of these instances of social participation. It retrieves, also, some proposals emanating from the Conferences, referring to the Councils and other channels of social participation, which should be highlighted and valued as challenges to the consolidation and strengthening of social control in the SUS and to the participation of the population.

14th National Conference on Health and NHP 2012-2015

The 14th National Conference of Health brings the theme 'Everyone uses SUS! SUS in Social Security, Public Policy and Brazilian People's Heritage', with the national stage occurring from November 30 to December 4, 2011. There were 4.374 municipal and state conferences, equivalent to 78% of the expected conferences, and participated in the stage more than 4.000 people, among guests, organizers and delegates representing society, workers, providers and managers.

It is important to highlight that there was a significant reduction in the number of resolutions contained in the Final Report of the 14th, as opposed to the increasing number of Conferences, which is mentioned as the result of the efforts to prioritize proposals and systematize proposals of states and municipalities. There was no room for the creation of new proposals at the national level, which represented almost 40% of the proposals of the 13th Conference, for example. Even so, there were not few Resolutions, being approved 343 of them.

In addition to the Final Report, was elaborated, also, another document for the brazilian society, entitled Letter of the 14th National Conference on Health, which, in addition to pointing out the main points discussed at the Conference, was intended to mobilize the population for the defense of the SUS, with great emphasis on social control and the fight against privatization of health.

The report of the 14th Conference is the one that makes less mention of aspects of the planning process in a general way. It advocates the need to improve the effectiveness of integrated planning among the spheres and community participation in health action planning, with the strengthening of strategic planning and participatory management. It contains, also, a resolution that guarantees that the proposals approved in the previous conferences will be used as subsidies to improve the municipal health plans, with follow-up of the councils. However, this aspect is not presented for the federal sphere.

The question of the referrals of the Conferences is presented in the final report in an incisive way, with the approval of a proposal for the accountability of managers who do not comply with Resolutions of councils and conferences, especially, regarding the budget allocation, and the guarantee of the execution of the proposals in the three spheres by means of a commitment term in the Bipartite and Tripartite Interagency Committees. The guarantee of wide and unrestricted dissemination in the national media about the holding of the conferences, as well as their reports, is also based. Moreover, the Conference Charter to the brazilian society reaffirms the commitment to implement all the deliberations of the 14th Conference, which will guide the actions in the following four years, to guarantee the right to health.

However, the National Health Plan 2012-2015 makes no mention of the 14th Conference and was also elaborated before the final stage of the Conference. The reference to Health Conferences is only made superficially in the Situational Analysis of the Plan, when it describes the challenges and limitations of Participation and Social Control. At this point, it mentions that the deliberations of Conferences, as well as the recognition of several problems related to the institutionalization of social participation, triggered several actions by the Ministry of Health, as actions of permanent education of health advisers. Guideline 12, which contemplates participatory management and social participation, is one of the goals of the 15th National Health Conference.

15th National Health Conference and NHP 2016-2019

The theme of the 15th National Health Conference was 'Quality public health to take care of people: the right of the Brazilian people', with the national stage being held from December 1 to 4, in Brasília, with the participation of about 3 thousand people, between delegates and guests. It was the first conference in which the Presidency of the National Health Council was in charge of a representative of the segment of users of the SUS.

The guidelines, proposals and motions approved at the conference were published in the Official Gazette of the Union, in May 2016, according to the Resolution of the National Health Council and homologation of the Minister of Health (BRASIL, 2016B______. Ministério da Saúde. Conselho Nacional de Saúde. Resolução nº 507, de 16 de março de 2016. Diário Oficial [da] República Federativa do Brasil, Poder Executivo, Brasília, DF, 5 mai. 2016b.), but, no complete Final Report was published up to 18 months after the Conference.

The conference presented an attempt to prioritize the proposals, and, for the first time, the percentage of approval of each guideline and proposal was published, counted from the electronic voting made by conference delegates. In total, there were 37 Guidelines and 560 Proposals approved.

The planning issue was not directly mentioned in any conference guideline, but appeared in some proposals. The integrated planning among the federative entities was again based on this conference, in the sense of improving the federation relationship of the SUS and strengthening shared management in health regions, with the adoption of the Organizational Contract of the Public Health Action (Coap) and with social control. The issue of planning instruments was also mentioned in the defense of increased federal health investment, with inclusion in the PPA, LDO and LOA.

