ABSTRACT

The study aims to compare the main guidelines of the National Health Plans of Brazil and Canada in the light of Mario Testa. The normative moment of both documents were compared, considering the guidelines of the mentioned plans, analyzed according to the strategies of strategic thinking addressed by Mario Testa. The Atlas.ti program was used, exploring as analysis categories the keywords that identify each of the guidelines, as well as the three strategies: institutional, programmatic, and social. As main results, we find that the national health plans of Brazil and Canada converge on the keywords related to care actions directly, although the North American country plans a greater number of health surveillance activities compared to Brazil. Both countries guide the normative moment of planning through programmatic strategies, which are intersectoral in the Brazilian scenario. Differences point to intersectoral action in Brazil and the organization of care with well-defined hierarchical levels of health care. However, the predominance of programmatic strategies in Canada allows us to infer that this scenario enjoys the consolidation of decision-making processes, as well as ensuring the social rights of the population, resulting in specific institutional and social strategies.

KEYWORDS
Health planning; Health policy; Strategic planning; Health management; Health systems

Introduction

The dominant conception of the act of planning in health is associated with the complex process that requires a theoretical mastery of the field of public administration, however, in addition to this knowledge, the appreciation of the social aspects and nuances of political action must also be prioritized. It is important to understand that governing today requires, in addition to traditional normative planning, the development of strategic planning stages¹1 Matus C. Política, Planejamento e governo. Brasília, DF: IPEA; 1997..

It starts from elements and aspects that must be identified and addressed during the planning process, such as the actors, the scenario, the limiting aspects, the time, among others that are fundamental in order to reach the expected results, taking into consideration the complexity of the interactions between them. This dynamic of interactions is a game of comings and goings between power and social actors, which exist uniquely in each culture²2 Testa M. Pensamento estratégico e lógica de programação: o caso da saúde. São Paulo-Rio de Janeiro: Hucitec-Abrasco; 1995..

Historically, the term strategy emerges as a military concept, which after the great transformation of modern society, with the conquest of the power of Russia by the forces of communism, becomes a 'way of ascending to power'²2 Testa M. Pensamento estratégico e lógica de programação: o caso da saúde. São Paulo-Rio de Janeiro: Hucitec-Abrasco; 1995.. In the health field, Mario Testa points out that planning can be strategic as long as it considers the behavior of actors and seeks the transformation of power relations; therefore, the teams of planners must pay attention to the diagnosis of the situation, analyzing its viability from the social practice of interactions between actors, scenarios and ideologies³3 Giovanella L. Planejamento estratégico em saúde: uma discussão da abordagem de Mário Testa. Brasil. Cad. Saúde Pública [internet]. 1990 [acesso em 2018 set 8]; 6(2):129-153. Disponível em: http://dx.doi.org/10.1590/S0102-311X1990000200003.
http://dx.doi.org/10.1590/S0102-311X1990... . From this perspective, health management practice applies from three strategies: institutional, programmatic and social.

In this study, an investigation will be carried out on the guidelines described in the National Health Plans of Canada and Brazil, that is, it is time to set a goal, where one wants to get from that previous diagnosis, named by Carlos Matus¹ as normative moment that must be objective and clear, built from the cognitive repertoire of the planner as a social actor⁴4 Mattos RA. (Re)visitando alguns elementos do enfoque situacional: um exame crítico de algumas das contribuições de Carlos Matus. Ciênc. Saúde Colet. [internet]. 2010 [acesso em 2019 fev 5]; 15(5):2327-2336. Disponível em: //dx.doi.org/10.1590/S1413-81232010000500008.
//dx.doi.org/10.1590/S1413-8123201000050... . Contemporary of Mario Testa, economist Carlos Matus adds that the planner cannot be a mere observer of the situation, therefore he proposes the Situational Strategic Planning (PES), not abstaining, either, from incorporating the concept of strategy and its typologies² in the second moment of the PES.

