ABTRACT

This study aims to evaluate the effectiveness of social participation in a municipal health council, with the purpose of producing informations that contribute to the improvement of deliberative democracy. This is a case study, with a qualitative approach, on the Municipal Health Council of Criciúma (SC), using semi-structured interviews and documentary analysis. The data organized and systematized resulted in two thematic categories, namely: empowerment and decision. Usually, the members who are in the first management and, therefore, have not yet been trained, have less knowledge about their role as counselors, when compared with the older counselors in the institution, noting that, when educational practices are employed appropriately, can minimize the asymmetries that permeate the performance of health counselors and achieve desirable levels of influence of these actors in public control. In addition, the members presented a positive performance, encouraging community participation and impact on access and quality of health services, leveraging practical results and progress according to the local needs highlighted by the population. In this scenario, it is evident the importance of informing and raising the awareness of the counselors, in order to broaden their political, ethical and theoretical knowledge.

KEYWORDS
Health councils; Social control, formal; Community participation; Effectiveness; Health systems

Introduction

The process of expanding democracy, strongly driven by social movements that fought for new rights and the democratization of relations between the State and society, occurred during the period of Brazilian political distension, post-military dictatorship, and is manifested in the creation of public spaces and the growing participation of civil society in the discussion and decision-making processes related to public policy issues¹1 Teixeira AC, Dagnino E, Silva CCA. La constitución de la sociedad civil en Brasil. In: Dagnino E, organizador. Sociedad civil, esfera pública y democratización em América Latina: Brasil. México: Fondo de Cultura Económica; 2002. p. 21-76..

Popular participation represents

Through deliberative practices, participation took different forms in the various spheres of social life, shaped by two strands of democratic theory: ‘deliberative democracy’ and ‘participatory democracy’³3 Serapioni M, Matos AR. Citizen participation and discontent in three Southern European health systems. Soc. Sci. Med. 2014; 123:226-233.. Both approaches emerged to defend the argument that new practices that involve citizen engagement should complement representative democracy⁴4 Carpini MXD, Cook FL, Jacobs LR. Public deliberation, discursive participation, and citizen engagement: A review of the empirical literature. Annu. Rev. Polit. Sci. 2004; 7:315-344..

Participatory democracy advocates the adoption of procedures and the construction of a political culture that allows the manifestation of popular sovereignty with greater intensity⁵5 Gaspardo M, Ferreira M. Inovação institucional e democracia participativa: mapeamento legislativo da Emenda do Programa de Metas. Rev. Adm. Pública. 2017; 51(1):129-146.. Participatory management is anchored in participatory democracy, and spaces for dialogue and joint construction presuppose the adoption of practices and mechanisms that effect social participation, users, workers and managers of the Unified Health System (SUS). In this context, the committees for the promotion of equity policies, working groups and management councils are created, and the role of the SUS ombudsman in the three spheres of government is also expanded⁶6 Souto KMB, Sena AGN, Pereira VOM, et al. Estado e políticas de equidade em saúde: democracia participativa? Saúde debate. 2016; 40(esp):49-62..

In turn, in deliberative democracy, democratic legitimacy comes from public debate and, therefore, legitimate decisions are those arising from the participation of subjects affected by their production, so that those affected by policies can point out problems and participate in the process of building solutions for those⁷7 Lopes BJ, Silva EA, Martins S. Conselho Municipal de Saúde sob a ótica de seus conselheiros: estudo realizado em uma capital brasileira. Interações (Campo Grande). 2016; 17(2):163-172.. For Monteiro and Fleury⁸8 Monteiro MG, Fleury S. Democracia deliberativa nas gestões municipais de saúde: um olhar sobre a importância dos conselhos municipais de saúde nas gestões. Saúde debate. 2006; 30(73-74):219-233., the greatest expression of deliberative democracy in Brazil has been the management councils at the local level. In health, councils stand out, representing the broadest political-administrative decentralization initiative implemented in the Country⁹9 Moreira MR, Escorel S. Conselhos Municipais de Saúde do Brasil: um debate sobre a democratização da política de saúde nos vinte anos do SUS. Ciênc. Saúde Colet. 2009; 14(3):795-806..