One of the proposals was made to require the managers to comply with the actions foreseen in the PPA, while others, in the sense of publicizing and transparency of the instruments, giving visibility and wide dissemination, through public hearings or other communication strategies, to the Health Plans, Annual Health Scheduling, demonstration of epidemiological indicators, application of financial resources and the conference resolutions themselves. In that sense, one of the proposals concerned the formatting of conference documents, in an objective format and with clear guidelines, in order to improve planning and facilitate the knowledge of the members of the councils, movements and entities in general.

As in the previous conference, the issue of the referrals of the Conferences was incisively addressed, and, in the 15th, it was the subject of several proposals, some even repeatedly, especially with regard to the monitoring of resolutions, either by means of instruments already established, as Monitoring System of Health Councils, or through social networks. The guarantee of the execution and effectiveness of the conference resolutions was also proposed by means of a Commitment Letter with the Regional Interagency Commissions (CIR), Bipartite (CIB) and Tripartite Commissions (CIT) or, by a committee set up by representatives of the State, Municipal and Local Health Councils and the Public Ministry. It should be noted that some proposals have a more general meaning, while going to a level of detail to suggest, even, the number of participants in the monitoring and scheduling committees. The monitoring of previous conferences is also proposed in a permanent way, verifying and comparing positive and negative results and the status of implementation, with periodic disclosure.

It was proposed, also, the inclusion of the conferences in the management instruments and that their implementation takes place up to the first 120 days of management. As in the previous conferences, there were also proposals defending the responsibility of the managers for not implementing the resolutions of the conferences and the councils, since this is the space of effective manifestation and popular vocalization about their health demands.

As for the National Health Plan 2016-2019, it was published later than the previous plan, and was approved by the National Health Council in July 2016. Considerations are presented on the structuring of the plan; a detailed situational analysis; the 13 objectives, with their respective goals; and information about the management of the plan.

In the introduction on the structure of the plan, it is pointed out that health plans in the three spheres should consider the guidelines defined in the conferences and by the councils, however, there is no mention of the use of the guidelines and proposals approved in the National Health Conferences as a basis for the preparation of the Plan. However, a table of the Directives of the National Health Council by Thematic Axes is presented, these being the same ones of the 15th Conference, with related guidelines.

Regarding the objectives of the Plan, the conferences are only mentioned, in general, in Objective 11, referring to social control and channels of interaction with users, but, with no specific goal.

Discussion

Based on the analysis carried out, it was verified that several proposals related to planning and necessary referrals are repeated throughout the conferences, especially those related to ensuring the implementation of the resolutions and their monitoring, which has not yet been effectively implemented. There is limited mention of planning in the reports, despite being present in all of them, and almost no mention of the conferences in the National Health Plans.

The decision to anticipate the Conferences for the first year of federal management was important, but, in itself, does not guarantee that planning in the SUS is guided by the Resolutions of the conferences, even because the preparation of the Pluriannual Plan occurs already at the beginning of the year, to be sent to the National Congress until August 31 of the first year of the administration, and the intention is for the National Health Plan to be built previously, to subsidize it. The national stages of the National Health Conferences have taken place at the end of the year, with a period of approximately one year between the completion and publication of the Final Report.

It should be emphasized that, according to Decree nº 2.135/2013, which establishes guidelines for the planning process within SUS, there should be compatibility between the health planning instruments (Health Plan and respective Annual Programs and Management Report) and government planning and budget instruments (PPA, LDO and LOA), in each management area (BRASIL, 2013A______. Ministério da Saúde. Portaria nº 2.135, de 25 de setembro de 2013. Estabelece diretrizes para o processo de planejamento no âmbito do Sistema Único de Saúde (SUS). Diário Oficial [da] República Federativa do Brasil, Brasília, DF, 26 set. 2013a.). In 2011, the Ministry of Health also elaborated its first Strategic Planning 2011-2015, aiming at reconciling the core of the planning instruments that were being finalized and the instruments in preparation (PPA, NHP, Strategic Agenda and Annual Health Programming) (BRASIL, 2013B______. Ministério da Saúde. Secretaria-Executiva. Departamento de Monitoramento e Avaliação do SUS. Planejamento Estratégico do Ministério da Saúde: 2011- 2015: resultados e perspectivas. Brasília, DF: Ministério da Saúde, 2013b.).

Although there is an annual revision of the planning instruments, there is a misalignment in the times of preparation of the basis for planning and conducting the conferences, which compromises their effectiveness. This was visible in the National Health Plans analyzed, which, with the exception of the first (2004-2007), do not mention the Conference as one of the bases for its elaboration. The same way the theme of SUS management, with the planning, execution, monitoring and evaluation stages, sometimes does not have the necessary centrality in the participation processes, as verified at the 14th Conference.