The PES consists of four moments: explanatory, when the situational diagnosis is made and problems are identified; normative, already characterized above; strategic, which is the moment to analyze the political, economic and organizational viability of the proposals, it would be how to do each action; and the tactical-operational, time to perform the action, perform what was planned and assess its consequences¹1 Matus C. Política, Planejamento e governo. Brasília, DF: IPEA; 1997.. Therefore, understanding that the planners of Brazil and Canada guide their actions in PES, and in the normative moment it is possible to identify the typologies of the strategies proposed by Mario Testa, which is the focus of the study.

Given the relevance of universal health systems in the world, as a triumph of historical struggles for health as a right and as an example of health reforms, that emerge with responses to the growing demands and needs of societies, it is important to reflect on the development of health planning in these universality scenarios, in this case, in two countries of the american continent that have a universal health system.

Therefore, this article aims to compare the main guidelines of the National Health Plans of Canada and Brazil, in the light of strategic thinking, more specifically, the normative moment proposed by Mario Testa.

The normative moment from the concepts of strategies by Mario Testa

In the reflections of Mario Testa²2 Testa M. Pensamento estratégico e lógica de programação: o caso da saúde. São Paulo-Rio de Janeiro: Hucitec-Abrasco; 1995. on strategic thinking and the logic of programming, relevant elements for planning are identified, such as power, which is the ability of the actors to achieve the goal, and may be administrative, technical and political; strength, while intensity of power's movement; ideology, conceived by the conception of the world of a subject and his/her conduct in respect to it²2 Testa M. Pensamento estratégico e lógica de programação: o caso da saúde. São Paulo-Rio de Janeiro: Hucitec-Abrasco; 1995.; actor, such as people or groups of people who defend an ideology; space, understood as a place of grouping of actors with similar ideology; and scenario, understood as an arena in which action is developed, not just the physical space, but also the relationship between the elements already presented in this paragraph.

Therefore, it is important to emphasize the strategies and their concepts comprising the moment of definition of the planning goals.

INSTITUTIONAL STRATEGIES

They refer to those strategies developed in and from the institutional space, and may, even, originate before the existence of the institution, as strategies of constitution of the institution. Institutional strategies aim to strengthen the organizational structure of that institution, in order to maintain its ideology based on internal and external relations. Mario Testa explains that internal relations also coexist with diversity of ideologies when it comes to the social and technical and/or intellectual and manual division of labor, which is the maximum contradiction that can exist in an institution.

The objective of the institution is to establish itself, to consolidate its objectives, mission, values and principles; in the meantime, the instituting process moves, exerting power over the workers and their relations⁵5 Baremblitt GF. Compêndio de análise institucional e outras correntes: teoria e prática. 5. ed., Belo Horizonte: Instituto Félix Guatarri; 2002.. Therefore, institutional strategies transform the daily lives of workers and society indirectly²2 Testa M. Pensamento estratégico e lógica de programação: o caso da saúde. São Paulo-Rio de Janeiro: Hucitec-Abrasco; 1995..

In this study, the institutional strategies are those directed to the technical, administrative and political strengthening of the institution responsible for the planning and execution of health actions in Brazil or Canada.

PROGRAMMATIC STRATEGIES

They are characterized as a proposal for the distribution of power through a delimited program, which orders available resources with a specific purpose, well-defined objective and by single normative approach. These strategies may be mistaken for the institutional ones, but differ in their transitional character from the program, making the conception of ideology and power difficult²2 Testa M. Pensamento estratégico e lógica de programação: o caso da saúde. São Paulo-Rio de Janeiro: Hucitec-Abrasco; 1995.. Therefore, the programmatic strategies may be directed to the qualification of the institution, people's health care, community strengthening or other objectives, but with a temporary nature, such as vaccination campaigns, financial incentive programs, combating arboviral vectors, among other actions.

SOCIAL STRATEGIES

These strategies are planned for the good of all people, society, in accordance with policies focused on the totality, thus, they seek to ensure actions in the global space. The guidelines also planned in sectorial spaces, such as the specific activities of health, education, economy and environment, when integrated, also include social strategies²2 Testa M. Pensamento estratégico e lógica de programação: o caso da saúde. São Paulo-Rio de Janeiro: Hucitec-Abrasco; 1995..