Health councils are important for society’s participation in decision-making, a strategic mechanism for ensuring the democratization of decision-making power, alongside universality and equity in SUS¹⁰10 Cotta RMM, Martins PC, Batista RS, et al. O controle social em cena: refletindo sobre a participação popular no contexto dos Conselhos de Saúde. Physis. 2011; 21(3):1121-1138..

According to Law nº 8.142/90, the health council is a permanent, deliberative collegiate body present in the three spheres of power. As a democratic system, this space must ensure the right of participation of the segments involved: institutional leaders, service providers, health workers and users of health services. This composition is equal: 50% are user representatives and the remaining 50% are divided among other segments¹¹11 Brasil. 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. 1990 Dez 28. [acesso em 2019 dez 20]. Disponível em: http://www.planalto.gov.br/ccivil_03/leis/L8142.htm.
http://www.planalto.gov.br/ccivil_03/lei... .

However, despite the legal apparatus, the difficulty in consolidating the effective ability to influence and control social decision-making and intervention in health policies is recurrent in the literature²2 Cruz PJSC, Vieira SCR, Massa NM, et al. Desafios para a participação popular em saúde: reflexões a partir da educação popular na construção de conselho local de saúde em comunidades de João Pessoa, PB. Saúde Soc. 2012; 21(4):1087-1100.^,88 Monteiro MG, Fleury S. Democracia deliberativa nas gestões municipais de saúde: um olhar sobre a importância dos conselhos municipais de saúde nas gestões. Saúde debate. 2006; 30(73-74):219-233.^,1212 Miwa MJ, Serapioni M, Ventura CAA. A presença invisível dos conselhos locais de saúde. Saúde Soc. 2017; 26(2):411-423.. The literature on participatory effectiveness regarding deliberative democracy has an American origin¹³13 Cohen J. Procedure and substance in deliberative democracy. In: Dans MJB, Rehg W (Dir. publ.). Deliberative democracy. Cambridge: MIT Press; 1997. p. 407.. The effectiveness of participation covers both the deliberative dimension and the implementation and results of public policies. In view of the two dimensions together – that is, on the one hand, the debate on the deliberative effectiveness and, on the other hand, the debate on the effectiveness of the institutions –, one can envision a significant theoretical-analytical framework for understanding both the functioning and the actual results presented by the participatory institutions¹⁴14 Avritzer L. A qualidade da democracia e a questão da efetividade da participação: mapeando o debate. In: Pires RRC, organizador. Efetividade das instituições participativas no Brasil: estratégias de avaliação. Brasília, DF: IPEA; 2011. p. 13-24..

Since it deals with central elements for the analysis of the quality of the political participation process in councils, the theme of effectiveness has stood out, in recent years, as the main element of discussion among researchers in the area. The ‘deepening’ of democracy is linked not only to the possibility of expanding participation spaces, but also to specific problems and challenges concerning its own implementation and consolidation as a space for dialogue between the State and civil society in the field of public policies¹⁵15 Avritzer L. Democracy and the public space in Latin America. Princeton: Princeton University Press; 2002..

In short, there is currently “a strong mismatch between the richness of participatory experiences in the Country and the precariousness of our knowledge of their effects”¹⁶16 Lavalle AG. Participação: valor, utilidade, efeitos e causa. In: Pires RRC, organizador. Efetividade das instituições participativas no Brasil: estratégias de avaliação. Brasília, DF: IPEA; 2011. p. 33-42.⁽³⁶⁾. What then arises is the crucial and indispensable need to assess the quality and participatory effectiveness of citizens¹⁷17 Serapioni M. Os desafios da participação e da cidadania nos sistemas de saúde. Ciênc. Saúde Colet. 2014; 19(12):4829-4839..

It is believed that the expansion and qualification of the effectiveness evaluations of participatory institutions have the potential to promote, more quickly, their own improvement, thus contributing to the strengthening of democracy and the improvement of public policies¹⁸18 Pires RRC, Vaz ACN, Almeida A, et al. Em busca de uma síntese: ambições comuns e abordagens diversificadas na avaliação da efetividade das instituições participativas. In: Pires RRC, organizador. Efetividade das instituições participativas no Brasil: estratégias de avaliação. Brasília, DF: IPEA; 2011. p. 347-364.. In this perspective, the present study sought to evaluate the effectiveness of social participation based on the results identified and the ability of members to act and influence, directly or indirectly, with the decision-making process of the Municipal Health Council of Criciúma (SC), with the aim of producing information that contributes to the improvement of the work developed through popular participation.

