ABSTRACT

This study is aimed at analyzing the conditioning and determining factors in the incorporation of health promotion proposals into the governmental agenda of the healthcare industry of the state of Bahia, in the period from 2007 to 2014, recognizing the inception of studies that analyze the constitution process of government agendas for health promotion. The research was theoretically anchored to the Multiple Flow model, proposed by Kingdon, which highlights the influence of the active participants and problem flow, as well as of alternatives and political streams in establishing government agenda. In addition, we were supported by Mario Testa's theory to recognize the resources of the power of the participants. A single case study was conducted, with research on secondary sources and interviews with key informants. In conclusion, the constitution of the health promotion agenda of the state of Bahia was based more on a symbolic representation than on a policy to be pursued. We recognize that the paths that lead to the choices of health promotion alternatives do not correspond to concrete problems, and it is essentially based on the political flow in which the situation was involved.

KEYWORDS
Health promotion; Public policy; Health priority agenda

Introduction

The incorporation of the topic on health promotion to governmental agendas has been more strongly discussed since the 1980's, when the idea of health promotion stood out in the international debate because of the lack of proposals to face the health problems based on hospital-centered healthcare models¹1 Carvalho SR. Saúde Coletiva e Promoção da Saúde: sujeito e mudança. 2. ed. São Paulo: Hucitec; 2007.^,22 Pellegrini Filho A, Buss PM, Esperidião MA. Promoção da Saúde e seus fundamentos: determinantes sociais da saúde, ação intersetorial e políticas saudáveis. In: Paim JS, Almeida Filho N, organizadors. Saúde coletiva: teoria e prática. Rio de Janeiro: MedBook; 2014. p. 305-326..

Different conceptions of health promotion have been shown with significant divergences regarding its nature. On one hand, there is the perspective of changing life habits of the individuals, with emphasis on behavioral risks. On the other hand, there is the improvement of the quality of life and the reduction of social inequities with emphasis on intersectoral actions¹1 Carvalho SR. Saúde Coletiva e Promoção da Saúde: sujeito e mudança. 2. ed. São Paulo: Hucitec; 2007.^,33 Heidmann ITS, Buss AMCP, Boehs AE, et al. Promoção à saúde: trajetória histórica de suas concepções. Texto Contexto Enferm. 2006 jun; 15(2):352-358..

The literature has shown difficulties in formulating policies on health promotion¹1 Carvalho SR. Saúde Coletiva e Promoção da Saúde: sujeito e mudança. 2. ed. São Paulo: Hucitec; 2007.^,44 Kickbusch I. The contribution of the World Health Organization to a new public health and health promotion. American J Public Health. 2003; 93:383-388.^,55 Mannheimer LN, Lehto J, Östlin P. Window of opportunity for intersectoral health policy in Sweden - open, half-open or half-shut? Health Promot Int. 2007 [acesso em 2015 jul 15]; 22(4):307-315. Disponível em: http://heapro.oxfordjournals.org/.
http://heapro.oxfordjournals.org/... . Even in Canada's experience, which is one of the first countries to take these types of actions, there is evidence showing that the integration of these actions into the health systems was not much significant, which shows that health promotion is not able to significantly influence the reorganization of the healthcare industry¹1 Carvalho SR. Saúde Coletiva e Promoção da Saúde: sujeito e mudança. 2. ed. São Paulo: Hucitec; 2007..

In the international scenario, regarding the establishment of a governmental agenda to promote health, a study⁵5 Mannheimer LN, Lehto J, Östlin P. Window of opportunity for intersectoral health policy in Sweden - open, half-open or half-shut? Health Promot Int. 2007 [acesso em 2015 jul 15]; 22(4):307-315. Disponível em: http://heapro.oxfordjournals.org/.
http://heapro.oxfordjournals.org/... has evidenced that the participants perceived the problem in different ways, depending on their specific agenda and interest, and that the politicians and experts showed a great power in the establishment of the agenda and in the policy formulation, agreeing on the political goals. However, the limited involvement of the top-ranking individuals was considered to be a difficult issue to implement this policy, as well as the involvement of participants from other political sectors.

Although one of the purposes of the Brazilian National Health Promotion Policy (PNPS) formulated in 2006 is to value macropolitics with interventions on social determinants, it has prioritized actions aimed at changing life habits⁶6 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Política Nacional de Promoção da Saúde. Brasília, DF: MS; 2006.. The topic was based on the agenda of the state of Bahia in two periods of consecutive governments, 2008-2011 and 2012-2015. However, after analyzing official documents, which show a modest achievement of physical and budget goals of the actions, it was possible to notice a distance between the agenda and the advance of the propositions.