Institutional and programmatic strategies can be understood as analytical categories of global space, as critical categories of sectoral spaces, which, in doing so, also modify the global space. Therefore, social strategies are planned by the State, based on its instituted power, but built on the participation of social actors and/or group of actors.

In this study, the main defining characteristic of social strategies will be their beneficence for the whole, for Brazilian or Canadian societies.

Methodological path

This is a comparative study with a qualitative approach of the exploratory type. The object of the study will be the National Health Plan made by the federal entities of Canada and Brazil. These countries were eligible, because they are located in the Americas and have a universal health system.

For data collection, the Canadian National Health Plan for the 2017-2018 biennium was explored, available on the website of the Ministry of Health of that country – http://www.hc-sc.gc.ca/ahc-asc/index-Eng.php⁶6 Health Canada. About Health Canada [internet]. [Ottawa]: Health Canada; [data desconhecida] [acesso em 2017 jan 4]. Disponível em: http://www.hc-sc.gc.ca/ahc-asc/index-eng.php.
http://www.hc-sc.gc.ca/ahc-asc/index-eng... ; as well as the Brazilian National Health Plan for the 2016-2019 quadrennium, available on the website of the National Health Council – http://conselho.saude.gov.br/ultimas_noticias/2016/docs/PlanoNationalSaude\2016\2016\2016\2016\2016\2016\2016\2016\2016.f.f.pd⁷7 Brasil. Ministério da Saúde. Plano Nacional de Saúde. Brasília, DF: Ministério da Saúde; 2016..

The drafting teams for each document used the terms 'guidelines' and 'objectives' at normative time; however, justified by the semantic similarity, the term guideline will be adopted in this study. Those terms that were often cited in the guidelines in both documents were chosen as keywords.

For the organization of data collection, as well as for analysis, the Atlas.ti software was used, a computer program based on the Grounded Theory of Glaser and Strauss, with application in various fields of knowledge, such as psychology, sociology, anthropology, education, economics, political science and also its use in qualitative health research⁶6 Health Canada. About Health Canada [internet]. [Ottawa]: Health Canada; [data desconhecida] [acesso em 2017 jan 4]. Disponível em: http://www.hc-sc.gc.ca/ahc-asc/index-eng.php.
http://www.hc-sc.gc.ca/ahc-asc/index-eng... . Atlas.ti software has great potential for the use of multimedia in qualitative analysis, because it accepts text, direct observations, photographs, graphic, sound and audiovisual data.

The use of Atlas.ti allowed the coding of sentences of the two documents under analysis, indicating which words, terms and expressions appear frequently. Next, the program builds relationships between coded data, with varieties of combinations⁸8 Varguillas C. El uso del Atlas.ti y la creatividad del investigador en el análisis de contendio. Revista de Educación Laurus [internet]. 2006 [acesso em 2019 mar 3]; 12(extra):73-87. Disponível em: https://www.redalyc.org/comocitar.oa?id=76109905.
https://www.redalyc.org/comocitar.oa?id=... .

For the analysis of information, it was used as categories of analysis the three strategies – institutional, programmatic and social – proposed by Mario Testa²2 Testa M. Pensamento estratégico e lógica de programação: o caso da saúde. São Paulo-Rio de Janeiro: Hucitec-Abrasco; 1995. on strategic thinking in health planning and programming. It is important to note that for each guideline, one keyword was assigned, as well as each guideline was classified as a single strategy.

Results and discussion

The following two sections present the central elements of the organization and of the content of both the National Health Plan of Canada and Brazil, as well as describe the guidelines contained in each of them. In the end, some reflections are made that place in contrast the normative moment of the two management tools.