Although the NHP 2008-2011 does not mention the 13th Conference as a basis, in 2010, it was published, by the Ministry of Health, in the framework of the 'Planning Notebooks' Series, a specific notebook on the NHP 2008/2009-2011, in which it is emphasized that, although the preparation of the Plan began in early 2007 and the guidelines for the PPA prepared in that year were constructed, some changes in the situation changed its process and were submitted and approved by the National Health Council only in 2009. It is highlighted that the preparation of the Plan was based on the guiding documents, among them, the Final Report of the 13th National Health Conference (BRASIL, 2010______. Ministério da Saúde. Secretaria Executiva. Subsecretaria de Planejamento e Orçamento. Sistema de Planejamento do SUS: Uma construção coletiva: Plano Nacional de Saúde (PNS) 2008/2009-2011. Brasília, DF: Ministério da Saúde, 2010.).

Health councils also play an important role in the planning process for consolidating the participatory and democratic management of the SUS. In addition to the role of the councils in defining the guidelines for the elaboration of the Health Plans in their respective spheres - guidelines that should be elaborated from health conferences -, plans need to be analyzed and approved by councils. Fleury and Ouverney (2012)FLEURY, S.; OUVERNEY, A. O sistema único de saúde brasileiro: desafios da gestão em rede. Revista de Gestão dos Países de Língua Portuguesa, Lisboa, v. 11, n. 2-3, p. 74-83, 2012. Disponível em: <http://www.scielo.mec.pt/scielo.php?script=sci_arttext&pid=S1645-44642012000200007>. Acesso em: 2 fev. 2017.
http://www.scielo.mec.pt/scielo.php?scri... point out that, with regard to the sharing of decision-making power, it is essential that managers understand that both the definition of macro-objectives, directives and goals of the public health policy agenda and procedural issues regarding their implementation are subject to the political action of the different interest groups that are part of the health councils.

Another important issue identified, referring to the Reports of the National Health Conferences, is the great number of Resolutions approved in the last conferences, without hierarchy between them. While this reflects the growing complexity of society and the interests of the conferences, it reveals possible loss of substance in the approved proposals and the inexistence of so many resolutions, making it difficult to identify the priorities and guidelines that should guide health policy. The 8th National Health Conference, a major milestone in social participation in health, occurred in 1986, had only 49 proposals approved, but, with a power that consolidated the bases of the proposal to create a SUS. As pointed out by the National Council of Health Secretaries - Conass (2009)CONSELHO NACIONAL DE SECRETÁRIOS DE SAÚDE (CONASS). As Conferências Nacionais de Saúde: Evolução e perspectivas. Brasília, DF: CONASS, 2009., if the conferences do not indicate what is most important, it is impossible to identify the priorities, which jeopardizes the analysis and follow-up effort that must be made by the Health Councils on the planning of the government action.

It is recognized that, in addition to the national stage, the other stages of the Conferences, which occur previously, can and should also bring important subsidies to the management, also because it is advocated that planning in the SUS should occur in an upward manner. Also, the mobilization generated by social participation spaces is of great importance for the strengthening of participatory management, and the tensions evidenced in the conferences contribute to the inclusion of themes in the health policy agenda.

The need to review the methodology of these spaces is reiterated at the various conferences. Successful experiences at local levels have been carried out and need to be considered in the process of evaluation and innovation of control and social participation in SUS (TOFANI; CARPINTÉRO, 2012TOFANI, L. F. N.; CARPINTÉRO, M. C. C. 3ª Conferência Municipal de Saúde de Várzea Paulista: a participação da sociedade no processo de priorização e compromisso político. Saúde e Sociedade, São Paulo, v. 21, p. 244-252, 2012. Disponível em: <http://www.scielosp.org/pdf/sausoc/v21s1/21.pdf>. Acesso em: 2 fev. 2017.
http://www.scielosp.org/pdf/sausoc/v21s1... ). This attempt is noticed, also, at the national level, especially at the 15th Conference, which has not yet had its full Final Report published, but has already predicted, in its guiding document, the prioritization of proposals from the municipal to the national stages, as well as strengthened the importance of free conferences and instituted fairness criteria for participants (BRASIL, 2015______. Ministério da Saúde. Conselho Nacional de Saúde. Resolução nº 501, de 7 de maio de 2015, Diário Oficial [da] República Federativa do Brasil, Brasília, DF, 2015. Disponível em: <http://conselho.saude.gov.br/ultimas_noticias/2015/docs/05mai13_Reso501_em_homologacao.pdf >. Acesso em: 5 jun. 2016.
http://conselho.saude.gov.br/ultimas_not... ). Still, the 15th included in the program a public act in front of the National Congress, at the moment of the beginning of a process of presidential impeachment quite debatable and contrary to the defenses of most movements, a situation that also directly influenced the planning process of the Ministry.