In a national literature review on health promotion policies in the 2007-2017 period, the analysis of the process of establishing governmental agendas was not identified. Some studies mention the process of policy formulation, such as the one that analyzes the institution of the Policy of the State of Minas Gerais, which highlights the values and principles, the foundations and the operational estrategies⁷7 Campos DSL, Turci MA, Melo EM, et al. Construção participativa da Política Estadual de Promoção de Saúde: caso de Minas Gerais, Brasil. Ciênc. saúde coletiva. 2017 dez; 22 (12): 3955-3964.. In addition, one can identify the analysis of the process of establishing the PNPS, when characterizing the contexts, statements and pressures in the political life⁸8 Malta DC, Morais Neto OL, Silva MMA, et al. Política Nacional de Promoção da Saúde (PNPS): capítulos de uma caminhada ainda em construção. Ciênc Saúde Colet. 2016 jun; 21(6):1683-1694., as well as the participants and the organizational and relational processes⁹9 Sá RMPF, Rezende R, Akerman M, et al. Autores-atores e processos organizacionais e relacionais na revisão da Política Nacional de Promoção da Saúde. Ciênc Saúde Colet. 2016 jun; 21(6):1707-1716..

In addition to focusing on health promotion, some studies try to understand the structure of the political agenda and the role of the government and the society in this process¹⁰10 Capella ACN. O processo da agenda-setting na reforma da administração pública (1995-2002) [tese]. São Carlos: Universidade Federal de São Carlos, Centro de Educação e Ciências Humanas; 2004. 245 p.

11 Pinto ICM. Ascensão e Queda de uma Questão na Agenda Governamental: o caso das Organizações Sociais da Saúde na Bahia [tese]. Salvador: Universidade Federal da Bahia, Núcleo de Pós-Graduação em Administração; 2004. 239 p.

12 Caldas EL. Formação de agendas governamentais locais: o caso dos consórcios intermunicipais [tese]. São Paulo: Universidade de São Paulo, Faculdade de Filosofia, Letras e Ciências Humanas; 2008. 227 p.^-1313 Gomide AA. Agenda Governamental e Formulação de Políticas Públicas: o projeto de lei de diretrizes da política nacional de mobilidade urbana. Brasília, DF: Ipea; 2008 [acesso em 2014 jan 20]. Disponível em: www.ipea.gov.br/sites/000/2/publicacoes/tds/td_1334.pdf.
www.ipea.gov.br/sites/000/2/publicacoes/... . These studies are based on the assumption that discussing how the problems are posed in the process of establishing an agenda and how the alternatives are presented and selected are fundamental issues to understand the dynamics of the governmental action.

This study is important because it sought to analyze the process of establishing the governmental agenda to identify the elements that may favor the implementation of the policies, especially regarding an object of action that involves the complexity of health promotion. This study was aimed at analyzing the incorporation of these propositions in the governmental agenda of the healthcare industry in the state of Bahia in the 2007-2014 period.

Material and methods

A case study on the process of including propositions about health promotion in the governmental agenda of the state of Bahia was conducted. The Health Secretariat of the State of Bahia (Sesab) was the unit analyzed. The period was selected based on the inclusion of health promotion actions in the health plans of the state in a scenario of administrative continuity (2008-2011 and 2012-2015).

The theoretical elements of the cycle of public policies, specifically the analytical model proposed by Kingdon¹⁴14 Kingdon JW. Agendas, Alternatives, and Public Policies. New York: HarperCollins; 2003., to establish a public agenda based on the characterization of the participants that have influenced the definition of the agenda, the problem flows and the alternatives, as well as the political flow that has supported the process, as shown in the analysis matrix (chart 1). The State Health Plan (PES) was the document that was recognized in this study as the governmental agenda of the healthcare industry.

The governmental agenda (or decision) corresponds to a list of topics or problems that the governmental and non-governmental agents focus on at a given moment and is the target of the government actions¹⁴14 Kingdon JW. Agendas, Alternatives, and Public Policies. New York: HarperCollins; 2003..

As Kingdon¹⁴14 Kingdon JW. Agendas, Alternatives, and Public Policies. New York: HarperCollins; 2003., when analyzing the capacity of intervention of the participants, does not explore the possibility that the participant will stay in different places and develop power relations that go beyond their position in the process of the agenda establishment, we used the power typology¹⁵15 Testa M. Estrategia, coherencia y poder en las propuestas de salud: Cuadernos Médico Sociales. Rosario: Centro de Estudios Sanitarios y Sociales; 1986. proposed by Testa, to recognize the various resources managed by the participants in the process, due to the position that they occupy and to their background. Three categories were used to analyze power: technical, administrative and political power, based on the analysis of the background of the interviewees, according to the criteria and classification shown in chart 2.