Methods

This is a case study on the Municipal Health Council (CMS) of the municipality of Criciúma, in the southern state of Santa Catarina. For Yin¹⁹19 Yin RK. Estudo de Caso: Planejamento e Métodos. Porto Alegre: Bookman; 2015., the case study is adequate when it is intended to investigate the ‘how’ and the ‘why’ of a set of contemporary events, and constitutes a research strategy that requires multiple methods and sources to explore, describe and explain a phenomenon in its context. The choice for this municipality followed the criterion of opportunity and it was also because the municipality of Criciúma is nationally recognized as one of the main centers of worker and union mobilization in Santa Catarina²⁰20 Teixeira JP. Os donos da cidade. Florianópolis: Insular; 1996. (Coleção Teses, v. 3)..

The study used a qualitative methodological approach, which seeks to apprehend the meanings attributed by the subjects to their practices and analyze them in the light of the theoretical references of the study. The qualitative approach works with the universe of meanings, beliefs and representations in a deeper space of relationships, processes and phenomena, which cannot be reduced to the operationalization of variables, nor to generalization, but must privilege the deepening of the analysis²¹21 Minayo MCS, organizadora. Pesquisa social: teoria método e criatividade. 17. ed. Petrópolis, RJ: Vozes; 1994..

Data collection was carried out through semi-structured interviews, with councilors and members of the executive secretary of the council; and documentary analysis of minutes, meeting reports and CMS resolutions.

The interviews were conducted with 12 members of the CMS, and the narratives were recorded in digital audio apparatus and subsequently transcribed; they had an average duration of 30-60 minutes, and were held in a reserved place, in order to guarantee the privacy of the participants. The anonymity of the individuals’ information and testimonies was preserved, and the interviewees were identified as follows: E01 to E12.

For the proposed document analysis, the frequency record and the categorization by subject of the actions and activities were used, as well as the types of demands discussed in the meeting, using the corresponding minutes and resolutions for the 2015-2017 biennium and the following biennium, until February 2018.

The collected data were analyzed using thematic categories divided into themes and subthemes, referring to the content analysis²²22 Bardin L. Análise de conteúdo. Lisboa: Edições 70; 1977.. The themes were empowerment and decision. The sub-themes of empowerment were: the ability of counselors to debate and influence deliberations, knowledge to understand certain debates and knowledge of the duties of the counselor, and the training activities sub-theme. The sub-themes related to the decision were: the content of the CMS resolutions and the interviewees’ perception of the council’s debates and decisions.

The research was approved by the Research Ethics Committee of the Federal University of Santa Catarina, under opinion nº 2.471.789, of January 22, 2018.

Results and discussion

Deliberative processes are a fundamental dimension to assess the quality of participation. Deliberation is an important component of participatory processes because it encompasses, among other things, a set of possibilities related to the degree of involvement of the actors in the process and, mainly, to the degree of commitment of these agents to the topics under discussion and with the effective possibility of implementation, follow-up and monitoring of these actions. Knowing not only who deliberates, but, mainly, how they deliberate can be fundamental to ensure greater quality in the participatory process¹⁸18 Pires RRC, Vaz ACN, Almeida A, et al. Em busca de uma síntese: ambições comuns e abordagens diversificadas na avaliação da efetividade das instituições participativas. In: Pires RRC, organizador. Efetividade das instituições participativas no Brasil: estratégias de avaliação. Brasília, DF: IPEA; 2011. p. 347-364..

To analyze the participatory effectiveness of the council, in order to identify the impacts of its intervention on the definition and execution of the municipality’s health policy, two categories were created, namely: empowerment and decision. This study is part of a dissertation that also investigated power relations in the council, which will not be addressed in this article due to its extension, but which, however, do not prejudice the analysis of participatory effectiveness in the proposed terms.

Empowerment

The term ‘empowerment’ has been used in the area of participatory public management to promote citizenship and consolidate democratic processes between the State and society.