Considerations on the organization and content of the National Health Plan of Canada

Canada is a country known worldwide for the health status of its population, confirmed by positive health indicators such as life expectancy of 83,6 years for women and 79,4 years for men, as well as economic indicators that signal the country as the tenth largest economy in the world based mainly on its resources and trade¹⁰10 Organização Pan-Americana da Saúde. Informe de país: Canadá [internet]. 2015. [acesso em 2019 mar 3]. Disponível em: https://www.paho.org/salud-en-las-americas-2017/?page_t_es=informes%20de%20pais/canada&lang=es.
https://www.paho.org/salud-en-las-americ... ^,1111 Silva HP, Elias FTS. Incorporação de tecnologias nos sistemas de saúde do Canadá e do Brasil: perspectivas para avanços nos processos de avaliação. Cad. Saúde Pública [internet]. 2019 [acesso em 2019 out 1]; 35(supl2):e00071518. Disponível em: https://doi.org/10.1590/0102-311X00071518.
https://doi.org/10.1590/0102-311X0007151... .

In order to maintain or raise health indicators, Canada relies on Health Canada, which is the federal department responsible for helping Canadians promote or rehabilitate their health conditions or cure their disease process, while respecting the uniqueness of people⁶6 Health Canada. About Health Canada [internet]. [Ottawa]: Health Canada; [data desconhecida] [acesso em 2017 jan 4]. Disponível em: http://www.hc-sc.gc.ca/ahc-asc/index-eng.php.
http://www.hc-sc.gc.ca/ahc-asc/index-eng... . In this sense, Health Canada 2017-2018 (name given to the National Health Plan) summarizes the priorities and proposed actions for the years 2017-2018, favoring assistance to the health needs of people²¹21 Tesser CD, Norman AH, Vidal TB. Acesso ao cuidado na Atenção Primária à Saúde brasileira: situação, problemas e estratégias de superação. Saúde debate [internet]. 2018 [acesso em 2019 mar 2]; 42(esp1):361-378. Disponível em: https://doi.org/10.1590/0103-11042018S125.
https://doi.org/10.1590/0103-11042018S12... .

To achieve such purpose, Health Canada addresses four priorities, which are: supporting innovation in the health system; strengthen openness and transparency such as modernization of legislation, regulation and health care; strengthen the health programming of the First Nations and Inuit (indigenous and eskimos nations); and, finally, recruit, maintain and promote a committed, high-performance and diverse workforce within a healthy working environment¹²12 Minister of health of Canada. Health Canada 2017-2018. Ottawa (CA): Department Plan; 2017..

The Health Plan has several sections that define its role, its functions, according to the principles of the federal department, in addition, the document considers aspects such as context, the conditions that affect its work and the risks that could affect the ability to make the plan effective and achieve the proposed results.

After these sections, the plan presents the Planned Results which are structured through three programs which, in turn, are divided into 13 specific guidelines¹²12 Minister of health of Canada. Health Canada 2017-2018. Ottawa (CA): Department Plan; 2017., which will be the analysis corpus of this study, presented in the chart 1.

Each of the guidelines in chart 1 are presented in five subsections: overview, planning highlights, planned results, financial resources, and human resources¹²12 Minister of health of Canada. Health Canada 2017-2018. Ottawa (CA): Department Plan; 2017..

The National Health Plan also describes Internal Services as “groups of activities and resources needed to support program needs and other corporate obligations of the organization”¹²12 Minister of health of Canada. Health Canada 2017-2018. Ottawa (CA): Department Plan; 2017.⁽⁵⁶⁾, finally, Health Canada 2017-2018 counts on total public spending and resources.

Considerations on the organization and content of the National Health Plan of Brazil

Instituted in the Federal Constitution of 1988, Brazil enjoys a Unified Health System (SUS) conceived as a duty of the State to regulate, finance it, and to propose a set of health actions that ensure the right of the population in question. be universally assisted, with equity and comprehensiveness¹³13 Brasil. Senado Federal. Constituição da República Federativa do Brasil. Brasília, DF: Senado; 1988..

Health plans refer to the planning of health actions, with analysis of the health situation, objectives, goals, responsible people and evaluation indicators, which may have a quadrennial or annual periodicity. National health policies guide fundamental practices, as they define goals to be achieved, determining the directions and strategies to ensure better quality of life for the population¹⁴14 World Health Organization. 2018. National health policies, strategies, plans [internet]. 2018. [acesso em 2019 mar 3]. Disponível em: https://www.who.int/nationalpolicies/nationalpolicies/en/.
https://www.who.int/nationalpolicies/nat... .