Data collection involved the analysis of documents and the conduction of 12 interviews. Official management documents and those resulting from sociopolitical mobilization actions developed by Sesab and other similar offices, showed ideas that supported or questioned the agenda of health promotion. All those involved in the agenda establishment were interviewed using the Snowball technique¹⁶16 Patton M. Qualitative evaluation and research methods. Beverly Hills, CA: Sage; 1990., namely: the secretary of health, the superintendents, the directors and the technicians of Sesab, and the representatives of the State Health Council in Bahia (CES), due to their significant role in formulating the Health Policy. Semi-structured interviews were used, and the fragments of the data collection sources were classified with the aid of the QSR Nvivo software. The data were compared according to the analytical categories of investigation, followed by the triangulation of the sources of evidence.

The research was approved by the Research Ethics Committee of the Institute of Collective Health of the Federal University of Bahia (UFBA), under the technical opinion 34772314.7.0000.5030.

Results and discussion

Flow of problems and alternatives

Health promotion has been explicitly shown as a priority since the Government Program, presented during the state election in 2007, which indicated a broad conception that valued the intersectoral articulation to improve health conditions with focus on socioenvironmental determinants and influence on the priorities of the PNPS. The Secretary of Health and the planning assistant participated in the development of the program.

Sesab defined the priorities for the 2008-2011 PES based on a set of problems and demands raised by the organization, by gathering epidemiological information, organizing regional workshops to identify and prioritize health problems, fostering the participation of representatives of the civil society and of the state and city management and hosting the 7th State Health Conference, as shown in the document and corroborated by the interviews. PES also included social demands from different regions of the state, which were consolidated in the Multiannual Government Plan, known as participative PPA.

The 2008-2011 PES¹⁷17 Salvador. Secretaria da Saúde do Estado da Bahia. Plano Estadual de Saúde (Gestão 2007-2011). Rev Baiana Saúde Pública. 2009; 33(supl.1). showed the consolidated problems in healthcare, some of which were implicitly related to the need for health promotion interventions, namely: 'high prevalence of chronic degenerative and cardiovascular diseases', 'high index of external causes', 'low effectiveness of social control' and 'low coverage and resolution of basic health'. No socioenvironmental problems were identified, and this may be linked to the lack of discussion about social determinants of health.

Regarding the interventions proposed, the 2008-2011 PES was structured according to actions, purposes, strategies, people in charge and corresponding goals. One of the lines of action was 'Health Promotion, Intersectorality and Health Protection', which was aimed at promoting intersectoral actions to consolidate healthy public policies for health promotion and public policies to promote healthy life habits, food security and society protection¹⁷17 Salvador. Secretaria da Saúde do Estado da Bahia. Plano Estadual de Saúde (Gestão 2007-2011). Rev Baiana Saúde Pública. 2009; 33(supl.1).. Despite the limitation in the recognition of the social and environmental problems, the proposals prioritized healthy public policies focused on some social determinants of health.

The Health Surveillance Superintendence (Suvisa) was designated to be in charge of the promotion of actions without identifying its bodies that are responsible for that. The Integral Health Assistance Superintendence (Sais) was particularly in charge of the second purpose, and the Basic Care Board of Directors (DAB) and the Care Management Board of Directors (DGC) were designated responsible for that. In all actions, the Municipal Health Secretariats (SMS) were co-responsible, although the representative entities are not evidenced as active participants in the definition of the agenda.

Another line of action that has incorporated the propositions of health promotion was the 'Democratic, Caring and Effective Management of SUS', which was aimed at strengthening the participation and social control at SUS-BA, involving two strategic actions under the responsibility of the Board of Directors in Education Management in Health (DGETS): one that predicted the social control in the Unified Health System (SUS) by re-structuring the Council of Health in the state of Bahia (CES), and the other one called Projeto Mobiliza SUS. This project showed two main implementation strategies: the development of regional seminars, with the participation of the representatives of social movements, professors and students, to sensitize and give them tools to gather in social activities in the territories and to establish a network of articulators and facilitators of permanent education for social control in SUS, by qualifying the representatives of the regional health and education offices, the Public Ministry, the Municipal Health Counselors and the social movements¹⁷17 Salvador. Secretaria da Saúde do Estado da Bahia. Plano Estadual de Saúde (Gestão 2007-2011). Rev Baiana Saúde Pública. 2009; 33(supl.1)..