Considering the diverse origins of the notion of ‘empowerment’, the translation of the term from the English language, from which it derives, has resulted in different meanings and definitions regarding the terminology. Due to this vast conceptual polysemy, it was decided to use the term in the source language to maintain the reliability of the translation and its essence, which refers to democracy, strengthening, autonomy and its relationships within society and socio-political institutions²³23 Almeida AC. O empoderamento de lideranças indígenas Kaingang no sul do Brasil. Interações (Campo Grande). 2015; 16(2):407-419..

In this sense, Carvalho²⁴24 Carvalho SR. Os múltiplos sentidos da categoria "empowerment" no projeto de Promoção à Saúde. Cad. Saúde Pública. 2004, 20 (4):1088-1095. proposes the alternative notion of ‘community empowerment’, taking as a reference the production of authors such as Julian Rappaport, Paulo Freire and Saul Alinsky. The author considers that the central aspect of ‘community empowerment’ is

Based on empirical research, it was possible to ascertain the following elements related to empowerment: the ability of counselors to debate and influence deliberations; knowledge for understanding certain objects of debate and knowledge of the duties as advisers; and training activities.

Therefore, it was observed that the absence or fragility in relation to the counselors’ argumentative capacity, the lack of specialized knowledge of the subjects covered, as well as the inability to produce debates and decisions can negatively impact activities and deliberations:

This way, the experiences in the area of social participation can be considered favorable for the optimization of the activities of the board, because over time the board members accumulate knowledge and experience. Technical and organizational learning, derived from previous experiences, would increase the capacity of councils to respond to the technical-bureaucratic demands of public policy management and their ability to intervene in policies formulated according to this logic²⁵25 Lima PPF, Alencar JLO, Ribeiro UC, et al. Conselhos Nacionais: elementos constitutivos para sua institucionalização. Brasília, DF: Ipea; 2014. (Texto para Discussão, nº 1951)..

It was found that the councilors, especially those who have been participating for a longer time, have knowledge about the legislation of the councils, the VIII National Health Conference and the role of the council in relation to the finances of the municipality, for example.

The experience acquired in these spaces of participation helps the board members to influence the decision-making process and allows its spread to members of the entities of which they are part:

However, older advisers in the institution do not always have more knowledge about their role:

In view of this, several studies address the unpreparedness and lack of knowledge of counselors about their role²⁶26 Correia MVC. Desafios para o controle social: subsídios para capacitação de conselheiros de saúde. Rio de Janeiro: Fiocruz; 2005.^,2727 Franchi EPLP, Galvani MS, Pereira RCR, et al. Participação social nos Conselhos de Unidades de Saúde. Cogitare Enfermagem. 2012; 17(4):690-696., highlighting the need to invest in guiding, raising awareness and preparing citizens with critical capacity to influence, claim and question the actions of health services²⁷27 Franchi EPLP, Galvani MS, Pereira RCR, et al. Participação social nos Conselhos de Unidades de Saúde. Cogitare Enfermagem. 2012; 17(4):690-696..

Correia²⁶26 Correia MVC. Desafios para o controle social: subsídios para capacitação de conselheiros de saúde. Rio de Janeiro: Fiocruz; 2005. states that training is not enough to overcome alienation, disengagement and manipulation, since other major determinants intervene in this reality. For the author²⁶26 Correia MVC. Desafios para o controle social: subsídios para capacitação de conselheiros de saúde. Rio de Janeiro: Fiocruz; 2005.⁽¹⁶⁾, training

Another weakness is the lack of technical-scientific knowledge of the advisers. Authors observe the shift in the centrality of the legitimate power of the workers’ representative, who are inserted in the process of local public policies and know the needs of that population, as they are closer to the territory, which could grant power of transformation to the councilors who hold more technical-scientific knowledge²⁸28 Kezh NHP, Bógus CM, Martins CL. Entraves à participação social dos representantes dos trabalhadores no conselho municipal de saúde. Saúde Soc. 2016; 25(4):950-963..

Another aspect is brought up by a counselor:

With regard to conducting training sessions, even after 30 years since the creation of SUS, these persist as some of the obstacles to participatory effectiveness.