The National Health Plan of Brazil, 2016-2019 quadrennium, is structured in four sections besides the introduction and the annex. The introduction describes the participation of all sectors of the Ministry of Health, compliance with the National Health Council guidelines and the overall objective of the plan to the

The attached item presents the evaluation indicators of each guideline.

The first section presents the legal foundations that support the construction of a health plan; the second one describes health conditions and needs, including resources currently being exploited by the federal entity; in the third section, reference is made to objectives and goals; while the latter thus exposes the plan management interface, such as the relevance of monitoring and follow-up of actions and its relationship with the management report⁷7 Brasil. Ministério da Saúde. Plano Nacional de Saúde. Brasília, DF: Ministério da Saúde; 2016..

Next, the objectives and goals of the plan are presented, in which the 13 guidelines⁷7 Brasil. Ministério da Saúde. Plano Nacional de Saúde. Brasília, DF: Ministério da Saúde; 2016. are presented, in chart 2, in the order they appear in the National Health Plan.

Weaving reflections that contrast with the National Health Plan of Canada and Brazil

Initially, from the analysis of the keywords, a greater variety of codes can be identified in the Brazilian plane, with strong evidence for social control issues, but, on the other hand, the same document did not present guidelines directed to workers' health and food security for example. In Canada's case, the plan repeated several of the keywords, such as health risks and health problems, indigenous health (in this scenario understood as natives and eskimos) and health surveillance. In the end, the three categories (keywords) that were most frequent in both plans were health risks and health problems, indigenous health and health surveillance.

This result indicates the relevance and prioritization of themes to be addressed in both study scenarios, which may or may not coincide by studying in-depth specific programs of each country.

According to Conill¹⁵15 Conill EM. Sistemas Comparados de Saúde. In: Campos GWS, Minayo MCS, Akerman M, et al. Tratado de Saúde Coletiva. Rio de Janeiro: Hucitec; Fiocruz; 2006. 51 p., health systems show similarities as well as differences, which are identified by comparative analysis: while similarities are given by more inclusive social policies, differences are rooted in people's access to the services offered, the organization of these services and the quality of health or their performance. Even though Canada and Brazil have universal health systems, there are historical, economic, political and cultural divergences between the two countries that determine health planning and policy making processes.

By exploring Table 1, it is inferred that the Brazilian health plan has a comprehensive character, in order to plan aspects directed to financing, supplementary health, social control, health research, training and qualification of the worker, as well as comprehensive care and Health Care Networks.

In this regard, it is noteworthy that the Brazilian health system is valued for its consistency between constitutional guidelines, financing, management model and qualification of professionals. Therefore, when compared to other systems mostly composed of private services, there is a complex system, organized from Primary Health Care (PHC) and efficient in health promotion and harm and health prevention¹⁶16 Conill EM. Sistemas universais para a américa latina: jovens e antigas inovações nos serviços de saúde. Rev Bras Promoç Saúde [internet]. 2018 [acesso em 2019 jan 4]; 31(4):1-13. Disponível em: http://dx.doi.org/10.5020/18061230.2018.8779.
http://dx.doi.org/10.5020/18061230.2018.... . Therefore, the purpose of the Brazilian system goes beyond purely curative care, that is why it requires expanded clinical practice and intersectoral actions.

The categories mentioned above illustrate the interdependence of the Brazilian Ministry of Health with other institutions in favor of SUS efficiency. Thus, it is understood that the resolution of health problems is complex, therefore, the Brazilian Ministry of Health carries out health planning shared with other Ministries¹⁷17 Pauli LTS. A integralidade das ações em saúde e a intersetorialidade municipal. Cad IberAmer Direito Sanit [internet]. 2013 [acesso em 2018 nov 14]; 2(2):578-594. Disponível em: http://dx.doi.org/10.17566/ciads.v2i2.106.
http://dx.doi.org/10.17566/ciads.v2i2.10... , such as Education and Management of Science, Technology and Innovation, in addition to regulatory agencies and deliberative bodies such as health councils.

As for the Canadian health plan, it is considered that its focus is on specific actions that can be developed autonomously by the federated health organization itself.