In the development of the 2012-2015 PES, the regional workshops to detect and prioritize problems was not held. The document reveals that the public consultation regarding the most important problems occurred through the participative PPA and the 8th State Health Conference (2011), which contributed to the agenda by presenting the topic 'access and user embracement at SUS - the challenges in the formulation of a healthy and sustainable policy - as one of its central theme. Several proposals approved by the plenary that incorporated the topic of health promotion considering the intersectoral articulation were added to this theme. The state management, supported by the academy, chose the topic of this conference to legitimate the theme of health promotion in the spaces where the civil society participates, as evidenced in the interviews.

Another important movement toward the mobilization of the internal subjects regarding the topic was the organization of a workshop in 2010, coordinated by Suvisa and conducted by a technical cooperation team of UFBA. The workshop, entitled Bahia Saudável, was attended by Sesab technicians and managers, the representatives of the Secretary of Education, the Municipal Health Secretariats (SMS) of the metropolitan area, Collective Health professors and graduation students. The result of this workshop was a technical document with operational propositions to structure the Health Promotion Policy in the state of Bahia (Peps). This project was also considered as a space to sensitize the subjects to understand and value health promotion¹⁸18 Salvador. Secretaria da Saúde do Estado da Bahia. Promoção da saúde no estado da Bahia: Oficina de trabalho para a formulação da Política Estadual de Promoção da Saúde. Salvador: SESAB; 2011..

The term Bahia Saudável was created during the preparation of the document Agenda 2023. This process, which was conducted by the Staff of the Governor in 2010, was aimed at preparing a strategic agenda to guide the priorities of the following 13 years of government, in which health promotion was a project supported by the representatives of the health industry.

The problems identified in the 2012-2015 PES made it clear that it was necessary to promote health. The problems mentioned were related to the governmental organization, including the lack of public policies that are effectively transversal, which are necessary for health promotion, well-being and society protection.

The 2012-2015 PES was related to the PPA of that period, which identified the sectorial health program as 'Bahia Saudável' and designated health promotion as one of its three structuring themes. This PES used the term commitment to identify its objects in a total of 13, of which 4 showed actions aimed at health promotion.

The first commitment recommended to expand the actions of health promotion and protection and disease and harm prevention in the context of SUS, under the responsibility of Suvisa, with only one operational initiative regarding health promotion - the elaboration of a normative framework of the state policy for health promotion¹⁹19 Secretaria da Saúde do Estado da Bahia. Plano Estadual de Saúde (Gestão 2012-2015). Rev Baiana Saúde Pública. 2012; 36(supl.1):1-86.. The second one was aimed at strengthening the basic healthcare, by changing the Healthcare Model in the context of SUS, under the responsibility of DAB/Sais, with three initiatives regarding health promotion: Health Gyms, State Policy for Health Promotion and State Policy for Primary Health Care with emphasis on health promotion and integration of the health surveillance practices implemented in the territory. The third commitment, related to the DGC and the Board of Directors for Network Management (DGRP), recommended to expand the actions of integral care at SUS, in order to promote active and healthy ageing. In order to do so, initiatives related to health promotion, prevention and treatment of non-communicable disease and harm were identified. However, the goals are only related to the reduction in the number of hospital stays. The fourth commitment followed the previous PES and proposed to strengthen the social control in health, with a democratic and participative management, and promote new ways to establish a dialog with society to consolidate the SUS-BA.

The actions shown in the 2012-2015 PES were more restricted compared to the previous PES, as most of them showed an organizational nature. Some interviewees have attributed such change to the difficulties associated with the implementation of the actions suggested in the previous PES and said that the political project elaborated in this plan has failed to show a feasibility analysis of the technical-administrative capacity and an external political feasibility to legitimate the action that required an intersectoral articulation. In the 2012-2015 PES, the participants adopted a pragmatic position and defined the actions that were performed to confer governability to Sesab. However, it was possible to see the fragmentation of responsibilities, as with the elaboration of the normative policy framework under the responsibility of Suvisa, while its implementation was DAB's responsibility.

Some interviewees who were against this mentioned that the subject matter in the second plan was valued in a more integrate manner among the groups within Sesab and showed a greater external articulation. This perception was supposedly associated with the movement of the Planning Division (Asplan), supported by Suvisa, during the elaboration of the 2012-2015 PPA, in order to mobilize other secretaries of the government to develop actions and promote health. However, as mentioned before, this movement was not properly organized. The external mobilization was shy and disorganized, and it was characterized as a movement for sensitization.

The importance of promoting health is recognized in the rhetoric of the set of governmental participants. However, the oppositions to the incorporation of propositions in practice, associated with financial disputes and the limitations of internal and external articulation, were evidenced. The most evident opposition was revealed in defining how to finance the actions. When the basic healthcare is in charge of organizing the health system and seeks to favor the investments to increase access to this level of care, it is necessary to reallocate the resources that once were majorly centered in the specialized and hospital networks. The interviewees mention divergences in this process, with power disputes in the spaces of Sesab.