In the municipality of Criciúma (SC), Ordinary Law nº 6.541/2014, in its art. 26, defines that the board of directors of the council, with the support of the Municipal Health Secretariat (SMS), should promote a training course for counselors, members and substitutes, with a workload of, at least, 20 hours, in which teaching material and certificate must be provided. The execution of the training usually takes place with speakers linked to the University of the Extreme South of Santa Catarina (Unesc), located in the municipality in question²⁹29 Criciúma. Lei nº 6.541, de 16 de dezembro de 2014. Disciplina as atribuições do conselho municipal de saúde do município de Criciúma, e dá outras providências. Criciúma (SC), 2014 dez 16. [acesso em 2019 dez 20]. Disponível em: https://leismunicipais.com.br/a/sc/c/criciuma/lei-ordinaria/2014/654/6541/lei-ordinaria-n-6541-2014-disciplina-as-atribuicoes-do-conselho-municipal-de-saude-do-municipio-de-criciuma-e-da-outras-providencias.
https://leismunicipais.com.br/a/sc/c/cri... .

The Internal Regulations of the CMS says that, from the moment that a third of the total members do not have the training course, a new course should be promoted.

This study identified, based on the interviews, that, with the exception of the counselors who are in the first term in the said CMS, the other members participated in training in other terms. In general, it was observed, according to Zambon and Ogata³⁰30 Zambon VD, Ogata MN. Controle social do Sistema Único de Saúde: o que pensam os conselheiros municipais de saúde. Rev. Bras. Enferm. 2013; 66(6):921-927., little training promoted among councilors in Brazil, which hinders and disqualifies performance.

In addition to training, the effective performance of the council requires financial resources, after all, however trained and engaged the directors may be, the lack of funds and difficulties with infrastructure, office and communication material, or the employee responsible for executing the secretariat may make the activities of the councilors unfeasible³¹31 Gaedtke KM, Grisotti M. Os Conselhos Municipais de Saúde: uma revisão da literatura sobre seus limites e potencialidades. Política&Sociedade. 2011; 10(19):115-137..

It was sought to highlight some aspects that enable and promote empowerment, although they do not guarantee it. In addition to resources and training, empowerment is also conditioned by the sociability standard of the community, which may be more individual or collective, the social values in question and the relationship that the community establishes with the public health service. In other words, empowerment as one of the fundamental conditions for the effectiveness of participation is highly complex, which makes it difficult to understand, even if partially.

Decision

The deliberative nature of the health council is a specific characteristic that distinguishes the Brazilian participation system from most international experiences³²32 Serapioni M, Romaní O. Potencialidades e desafios da participação em instâncias colegiadas dos sistemas de saúde: os casos de Itália, Inglaterra e Brasil. Cad. Saúde Pública. 2006; 22(11):2411-2421.. Councils ensure their members direct participation in the decision-making process, with the capacity to produce decisions related to public policies and programs, while advisory councils are characterized only as spaces for discussion, without the power to constitute final decisions on themes in the health field.

With the research, it was possible to verify the content of the CMS resolutions and the perception of the interviewees regarding the council’s debates and decisions, which, according to them, were able to effectively influence the production of public policies.

Initially, some counselors mentioned as a CMS achievement the approval of 12 new beds in the Intensive Care Unit (ICU) of the SUS in the São José de Criciúma Hospital (Minute 481/2017). The hospital had 18 beds available through SUS and, with the other 12, there will be an increase of approximately 65% in availability at the institution:

However, what some consider to be a victory from the council was just the approval of the demand that came from the management, and other members acknowledge: “[...] I think the coolest one that we approved, but that was no struggle, or anything, was to approve the ICU beds...” (E05).

These results, although they represent the conception of a minority among the members of the Municipal Council of Criciúma (CMC), are in line with other national studies carried out with councilors, who pointed out the predominance of only consultative character of these instances, to the detriment of their role decision-making, emphasizing that, in some situations, participation channels operate only in legitimizing decisions previously defined by the Executive⁸8 Monteiro MG, Fleury S. Democracia deliberativa nas gestões municipais de saúde: um olhar sobre a importância dos conselhos municipais de saúde nas gestões. Saúde debate. 2006; 30(73-74):219-233..