Table 2 presents the classification of the guidelines based on the planning strategies designed by Mario Testa and presented in the introduction. It is observed that in both health plans, programmatic strategies and a shortage of institutional strategies predominate. Even with the predominance of programmatic strategies, the Brazilian document contains a more equitable distribution among the other strategies when compared to the Canadian one.

The information in Table 2 allows us to infer about the health concept of the planners of both countries and the health needs of the population. By proposing guidelines classified as social strategies, both planners seem to conceive that the health-disease-care process is shaped by social determinants, as outlined in the guidelines “promote integral care for people in life cycles and promote the production and dissemination of science and technology knowledge in health” ⁷7 Brasil. Ministério da Saúde. Plano Nacional de Saúde. Brasília, DF: Ministério da Saúde; 2016.⁽⁶⁾; as well as “promoting the ability to design, manage, develop and evaluate health programs and services by indigenous and Eskimos”⁶6 Health Canada. About Health Canada [internet]. [Ottawa]: Health Canada; [data desconhecida] [acesso em 2017 jan 4]. Disponível em: http://www.hc-sc.gc.ca/ahc-asc/index-eng.php.
http://www.hc-sc.gc.ca/ahc-asc/index-eng... ⁽⁴⁹⁾ and “emphasize the vitality of communities with minority languages and the recognition of English and of the French”⁶6 Health Canada. About Health Canada [internet]. [Ottawa]: Health Canada; [data desconhecida] [acesso em 2017 jan 4]. Disponível em: http://www.hc-sc.gc.ca/ahc-asc/index-eng.php.
http://www.hc-sc.gc.ca/ahc-asc/index-eng... ⁽²²⁾.

Social strategies can be considered as health innovations¹¹11 Silva HP, Elias FTS. Incorporação de tecnologias nos sistemas de saúde do Canadá e do Brasil: perspectivas para avanços nos processos de avaliação. Cad. Saúde Pública [internet]. 2019 [acesso em 2019 out 1]; 35(supl2):e00071518. Disponível em: https://doi.org/10.1590/0102-311X00071518.
https://doi.org/10.1590/0102-311X0007151... ^,1616 Conill EM. Sistemas universais para a américa latina: jovens e antigas inovações nos serviços de saúde. Rev Bras Promoç Saúde [internet]. 2018 [acesso em 2019 jan 4]; 31(4):1-13. Disponível em: http://dx.doi.org/10.5020/18061230.2018.8779.
http://dx.doi.org/10.5020/18061230.2018.... , represented by communication and information technologies in order to ensure quaternary prevention, patient safety and the horizontal relationship between health professionals and patients, themes that have been little discussed before.

The guidelines that address the health of the indigenous seek to ensure comprehensive care for such a population group, and favor the social inclusion of indigenous people who were once marginalized and whose rights to health were curtailed.

The greater number of social strategies in Brazil is justified by the health needs of the population to ensure social rights not yet realized since the Brazilian Constitution of 1988, for example,

The realization of the right to health is up to the State, as the foundation of human right and as a 'primordial social right', thus, the Brazilian State must ensure the protection of the health of all people, enabling, for example, the access of minority populations, such as of indigenous peoples¹⁸18 Mendes KR. Curso de direito da saúde. São Paulo: Saraiva; 2013..

In contrast, Canadian society, based on health plan analysis, is considered to enjoy consolidated social rights, as emphasized in the Canadian Charter of Rights and Freedoms Canada, document that composes the Constitution of Canada and seeks to ensure the rights of society, be they fundamental, rights to mobility, legal rights, equal rights, official languages of Canada and educational rights in minority languages¹⁹19 Canadian Government. The Canadian Charter of Rights and Freedoms [internet]. 1982 [acesso em 2019 mar 3]. Disponível em: http://publications.gc.ca/collections/Collection/CH37-4-3-2002E.pdf.
http://publications.gc.ca/collections/Co... . In this sense, 25 years after the letter was published, it still stands out as a model for other countries²⁰20 McLachlin B. The Charter 25 Years Later: The Good, the Bad, and the Challenges. Osgoode Hall Law Journal [internet]. 2007 [acesso em 2019 out 8]; 45(2):365-377. Disponível em: https://digitalcommons.osgoode.yorku.ca/cgi/viewcontent.cgi?referer=https://www.google.com/&httpsredir=1&article=1245&context=ohlj.
https://digitalcommons.osgoode.yorku.ca/... . Like the historic approach to rights in Canada, the health plan guidelines emphasize programmatic strategies based on the guarantee of social rights.