Therefore, the problem flow was underestimated in the establishment of the agenda, especially in the first PES. In the second period, the institutional support was sought by prompting the discussion of the theme by the management team at SES. Despite that, the defense of health promotion as an object of action was neither sufficiently supported by social groups and the team set at SES, nor by the external participants. Defining the problem is a central strategy to the process of establishing the agenda, because it gives rise to the transformation of certain interpretations of the reality in shared perceptions, which is an essential aspect to defend a proposal²⁰20 Capella ACN. Formação da Agenda Governamental: perspectivas teóricas. In: XXIX Encontro Anual da Anpocs; 2005 ago. São Paulo: Unesp; 2005. [acesso em 2018 out 11]. Disponível em: https://www.anpocs.com/index.php/papers-29-encontro/gt-25/gt19-21/3789-acapella-formacao/file.
https://www.anpocs.com/index.php/papers-... .

Regarding the flow of alternatives, in the first PES, they were the result of the political idealization of some high-rank participants of Sesab that come from the academia. Influenced by ideological values, they searched for an innovative political project, which would value the ample conception of health. Therefore, health promotion would be the main image of this project. However, this process of defining the alternatives was not negotiated with the subjects who would be necessary to put forward the proposals. It is worth mentioning that there were no objections or the disputes regarding the project constitution and the alternatives adopted.

In the second period of the government, divergences regarding the organizational locus of the project at SES were evidenced. Suvisa, which was identified as the body in charge of most of the actions in the 2008-2011 PES, retroacted, as it did not want any more to be responsible for actions with no governability. Thus, the result is an agenda with fragmented responsibilities. Actions toward the encouragement of social participation, which appeared more organically, are exceptions. This participation was conducted by a specific board of directors, with clear goals and objectives and well-guided external articulations.

In conclusion, the topic about promotion has turned out into an agenda and is the result of the interest of only one group responsible for establishing the agenda, that is, it was not a historically built demand, nor a socially conditioned one, which are elements that are essential for the success of the project²¹21 Testa M. Pensamento Estratégico e Lógica de Programação (O caso da saúde). São Paulo: Hucitec; Rio de Janeiro: Abrasco; 1995.. As evidenced by the study of Pinto¹¹11 Pinto ICM. Ascensão e Queda de uma Questão na Agenda Governamental: o caso das Organizações Sociais da Saúde na Bahia [tese]. Salvador: Universidade Federal da Bahia, Núcleo de Pós-Graduação em Administração; 2004. 239 p., the preferences were not clearly defined by the participants, neither were the objects to be pursued.

Political flow

In the national context, it is worth mentioning the formalization of the PNPS in 2006 and its incorporation into the National Health Plan (PNS). The revision of the PNPS, published in 2014, did not influence the state agenda analyzed, as the publication occurred in the end of the state government.

In the 2008-2011 PNS, a specific budget plan was created to promote health²²22 Cruz DKA. Da promoção à prevenção: o processo de formulação da Política Nacional de Promoção da Saúde no período de 2003 a 2006 [dissertação]. Recife: Fundação Oswaldo Cruz, Centro de Pesquisa Aggeu Magalhães; 2010. 116 p.^,2323 Malta DC, Silva MMA, Albuquerque GM, et al. A implementação das prioridades da Política Nacional de Promoção da Saúde, um balanço, 2006 a 2014. Ciênc Saúde Colet. 2014 nov; 19(11):4301-4312.. Between 2008-2011, the PNPS was included in the national agenda, by means of the commitment called Pacto pela Vida, with the definition of monitoring indicators, focusing on reducing the prevalence of a sedentary life and smoking in the capitals, as well as in the implementation of centers for violence prevention and health promotion²³23 Malta DC, Silva MMA, Albuquerque GM, et al. A implementação das prioridades da Política Nacional de Promoção da Saúde, um balanço, 2006 a 2014. Ciênc Saúde Colet. 2014 nov; 19(11):4301-4312.. In the 2012-2015 PNS, health promotion was associated with actions of health surveillance under the guideline that proposed the reduction of risks and harm to the health of the population²⁴24 Brasil. Ministério da Saúde. Secretaria-Executiva. Subsecretaria de Planejamento e Orçamento. Plano Nacional de Saúde - PNS: 2012-2015. Brasília, DF: MS; 2011., whose actions basically referred to the priority themes of PNPS.