The major factor limiting the advance of deliberative democracy is the asymmetry of power between the State and society. This prevents the councils from being, in fact, co-managers of public policies, participating not only in a consultative way and in social control. Perhaps the health manager does not understand or truly recognize that the role of the board goes beyond social controll⁸8 Monteiro MG, Fleury S. Democracia deliberativa nas gestões municipais de saúde: um olhar sobre a importância dos conselhos municipais de saúde nas gestões. Saúde debate. 2006; 30(73-74):219-233..

Lyra³³33 Lyra RP. Democracia representativa x democracia participativa: a representação do estado e da sociedade civil nos conselhos de políticas públicas. Anais do Seminário nacional sobre movimentos sociais, participação e democracia, 2; 2007 abril 25-27; Florianópolis: Universidade Federal de Santa Catarina; 2007. [acesso em 2020 jan 12]. Disponível em: http://www.dhnet.org.br/direitos/militantes/rubenspinto/rubens_democracia_representativa_participativa.pdf.
http://www.dhnet.org.br/direitos/militan... indicated that the city councils, in addition to not effectively influencing the development of social policies, were co-opted by management, what the author calls ‘municipalization’. It is a control that legitimizes questionable actions and measures from the technical, administrative and ethical and political points of view, as it transforms allegedly democratic spaces into instruments for legitimizing the ruling classes³³33 Lyra RP. Democracia representativa x democracia participativa: a representação do estado e da sociedade civil nos conselhos de políticas públicas. Anais do Seminário nacional sobre movimentos sociais, participação e democracia, 2; 2007 abril 25-27; Florianópolis: Universidade Federal de Santa Catarina; 2007. [acesso em 2020 jan 12]. Disponível em: http://www.dhnet.org.br/direitos/militantes/rubenspinto/rubens_democracia_representativa_participativa.pdf.
http://www.dhnet.org.br/direitos/militan... .

In the resistance of civil society, several councilors recalled struggles and achievements achieved thanks to the CMS, among them: the case of the Instituto de Saúde e Educação Vida (Isev), insulin therapy, the agreement provided for in Law nº 6.541/2014 and others that will be discussed below.

In the case of Isev, responsible for administering the Santa Catarina Maternal and Child Hospital (HMISC), the CMS found irregularities and non-compliance with the contract, causing the city to terminate the contract with the Institute:

Thus, it is necessary that the counselors are convinced of their citizenship responsibilities and prepared to face the challenges, as well as carry out control and inspection, in order to strengthen the SUS.

Regarding insulin therapy, the active participation of the CMS was found, including a walk in protest against the government’s neglect, reflecting on the regularization of the supply of medicines and glycemic control tapes.

According to one of the advisers:

Another important issue was infant mortality, in which the CMS was active, seeking support from the State Public Ministry to help with its control (Minutes 437,445):

Furthermore, research participants listed other points, no less important, addressed in the institution:

In this way, it is possible to observe the effort of the council, even if supported by the State Public Ministry, to improve access and the quality of the assistance provided, resulting in improvements in health indicators in the municipality. Resolution nº 333 presents mechanisms for the council to place itself as a deliberative instance in the relationship with the Executive, even suggesting actions before the State Public Ministry when mayors do not approve the resolutions³⁴34 Brasil. Resolução nº 333, de 4 de novembro de 2003. Aprova as diretrizes para criação, reformulação, estruturação e funcionamento dos Conselhos de Saúde. Brasília, DF: Diário Oficial [da] República Federativa do Brasil. 4 Nov 2003 [acesso em 2019 dez 20]. Disponível em: https://conselho.saude.gov.br/biblioteca/livros/resolucao_333.pdf.
https://conselho.saude.gov.br/biblioteca... .

In addition, the CMS of Criciúma (SC) acted vigorously in the elaboration and maintenance of the agreement that regulates the relationship between CMS and the municipal government, establishing rules for participation in local councils and implementing the CMS ombudsman.

According to the reports of the counselors, in the previous management (2015-2017), a physical structure for the functioning of the council was also achieved, through the agreement with the city hall provided for in Law nº 6.541/2014: “The council won a space where it achieved great visibility, and materials to do its work...” (E01).