Besides regulations and planning documents, it is known that changes in the scenario, the search for solutions to identified recurrent or specific problems and the actors involved in the processes influence the change and the creation of policies and programs, as, for example, occurred with the Pact for Health, instituted in the first management analyzed in this study; the National Policy of Strategic and Participatory Management, instituted in the second period; and the More Doctors Program, established in the third; among many others, which are not always included in the National Health Plan. Even the structure of the Ministry of Health was altered about ten times in the analyzed period.

However, this does not exclude the need to invest in the planning and strengthening of the participation bodies, in order to guarantee even more effectiveness in social control and participation. In an exploratory study published by the Institute of Applied Economic Research (Ipea), referring to the effectiveness of three National Conferences - 2nd National Conference on Aquaculture and Fisheries (2006), 3rd National Conference on Science, Technology and Innovation (2005) and I National Conference of Policies for Women (2004) -, based on the analysis of conference reports and action plans prepared by management after the conferences, the average effectiveness for the first and second sessions was verified (40% of inclusion of proposals) and high for the third (72% of inclusion). Four explanatory factors about the effectiveness of participatory instances are pointed out, namely: the political context; the nature of public policy; the organization of civil society; and the institutional design of the conference (PETINELLI, 2013PETINELLI, V. Contexto político, natureza da política, organização da sociedade civil e desenho institucional: alguns condicionantes da efetividade das conferências nacionais. In: AVRITZER, L.; SOUZA, C. H. L. (Org.). Conferências Nacionais: atores, dinâmicas participativas e efetividade. Brasília, DF: IPEA, 2013. p. 207-242.).

It is perceived, thus, that the conferences also express disputes, characteristic of the political game, and, as pointed out by Guizardi (2004, P. 17)GUIZARDI, F. L. et al. Participação da Comunidade em Espaços Públicos de Saúde: uma Análise das Conferências. Physis, Rio de Janeiro, v. 14, n. 1, p. 15-39, 2004. Disponível em: <http://www.scielosp.org/pdf/physis/v14n1/v14n1a03.pdf>. Acesso em: 2 fev. 2017.
http://www.scielosp.org/pdf/physis/v14n1... ,

Conclusions

It was verified that the NHP and other planning instruments and processes are recurrent themes in the reports - albeit sometimes not prioritized - both in terms of health policy in general and in the implementation of specific public policies and programs. On the other hand, in the elaboration of the Plans, this seems to be little considered. As seen, there are plans that do not even mention the previous Conferences as a basis nor the participation of states and municipalities in their elaboration for the construction of an ascending process, as advocated. It should be emphasized that not mentioning this does not mean, necessarily, that there was no consideration for participatory processes, but, it may signal that some aspects need to be revised to increase its effectiveness.

It was identified that the Conferences have not been strategic in some aspects, because often there is lack of continuity, of reflection on the own management of the system and lack of monitoring and evaluation. One of the limiting aspects of the effective role of the National Health Conferences was the issue of temporality. Holding the Conference after the elaboration of the planning instruments makes it difficult to achieve its main objective, which is to set the guidelines for Health Policy. In addition, it is also essential to review the processes for elaborating resolutions and identifying priorities.

This does not mean that the Conference has no power and that it does not guide the management of the SUS, but, rather, that this instance needs to be revaluated, in order to ensure greater effectiveness and strengthening of participatory processes in SUS and other public policies, with the population and empowered workers, guiding and collectively building with management the direction to ensure the right to health and to strengthen democracy.

As a limitation of this study, it is pointed out the insufficiency of the documents analyzed in identifying what was, indeed, accomplished from the resolutions of the conferences, an aspect that goes beyond the objective here, but which also has relevance in the analysis of the effectiveness of the participation. It is suggested a greater follow-up of the academy, the management and the population on the planning and execution of the health policy and the accomplishment of more studies referring to the theme of the conferences of health and their impacts, contemplating, also, other methodologies and objects of analysis.

References

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