Between 2008 and 2015, the Brazilian federal government expanded its preexisting initiatives and implemented programs related to PNPS. It is worth mentioning the program 'Academia da Saúde', launched in 2011, with the implementation of centers to guide body practices, physical and leisure activities²⁵25 Brasil. Ministério da Saúde. Portaria nº 719, de 07 de abril de 2011. Institui o Programa Academia da Saúde no âmbito do Sistema Único de Saúde. Diário Oficial da União. 7 Abr 2011.. The Program represented a beginning of a line of projects financed by the Piso Variável em Vigilância e Promoção da Saúde and the Piso da Atenção Básica Variável, replacing the funding of individual projects conditioned to federal approval, therefore searching for the sustainability of the projects²³23 Malta DC, Silva MMA, Albuquerque GM, et al. A implementação das prioridades da Política Nacional de Promoção da Saúde, um balanço, 2006 a 2014. Ciênc Saúde Colet. 2014 nov; 19(11):4301-4312.^,2626 Sá GBAR, Dornelles GC, Cruz KG, et al. O Programa Academia da Saúde como estratégia de promoção da saúde e modos de vida saudáveis: cenário nacional de implementação. Ciênc Saúde Colet. 2016 jun; 21(6):1849-1860.. Until May 2015, there were 2,849 cities considered by the Program in the country, with a total of 4,240 units, of which 1,165 had the works concluded²⁶26 Sá GBAR, Dornelles GC, Cruz KG, et al. O Programa Academia da Saúde como estratégia de promoção da saúde e modos de vida saudáveis: cenário nacional de implementação. Ciênc Saúde Colet. 2016 jun; 21(6):1849-1860.. A study conducted by Sá et al.²⁶26 Sá GBAR, Dornelles GC, Cruz KG, et al. O Programa Academia da Saúde como estratégia de promoção da saúde e modos de vida saudáveis: cenário nacional de implementação. Ciênc Saúde Colet. 2016 jun; 21(6):1849-1860. reveals that of the 2,481 cities analyzed, only 856 units were operating, which shows difficulties in the implementation of the Program.

Specific legislations were introduced aimed at restricting the consumption of alcoholic drinks in the traffic, intensifying the requirement of using helmets and other safety tools by motorcyclists, and the obligation of using child car seats²³23 Malta DC, Silva MMA, Albuquerque GM, et al. A implementação das prioridades da Política Nacional de Promoção da Saúde, um balanço, 2006 a 2014. Ciênc Saúde Colet. 2014 nov; 19(11):4301-4312.. In 2010, the Projeto Vida no Trânsito (PVT) was created to prevent accidents and deaths in the traffic, by defining the local intersectoral plans²³23 Malta DC, Silva MMA, Albuquerque GM, et al. A implementação das prioridades da Política Nacional de Promoção da Saúde, um balanço, 2006 a 2014. Ciênc Saúde Colet. 2014 nov; 19(11):4301-4312.. In 2012, the PVT involved all capitals, the Federal District and the cities with more than one million inhabitants.

Another initiative with an important expansion in this period was the Programa Saúde na Escola (PSE), created in 2007, aiming at articulating the actions among the health and education sectors, so as to contribute to the complete training of the students at public schools, by means of prevention, promotion and health assistance actions²³23 Malta DC, Silva MMA, Albuquerque GM, et al. A implementação das prioridades da Política Nacional de Promoção da Saúde, um balanço, 2006 a 2014. Ciênc Saúde Colet. 2014 nov; 19(11):4301-4312.. The PSE was not predicted in the PNPS; however, since 2008, it has incorporated actions that valued political priority guidelines.

According to Rocha et al.²⁷27 Rocha DG, Alexandre VP, Marcelo VC, et al. Processo de revisão da Política Nacional de Promoção da Saúde: múltiplos movimentos. Ciênc Saúde Colet. 2014; 19(11):4313-4322., since the publication of PNPS in 2006, it has been possible to identify controversies and reorientations, especially regarding the financial resources predicted and effectively allocated for the development of the priority actions.

It is important to highlight the limits of the process agents' evaluation of the priority actions of the PNPS, mostly descriptive and exploratory, with a limited discussion of the determining factors of this process. According to Magalhães²⁸28 Magalhães R. Avaliação da Política Nacional de Promoção da Saúde: perspectivas e desafios. Ciênc Saúde Colet. 2016; 21(6):1767-1776., the evaluation of the implementation of the strategies suggested at PNPS is limited and does not demonstrate relevance to the theory of the programs and to the sociopolitical context of its insertion.

Regarding the state context, the period analyzed was characterized by a government change, in which the Worker's Party (Partido dos Trabalhadores, PT) held the post in two mandates and maintained half of the greatest 10 electoral colleges in the municipalities in the state of Bahia²⁹29 Dantas Neto PF. Mudança política na Bahia: circulação, competição ou pluralismo de elites. Fundação Joaquim Nabuco [internet]. Recife: Fundaj; 2008 [acesso em 2014 out 30]. Disponível em: http://www.fundaj.gov.br/index.php?option=com_content&view=article&id=2160%3Amudanca-politica-na-bahia-circulacao-competicao-ou-pluralismo-de-elites-&catid=58&Itemid=414.
http://www.fundaj.gov.br/index.php?optio... . The PT was also holding the presidency in that period.