The administrative support and physical infrastructure of the councils is not just about operating conditions, but indicates the political support of managers. The lack of budgetary allocation restricts the autonomy of the council, mainly in the participation in regional, state and national events³⁵35 Van Stralen CJ, Lima AMD, Fonseca SD, et al. Conselhos de Saúde: efetividade do controle social em municípios de Goiás e Mato Grosso do Sul. Ciên. Saúde Colet. 2006; 11(3):621-632.. In addition, it was evident that the lack of own resources of the council compromises decisions, since, instead of advisors allying themselves with the government in the search for improvements, they feel subordinate and intimidated by the city, recalling practices used during the authoritarian period.

Nevertheless, this reality, which favored the full functioning of the council and the operationalization of the work of the member committees, was compromised, because the financial transfers did not occur as provided by law. Even in the face of this situation of difficulties, the councilors did not allow themselves to falter and continued with the spirit of struggle:

Subsequently, the Internal Regulation was approved, which guides the creation, deployment and functioning of the Local Health Councils (CLS) (Resolution nº 010/2016).

The operation and development of the CLS are directly associated with the establishment of links between the municipal and local levels. In the absence of these connections, the CLS become limited when they exercise their role of mediators between community and municipal management³⁶36 Lisboa EA, Sodré F, Araújo MD, et al. Conselhos locais de saúde: caminhos e (des)caminhos da participação social. Trabalho, Educação e Saúde. 2016; 14(3):679-698., an aspect that is supported by most councilors: “[...] working with local councils is a concrete way and I think that would give a good effectiveness to the council...” (E02).

This support from the CMS is a positive point of the collegiate, but it is not the reality of other municipalities. In the study by Lisboa et al.³⁶36 Lisboa EA, Sodré F, Araújo MD, et al. Conselhos locais de saúde: caminhos e (des)caminhos da participação social. Trabalho, Educação e Saúde. 2016; 14(3):679-698., CLS members in the state of Espírito Santo expressed expectations about the assistance of the municipal council in relation to the construction of internal regulations, clarification of doubts and discussion of their demands at CMS meetings. Failure to meet their desires triggered a feeling of frustration, impairing the functioning of the CLS.

Another recent study carried out with the CLS of Ribeirão Preto (SP) reports that the behavior of the counselors indicates a weak relationship between the CLS and the CMS. For example, one of the CLS studied does not even have a representative at the CMS, which demonstrates a low use of spaces for social participation and the maintenance of its invisibility in larger areas of activity¹²12 Miwa MJ, Serapioni M, Ventura CAA. A presença invisível dos conselhos locais de saúde. Saúde Soc. 2017; 26(2):411-423..

In order to strengthen ties between CMS and CLS and listen to the concerns of the population on a larger scale, the CMC started holding its meetings at the headquarters of the local councils. What was observed during the monitoring of a CMS meeting that took place in the São Sebastião neighborhood, was the massive participation of the community, exposing the problems faced and suggestions for improvements.

Another possibility that emerged in the research was to strengthen ties between the university and civil society, through advisory services, consultancies or training capable of contributing to the discussions about the democratic process and the responsibility of the various civil society actors.

Despite the municipal government’s attempt to hinder the full performance of the council, most councilors recognize the importance of their exercise of citizenship. The resistance of the council members resulted in achievements for health services, achievements that should serve as an incentive for councilors to continue to act for citizen emancipation and for improvements in public policies.

These findings confirm the results of another study carried out at the Municipal Health Council of Canindé (CE), which considered positive the assessment, by the councilors, of the impact of the performance of the collegiate towards the represented community. Among the interviewees, 76% understood that there were practical results from the council’s deliberations, even with low user participation. In this study, user participation was not decisive for the effectiveness of the municipal council³⁷37 Duarte EB, Machado MFAS. O exercício do controle social no âmbito do Conselho Municipal de Saúde de Canindé, CE. Saúde Soc. 2012; 21(supl1):126-137..

