ABSTRACT

The present article presents the outcomes of the normative research on the combat against the COVID-19 pandemic at the National Health Council (Conselho Nacional de Saúde - CNS) from February 2020 to March 2022. This is a documental, descriptive-analytical study, with qualitative approach, using the technical analysis of content. Seventy-seven acts were issued by the CNS Collegiate, there included 63 recommendations, 6 opinions, 5 motions, 2 technical notes and 1 resolution. Most part of the documents (59%) were worked out during the first year of the pandemic. Despite the Council’s performance when combating the COVID-19, non-binding acts may be highlighted, the CNS normative production concentrating in merely guidance recommendations.

KEYWORDS
Social control; formal; Health council; COVID-19

Introduction

The social control consolidation in the health area took place as the 1988^{11 Brasil. Constituição, 1988. Constituição da República Federativa do Brasil. Brasília, DF: Senado Federal; 1988.} Constitution was consolidated, followed by Laws Nr. 8080, as of 1990^{22 Brasil. Lei nº 8.080, 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União. 20 Set 1990.}, and Nr. 8143, as 1990^{33 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 União. 31 Dez 1990.}, which did institutionalize both the guidelines and the principles of the Unified Health System (Sistema Único de Saúde - SUS).

The National Health Council (CNS), a permanent and deliberative organ of the SUS, counting on representatives of different social actors^{44 Costa AM, Noronha JC. Controle Social na Saúde: construindo a Gestão Participativa. Saúde debate. 2003; 27(65):358-363.}, is legally in charge of formulating strategies and controlling the execution of the health policy, there included logistic, economic and financial aspects; and of supervising, accompanying and monitoring the health public policies, directing the population’s need to health management.

The SUS was created under Law Nr. 378, as of January 13, 1937^{55 Brasil. Lei nº 378, de 13 de janeiro de 1937. Dá nova organização ao Ministério da Educação e Saúde Pública. Diário Oficial da União. 15 Jan 1937.}, aimed at assisting the Education and Health Ministry as to subjects under its responsibility. As that ministry was separated into Health and Public Education, the CNS was ruled by Decree Nr. 34.347, as of April, 1954^{66 Brasil. Decreto nº 34.347, de 8 de abril de 1954. Aprova o Regimento do Conselho Nacional de Saúde. Diário Oficial da União. 9 Abr 1954.}, with nothing more than consultive competence. In 1970, as the Decree Nr. 67.300^{77 Brasil. Decreto nº 67.300, de 30 de setembro de 1970. Dispõe sobre o Conselho Nacional de Saúde e dá outras providências. Diário Oficial da União. 1 Out 1970.} was passed, it gained competence to issue non-binding opinions on health-related subjects.

On January 14, 1987, as the first glances of the social control growth came up in the country, the Decree Nr. 93.933^{88 Brasil. Decreto nº 93.933, de 14 de janeiro de 1987. Dispõe sobre a organização e atribuições do Conselho Nacional de Saúde, e dá outras providências. Diário Oficial da União. 15 Jan 1987.} was issued meant to establish both the organization and the attributions of the CNS, with binding normative and advisement functions to assist the Ministry of Health.

Nevertheless, the Executive Power did not recognize the full competency of the CNS to produce normative resolutions but on July 11, 2006, when Decree Nr. 5.839^{99 Brasil. Decreto nº 5.839, de 11 de julho de 2006. Dispõe sobre a organização, as atribuições e o processo eleitoral do Conselho Nacional de Saúde - CNS e dá outras providências. Diário Oficial da União. 12 Jul 2006.} was issued.

Resolution Nr. 407/2002^{1010 Conselho Nacional de Saúde (Brasil). Resolução nº 407, de 12 de setembro de 2008. Aprova o Regimento Interno do Conselho Nacional de Saúde. Diário Oficial da União. 11 Mar 2009.}, which approved CNS Internal Rules, determines that:

Nevertheless, it must be remarked that, out of all the normative and technical-political types issued by the CNS, the Resolution is the only one with binding form of its content: they are the normative acts the Health Council makes use of to exert its social control^{1111 Acipreste MTL, Castro JL, Lima JCS, et al. Atuação do Conselho Nacional de Saúde frente à pandemia do Covid-19: uma análise documental. Rev. Ciênc. Plur. 2022 [acesso em 2022 out 8]; 8(3):1-19. Disponível em: https://doi.org/10.21680/2446-7286.2022v8n3ID28241.
https://doi.org/10.21680/2446-7286.2022v...} .

According to Di Petro’s^{1212 Di Pietro MSZ. Direito Administrativo. 35. ed. Rio de Janeiro: Editora Forense; 2022.} definition, normative acts are general acts that reach all those in the same situation. They are practiced by the administration, and include orders, resolutions, decrees, rules, with either general or abstract effects. A number of administrative departments receive from their guiding laws the ability to rule the subjects affected by normative acts. Furthermore, provided issued respecting the Constitution and the laws, they are binding acts that oblige administrative authorities.