The project of government change prioritized the ample participation of society in the definition of the priorities of action. Since 2007, Sesab has developed its own planning, with evidence of a greater participation of the civil society and of the operational technical workforce in surveying and prioritizing the demands that supported the elaboration of the 2008-2011 PES. The appreciation of the social participation by means of strengthening the CES was highlighted according to the process of restructuring the Council in the first management period, a project that is legitimated by the health manager.

The agenda of health promotion of the 2008-2011 PES was neither supported nor opposed by the problems and demands of the civil society. The project was highly regarded in the academia and was accepted by CES, but its implementation depended on the support by the state government regarding the tendency to grow in the various government sectors and the funding of the actions. The diversity of the interests of the political parties in these sectors was a negative aspect that suggested the difficulty in their articulation.

The political flow is like a policy window, that is, an 'opportunity of change' to consider the subject matter as a priority in the decision agenda, as the PNPS was implemented and the state government plan was aimed at searching for a political image of opposition to the previous government in a context of management change, which, according to Kingdon¹⁴14 Kingdon JW. Agendas, Alternatives, and Public Policies. New York: HarperCollins; 2003., is one of the most favorable moments to make new issues emerge.

In the second management period, even facing an unfavorable context in the state, which prioritized the policies of political growth, the agenda of health promotion was maintained. In this case, it was maintained due to a favorable federal context of financial incentive to some specific programs, and was supported by a flow of problems inducted by the active participation of few participants of Sesab. The planning team of the Secretariat induced the consideration of the topic as a priority of discussion in an important forum for debate in the decision agenda for health, in order to obtain social support to include the topic in the decision agenda of the sector in the 2012-1015 PES. Suvisa has tried to favor the discussion on the subject matter with the other managers of Sesab, in the sense of mobilizing new groups to commit themselves to the project. This movement, together with the federal context of financial incentive to some specific programs of health promotion, has represented a policy window to maintain the topic in the decision agenda in the second period of the government.

In summary, the political flow shows the confluence of government change and the valuation of new concepts and planning methods, with apparent mobilization of the participation of the society in the new management, which is coherent with the principles defended by the political party of the current government.s

Mannheimer et al.⁵5 Mannheimer LN, Lehto J, Östlin P. Window of opportunity for intersectoral health policy in Sweden - open, half-open or half-shut? Health Promot Int. 2007 [acesso em 2015 jul 15]; 22(4):307-315. Disponível em: http://heapro.oxfordjournals.org/.
http://heapro.oxfordjournals.org/... , when analyzing the window of opportunities to establish and implement an intersectoral politics of health promotion, recognize that the involvement of the high-ranking members of the government is essential, as well as the mobilization to favor small opportunity windows throughout the process, as it corresponds to a long-term politics. The authors highlight that what is essential is the involvement of the participants from other sectors, and the negotiation of their responsibilities regarding the new political action.

The participants in the process

Among the interviewees, ten were governmental participants and two were non-governmental participants. Ten were favorable to mentioning the topic in the agenda and two remained neutral. Regarding the power resources, the predominance of the technical power was observed, to the detriment of the administrative and political power resources, as shown in chart 3 and discussed in the following.

The most active participants of the process were the governmental participants of Sesab's high-ranking members, with direct participation of the secretary, the head of Asplan and the superintendent of Suvisa, participants with high resources of technical, administrative and political power. Managers from other superintendence did not actively participate in this process.

The magnitude of the power resources of the secretary is related to the recognition of a position of leadership of the manager, which is characterized by several interviewees. Moreover, the profile of the manager in conducting politics was evidenced as flexible and, except for the management collegiate, the access to him and his advisors was identified as 'horizontal' and 'direct'.

Several interviewees considered Suvisa's superintendent, who took office in the 2007-2010 period, as one of the main people responsible for the mobilization of the theme. It is worth mentioning the participation of managers and technicians of this Superintendence in national forums about the theme, which may have influenced the position of this group in order to set it as a priority.

Most of the governmental participants (6) had high or very high technical power (chart 3). Supposedly, this aspect justifies the capacity of persuasion of this group over the technical team of SES and over social groups that were mobilized around the sector, considering the technical support associated with the ample academic background. However, few participants had expertise in health promotion.