This result, however, is contrary to those obtained in other studies, such as the one carried out in Goiás and Mato Grosso do Sul, which suggests that municipal councils have little impact on the restructuring of health services³⁵35 Van Stralen CJ, Lima AMD, Fonseca SD, et al. Conselhos de Saúde: efetividade do controle social em municípios de Goiás e Mato Grosso do Sul. Ciên. Saúde Colet. 2006; 11(3):621-632.. According to Bispo Júnior and Sampaio³⁸38 Bispo Júnior JP, Sampaio JJC. Participação social em saúde em áreas rurais do Nordeste do Brasil. Rev. Panam. Salud Publica. 2008; 23(6):403-409., the municipal health councils of Lafayete Coutinho (BA) and Groaíras (CE) did little to improve the assistance provided to the population, although the CMS constantly deliberated and charged the SMS³⁸38 Bispo Júnior JP, Sampaio JJC. Participação social em saúde em áreas rurais do Nordeste do Brasil. Rev. Panam. Salud Publica. 2008; 23(6):403-409..

This little influence on decisions, according to Serapioni and Romaní³²32 Serapioni M, Romaní O. Potencialidades e desafios da participação em instâncias colegiadas dos sistemas de saúde: os casos de Itália, Inglaterra e Brasil. Cad. Saúde Pública. 2006; 22(11):2411-2421., is possibly due to the problem of the representativeness of collegiate bodies and the difficulty of the spokesmen of the citizens to exercise their influence on the decision-making processes of managers. Other factors also influence this process, such as the availability of resources for the operation of the councils, the political culture of each municipality, the level of education of the population, the relations of the Executive with the Legislative, the leadership action, the social origin of the members of the councils themselves, among others³⁹39 Fleury S, Ouverney ASM, Kronemberger TS, et al. Governança local no sistema descentralizado de saúde no Brasil. Rev. Panam. Salud Publica 2010; 28(6):446-455..

Therefore, the performance of social participation in the health policy formulation and management process has been affected due to the fact that social participation – which was expected as an almost natural result of the process of political decentralization and redemocratization – started to have its performance associated with sociocultural factors, which are strongly rooted in our history⁴⁰40 Coelho VSP. A democratização dos Conselhos de Saúde: o paradoxo de atrair não aliados. Estud. CEBRAP. 2007; (78):77-92..

In this perspective, it is necessary to expand the integration and participation of civil society in processes of elaboration, evaluation and management of public policies, as a strategy of strengthening them, and of their conception from the perspective of the right of citizenship.

Within the scope of health systems, it is also necessary to develop a series of reforms to give new impetus and vigor to the citizenship project, understood as an active participation in the decision-making process and in the definition of collective objectives¹⁷17 Serapioni M. Os desafios da participação e da cidadania nos sistemas de saúde. Ciênc. Saúde Colet. 2014; 19(12):4829-4839..

Thus, it is in this scenario that the fundamental role of education emerges in the training of citizens, as well as practices that value empowerment, through information and awareness of the community, regarding their participation in community, political and health management matters, which can contribute to the creation of citizens capable of experiencing democracy to its fullest, thus achieving improvements for the collective. It is worth considering, as well, the importance of promoting the improvement of the living conditions of social groups in situations of social exclusion, in addition to the inclusion of an educational function, primarily in political, ethical and theoretical education, in order to qualify decision-making through an inclusive and conscious public dialogue.

Final considerations

The analysis on the CMS of Criciúma (SC) shows that it has continuously organized several strategies, aiming to improve the empowerment of the counselors, such as training courses for counselors and participation in conferences, in addition to the establishment of the ombudsman and thematic commissions to deepen the debates. Even so, informational and cognitive asymmetries were detected between the actors, which interfere in the deliberative quality and allow unequal conditions of argument among the counselors.

In addition, counselors, in their first management (untrained), have less knowledge about their role when compared to experienced counselors. Although the educational practices employed in the council do not resolve such non-conformities in their completeness, as they depend on managers and suffer the unequal reality of Brazil, they can minimize the asymmetries that permeate the performance of health counselors and achieve desirable levels of influence of these actors in the public control.

In this council, a real tug of war is perceived, with civil society on one side and the government on the other, going against the democratic proposal that guides SUS. Furthermore, the municipal government and civil society should not go in the opposite direction, but act together to solve the municipality’s health problems, making the use of resources more effective, according to the needs of the population.

It can be concluded that, despite the difficult reality of the studied council, its performance was positive, strengthening the bond with the community, encouraging participation and impacting the access and quality of health services, with effective results, according to the local needs of the population.

References

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