Within a few weeks, the COVID-19 pandemic led to a deep crisis that changed the economic, social, political and cultural dynamic worldwide. As they faced the crisis, governments reacted differently, and those differences reflected public policies options which led to different effects as well. In some cases, crises got even worse; in other cases, effects went softened, as well as the multiple inequalities that had previously gone deeper^{1313 Vommaro PA. O mundo em tempos de pandemia: certezas, dilemas e perspectivas. Rev. Direito Práx. 2021 [acesso em 2022 dez 12]; 12(2):1095-1115. Disponível em: https://www.e-publicacoes.uerj.br/index.php/revistaceaju/article/view/51001.
https://www.e-publicacoes.uerj.br/index....} . In this sense, actions had to be organized all over the health system management, and actions had to take place regarding both the economy and the legislation, there include the infra-legal level.

The CNS does not evade from its important role in the scenario of sanitary emergencies: its history tells actions in epidemics situations and as contributor to the process of formulating and executing health policies, as the HIV/Aids (the Human Immunodeficiency Virus/ Acquired Immune Deficiency Syndrome) and the Zika Virus (ZIKV).

Soon after the Administrative Rule Nr. 188/2020^{1414 Brasil. Ministério da Saúde. Portaria nº 188 de 3 de fevereiro de 2020. Declara Emergência em Saúde Pública de Importância Nacional (ESPIN) em decorrência da Infecção Humana pelo novo Coronavírus (2019-nCoV). Diário Oficial da União. 4 Fev 2020.} was issued - the normative that declared the Public Health Emergency with National Importance (ESPIN) caused by the Human Infection by the Coronavirus - 2019-nCOV -, the CNS organized its site atm the internet with both its normative and non-normative production on the pandemic. Those data are grouped in the panel ‘Special CNS in the confrontation with the COVID-19’ (http://conselho.saude.gov.br/especial-cns-no-enfrentamento-a-covid-19)^{1515 Conselho Nacional de Saúde (Brasil). [Brasília, DF]: CNS; [data desconhecida] [acesso em 2023 set 4]. Disponível em: http://conselho.saude.gov.br/especial-cns-no-enfrentamento-a-covid-19.
http://conselho.saude.gov.br/especial-cn...} , thus indicating that the CNS did issue important acts aimed at the confrontation of the COVID-19.

The above led to the purpose of building up the documental study on the repository of normative and technical-political acts of the Council over the period since the ESPIN was declared until 2022, so as to get to know and to analyze the acts brought up by the CNS on the confrontation of the COVID-19 pandemic.

Methodology

This is a descriptive-analytical study with qualitative approach, with content analysis of both normative and technical-political documents produced by the CNS.

The research was built-up based on the following acts: resolutions, recommendations, motions, opinions and technical notes. The documents, free for public access, produced from February 3, 2020, to May 22, 2022, were drawn out at the web address: http://conselho.saude.gov.br/^{1616 Conselho Nacional de Saúde (Brasil). [Brasília, DF]: CNS; [data desconhecida] [acesso em 2023 set 4]. Disponível em: http://conselho.saude.gov.br/.
http://conselho.saude.gov.br/...} , on browser tabs ‘Atos normativos’ e ‘CNS contra Covid’, using descriptors: Covid-19; Pandemia Covid-19; and Sars-CoV-2. The research found 129 documents, total.

As the floating^{1717 Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011.} reading of the acts was complete - that is, the normative and non-normative documents submitted to the analysis -, those that included at least one descriptor in the text or the list were chosen, those that did not fulfill the criteria were discarded, thus remaining 77 acts.

The documents were organized according to the type so as to identify the numeric ratio of each act studied herein.

As to the recommendations, because they were the larger number of documents, the option was to organize them and put them into categories based on the themes, defined after the complete reading of the acts, so as to compare the entire production.

The full wording of the opinions was accessed by means of documents annexed to the recommendations, as they were not available separately. Technical notes were located on the browser tabs ‘CNS contra Covid’, which include the panel ‘Especial CNS no enfrentamento à Covid-19’, following the subtopic ‘Notas Públicas’ on that panel.

Outcomes and discussion

Out of the total acts issued by the CNS over the period investigated, most part (59%) was concentrated on the first year of the pandemic (table 1). The search for the acts posed some complexity, as the site of the Council was nor updated on the dates the research was carried out.

Considering that the World Health Organization (WHO) declared pandemic state on March 11, 2020, warning it was an unknown disease, thus requiring every person to put into practice measures that would change as the natural history of the disease would be unveiled, the CNS proved diligent to a certain measure, as the acts would deliberate on different contents, such as health preservation and safety of workers in the health area and people in general; the approval and the use of extraordinary resources to confront the pandemic; and recommendations to the National tripartite Coordination for the Combat to COVID-19 and the Inquiry Parliament Commission on the COVID-19, in the Federal Senate House.