Regarding the third ranking of SES (directors), the participation of the managers of DAB, DGC and DGETS is evidenced only in the propositions of alternatives. The direct participation of the directors of Suvisa in the process of establishing the agenda was not identified. Only the advisor team participated in this superintendence.

Regarding the non-governmental participants, the CES followed the elaboration of the 2008-2011 PES by means of the performance of the Committee for Planning, Budget and Finances, which gathered representatives of all those involved at CES (users, workers and management staff). Despite that, the neutral position of CES in the establishment of the health promotion agenda is recognized.

Another non-governmental participant, but with a favorable participation in the process of setting an agenda was the Collective Health Institute of UFBA. One of the institution's professor was a consultant in the elaboration process of the 2008-2011 PES; and, in the end of 2010, the Collective Health Institute supported the conduction of a workshop to define the priorities in the formulation of a state policy to promote health.

Most of the participants showed a significant management power, although eight interviewees were classified as having low or medium power (chart 3), mostly due to lack of previous experience in management positions.

Most of the participants did not show expressive political power, and only four interviewees did not show expressive political power and were classified as having high or extremely high power (chart 3). Less than half of the interviewees (five) had links with a political party, but only one had a prominent position in the party's hierarchy.

The analysis of the relationship network of the interviewees showed that half (6) of them had a satisfactory internal relationship within SES, that is, they participated in the management collegiate of the institution or had a direct dialog with the secretary of health and the superintendents. The dialog with the high-ranking managers of other sectors was limited, and occurred more regularly only through the secretary of health.

It was made clear that the accumulation of technical power resources by the interviewees, considering the expertise in the area of collective health and the articulation with the academia favored, in theory, a greater acceptance of the propositions of health promotion by the participants responsible for establishing Sesab's agenda. However, the limited expertise in health promotion may have influenced the fact that the proposals offered are not much objective and that there is limited coherence between them and the goals adopted. Furthermore, the lack of objectivity of the proposals may have also hindered the advocacy of the project facing the potential partners for its implementation.

The limitation in the representation of the forces with the greatest management power of the several superintendence of SES shows low capacity for mobilizing resources, especially the financial ones, to conceive a project. The low accumulation of political power resources was associated with this, especially regarding the strength of the external articulation to the sector.

It can be concluded that there were few active participants in this process. Although they have an important technical capacity and internal political strength within the sector, they showed limitations on mobilization in the external context, which means that they were able to express their commitment, but did not gain political and administrative support to integrate it into the external agenda, as demanded by the theme. These participants, as evidenced by Kingdon¹⁴14 Kingdon JW. Agendas, Alternatives, and Public Policies. New York: HarperCollins; 2003., can be characterized as policy entrepreneurs, who act to interfere in the flows. They are clever negotiators, and persistent in defending their ideas and taking their conceptions of problems and alternatives to different forums.

Final remarks

The results of this study show that the establishment of the health promotion agenda in the state of Bahia was based on a symbolic representation, instead of being a policy to be pursued. The paths that led to the political choices of the alternatives were essentially based on the political flow and the role of policy entrepreneurs.

The symbolic subject matter in the first period of the government, associated with the political context of the management change in the state and with the publication of the PNPS, together with the power of persuasion of the high-ranking members of SES, have characterized a 'window of opportunities' and explain the inclusion of them in the agenda. The defense of the theme by these participants, who took the role of entrepreneurs of the process, was essential to guide the government's decision. However, such entrepreneurs did not have enough management and political power and did not mobilize effectively to advance the agenda elaborated in the first period of the government.

Despite the changes in the purpose of the government, health promotion has remained in the agenda in the second period, which is translated in organizational strategies, limited to the action of few participants and centered in the SES.

This research corroborates the model of multiple flows proposed by Kindon¹⁴14 Kingdon JW. Agendas, Alternatives, and Public Policies. New York: HarperCollins; 2003.. The opening of the windows of opportunity is transient, that is, the opportunity of change stops when one of the flows is separated from the others¹⁴14 Kingdon JW. Agendas, Alternatives, and Public Policies. New York: HarperCollins; 2003..

In addition to establishing an agenda, the goal of health promotion is complex and fluid, facing the diversity of relevant strategies, involved by different perceptions. Thus, it is fundamental to have a foundation for the agenda, based on an ample and intersectoral problematizing involving the greatest number of governmental and non-governmental participants with a coordination of political and administrative consistency, so as to find a better condition for its implementation.

Finally, we consider that the conclusions of this study contribute to the analysis of health promotion politics, as it focuses on a topic that has not been fully explored - the agenda - in which social and political interests - the bases for the governmental projects - are shown. Thus, other foundations that can be considered in other studies about the formulation of health promotion policies are included and support the identification of difficulties that need to be surpassed by the participants interested in projects of this nature.

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