Next, by relating the keywords of the guidelines to the strategies, we built Table 3, allowing the analysis and inferences survey. The guidelines that imply an institutional strategy deal with financing and the role of management in the health system. The institutional strategies of Brazil's health plan are reserved for the strengthening of the Ministry of Health as an organization and the improvement of its decision-making process.

Similarly, the only institutional strategy of the Canadian health plan seeks to provide strategic policy recommendations, investigations and analysis to support decision-making on health system issues, as well as to support programs for provinces and territories, partners and interested parties in health care priorities⁶6 Health Canada. About Health Canada [internet]. [Ottawa]: Health Canada; [data desconhecida] [acesso em 2017 jan 4]. Disponível em: http://www.hc-sc.gc.ca/ahc-asc/index-eng.php.
http://www.hc-sc.gc.ca/ahc-asc/index-eng... .

As for the programmatic strategies, these were defined by guidelines that described specific actions, in which it was possible to identify a deadline for termination of the action. Programmatic guidelines are mainly aimed at vulnerable groups and specific policies. Among them, the theme of access to health services and medicines, the deployment of health networks in different health regions, the development and implementation of regulatory frameworks on health and protection for citizens of substances and products harmful to health are emphasized.

Guidelines related to the most specific elements are perceived, such as PHC, health care networks, health risks and health problems, worker health, indigenous health, supplementary health, food safety, pharmaceutical services and health surveillance. In turn, social strategies require an intersectoral approach, such as the guideline codified as 'health research':

It is important to highlight that Latin American countries live with the epidemiological profile of continuous transition, acting concomitantly with chronic and infectious morbidities and 'traditional' or 'typical' problems of social and economic backwardness, a different scenario from that experienced in Canada¹⁵15 Conill EM. Sistemas Comparados de Saúde. In: Campos GWS, Minayo MCS, Akerman M, et al. Tratado de Saúde Coletiva. Rio de Janeiro: Hucitec; Fiocruz; 2006. 51 p.. This may also be related to the fact that the guidelines of the Brazilian National Health Plan prioritize both social and programmatic strategies, while the Canadian National Health Plan highlights programming ones by probably having a better resolution of those social problems that generate injustices and inequities in health.

For the Brazilian scenario, it is worth discussing the specificities of PHC and indigenous health that led the classification as two strategies, the programmatic type and the social type, respectively. PHC is understood as the most interconnected hierarchical level of health care, bringing together health practices that mainly aim at health promotion and prevention of risks and health problems²¹21 Tesser CD, Norman AH, Vidal TB. Acesso ao cuidado na Atenção Primária à Saúde brasileira: situação, problemas e estratégias de superação. Saúde debate [internet]. 2018 [acesso em 2019 mar 2]; 42(esp1):361-378. Disponível em: https://doi.org/10.1590/0103-11042018S125.
https://doi.org/10.1590/0103-11042018S12... . Guidelines directly related to PHC were classified as program strategies according to the Canadian health plan guidelines.

Furthermore, because of the potential for high capillarity, PHC must act to strengthen the principles of solidarity, justice, citizenship and community protagonism²²22 Gil CRR. Atenção primária, atenção básica e saúde da família: sinergias e singularidades do contexto brasileiro. Cad. Saúde Pública [internet]. 2006 [acesso em 2018 set 8]; 22(6);1171-1181. Disponível em: http://dx.doi.org/10.1590/S0102-311X2006000600006.
http://dx.doi.org/10.1590/S0102-311X2006... , aspects that can be put into practice through social strategies, such as the guideline of the health plan of Brazil:

For their part, Santos and Melo²³23 Santos J, Melo W. Estudo de saúde comparada: os modelos de atenção primária em saúde no Brasil, Canadá e Cuba. Gerais, Rev Interinst Psicol [internet]. 2018 [acesso em 2019 fev 4]; 11(1):79-98. Disponível em: http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1983-82202018000100007.
http://pepsic.bvsalud.org/scielo.php?scr... , in their comparative study of PHC models in Brazil, Canada, and Cuba, concluded that a marked difference between the Brazilian and the Canadian health system corresponds to decentralization: “the fact that Canada has thirteen health systems (ten provincial and three territorial) confers a fundamental difference between the Canadian system and the Brazilian system, characterized by being a single system”²³23 Santos J, Melo W. Estudo de saúde comparada: os modelos de atenção primária em saúde no Brasil, Canadá e Cuba. Gerais, Rev Interinst Psicol [internet]. 2018 [acesso em 2019 fev 4]; 11(1):79-98. Disponível em: http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1983-82202018000100007.
http://pepsic.bvsalud.org/scielo.php?scr... ⁽⁹⁴⁾, which may be acting in the manner in which the national health plans for each of the above countries are understood and drawn up. About this, Rabello²⁴24 Rabello LS. Estudo comparado Brasil e Canadá. In: Rabello LS, organizadora. Promoção da saúde: a construção social de um conceito em perspectiva do SUS. Rio de Janeiro: Fiocruz; 2010. p. 107-155. refers to decentralization as consolidated in Canada, where health is the responsibility of the provinces and territories, while in Brazil it is considered incomplete, because norms and resources are concentrated in the federal entity.

Santos and Melo²³23 Santos J, Melo W. Estudo de saúde comparada: os modelos de atenção primária em saúde no Brasil, Canadá e Cuba. Gerais, Rev Interinst Psicol [internet]. 2018 [acesso em 2019 fev 4]; 11(1):79-98. Disponível em: http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1983-82202018000100007.
http://pepsic.bvsalud.org/scielo.php?scr... ⁽⁹⁵⁾ evaluated that “although constantly cited as a reference in many academic texts, the Canadian influence on the Brazilian system, in practice, is quite limited”, which can be evidenced by seeing that, with similarities in the principles that guide both health systems, there are substantial differences between their national health plans.

Final considerations

The national health plans of Canada and Brazil converge on the keywords for care actions directly, although the North american country plans a greater number of health surveillance activities.

The divergence of the documents lies in the diversity of strategies that are proposed by the guidelines contained in the Brazilian Health Plan. Therefore, it is considered that Brazilian society lives with health needs that permeate the socioeconomic, cultural, environmental, work and income conditions, and people's lifestyle, justifying the planning of programmatic and social strategies. The SUS, based on universality and equity, seeks to ensure health care to people long neglected by the State, such as indigenous people, quilombolas, settlers, homeless people, refugees, among others. Therefore, it stands out and distinguishes itself from the Canadian for its comprehensiveness.

Based on this scenario, it is permissible to assume that the struggle of social movements, especially those that emerged with greater vehemence in the years 2000, provoked a severe power dispute²2 Testa M. Pensamento estratégico e lógica de programação: o caso da saúde. São Paulo-Rio de Janeiro: Hucitec-Abrasco; 1995. identified by the results of this study, when goals that were previously planned for all citizens, but without achieving them, were replaced by goals for all, including vulnerable groups, justifying the multiplicity of guidelines analyzed in this study.

It is worth noting that the analysis of a document such as the National Health Plan limits the understanding of strategic thinking, such as the actors involved, the power game, the dynamism of intersectoral relations and the scenario in question. Therefore, other data collection techniques could be used to deepen these elements.

In this regard, both Brazil and Canada guide the normative moment of planning through programmatic strategies, which have an intersectoral character in the Brazilian scenario. The differences point to intersectoral action and the organization of care with well-defined hierarchical levels of health care in Brazil. However, the predominance of programmatic strategies in Canada allows us to assume that this scenario enjoys the consolidation of decision-making processes, as well as securing the social rights of the population, resulting in specific institutional and social strategies.

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