Acipreste et al.^{1111 Acipreste MTL, Castro JL, Lima JCS, et al. Atuação do Conselho Nacional de Saúde frente à pandemia do Covid-19: uma análise documental. Rev. Ciênc. Plur. 2022 [acesso em 2022 out 8]; 8(3):1-19. Disponível em: https://doi.org/10.21680/2446-7286.2022v8n3ID28241.
https://doi.org/10.21680/2446-7286.2022v...} consider that, in early moments, the CNS seemed to attach greater priority to both the health and the security of health workers, there included residents and trainees, rather than the population as a whole. However, those authors consider - and we agree on that - that the option to ‘care of those who care’ was correct, as by that time they were the most exposed to the virus, that was not yet properly known. As to the vaccines, the CNS suggested, in Recommendation Nr. 21^{1818 Conselho Nacional de Saúde (Brasil). Recomendação nº 21, de 24 de agosto de 2021. Recomenda ações referentes à priorização de trabalhadores e trabalhadoras que estão em exposição diária à Covid-19 no Plano Nacional de Operacionalização da Vacinação contra a Covid-19. [acesso em 2023 jul 18]. Disponível em: https://conselho.saude.gov.br/recomendacoes-cns/recomendacoes-2021/1985-recomendacao-n-021-de-24-de-agosto-de-2021sa.
https://conselho.saude.gov.br/recomendac...} , that workers should be the first group to be assisted, but not necessarily health workers.

Recommendation was the most frequently used normative act (81%). It is an act issued by the collegiate or yet by the President of the CNS, ad referendum, consisting in suggestion, award or notice on the content, or in how to carry out sectorial policies and strategies, or yet on the convenience or opportunity to adopt one certain provision. It deals with specific themes or subjects not usually under the straight responsibility of the CNS, but which are relevant and necessary, aimed at institutional entities or the society itself, from whom one certain behavior or providence is expected or required^{1010 Conselho Nacional de Saúde (Brasil). Resolução nº 407, de 12 de setembro de 2008. Aprova o Regimento Interno do Conselho Nacional de Saúde. Diário Oficial da União. 11 Mar 2009.}. In this sense, it is a not a very complex act, one that does not depend on homologation by the Minister of Health, and is meant to guide the management as to the need to follow the collegiate concerning the health policy.

In whole, the CNS issued 63 recommendations, dealing with a variety of themes (box 1).

It must be remarked that most recommendations were issued on the very first day of the pandemic and became scarce over 2022. Although non-binding, the recommendation is an act requiring not much bureaucracy, which may be published by the collegiate meeting of the CNS ad referendum. On days of COVID-19 crises, this kind of act may be justified when decision-makers must be informed of the necessary provisions, as the act may be issued concomitantly to a number of addressees, being duly homologated by the collegiate the next meeting following the publication.

Therefore, during the period under analysis, 97% of the recommendations were passed ad referendum. The exception was the Recommendation Nr. 71, as of December 11, 2020^{1919 Conselho Nacional de Saúde (Brasil). Recomendação nº 71, de 11 de dezembro de 2020. Recomenda medidas corretivas que promovam a execução orçamentária e financeira do Ministério da Saúde com a celeridade requerida pela emergência sanitária causada pela pandemia do Covid-19. [acesso em 2023 jul 18]. Disponível em: https://conselho.saude.gov.br/recomendacoes-cns/recomendacoes-2020/1545-recomendacao-n-070-de-18-de-novembro-de-2021.
https://conselho.saude.gov.br/recomendac...} , approved by the CNS plenary in its 66 ^th Extraordinary Meeting; and Recommendation Nr. 8, as of April 27, 2022^{2020 Conselho Nacional de Saúde (Brasil). Recomendação nº 8, de 27 de abril de 2022. Recomenda a revogação da Portaria GM/MS nº 913/2022 e outras medidas correlatas. [acesso em 2023 jul 18]. Disponível em: https://conselho.saude.gov.br/recomendacoes-cns/recomendacoes-2022/2448-recomendacao-n-008-de-27-de-abril-de-2022.
https://conselho.saude.gov.br/recomendac...} , approved by the plenary at its 329^th Ordinary Meeting.

As it is performed by someone without unlimited authority, the ad referendum act will only be valid upon ulterior ratification by the competent authority^{2121 Diniz MH. Dicionário Jurídico Universitário. São Paulo: Editora Saraiva; 2022.}.

One must keep in mind that such situation came up as both ordinary and extraordinary meetings turned to be not presential, thus making more difficult those discussions involving the themes of recommendations under analysis.

Under CSN Resolution Nr. 645/2020^{2222 Conselho Nacional de Saúde (Brasil). Resolução n° 645 de 30 de setembro de 2020. Converte a Instrução Normativa em Resolução e estabelece os procedimentos relativos ao funcionamento do CNS, através da realização remota de reuniões colegiadas, durante a pandemia provocada pelo Covid-19. [acesso em 2023 fev 6]. Disponível em: http://conselho.saude.gov.br/resolucoes-cns/resolucoes-2020/1395-resolucao-n-645-de-30-de-setembro-de-2020.
http://conselho.saude.gov.br/resolucoes-...} , Art. 4, the collegiate decided that, as long as the ESPIN would in force, meetings should be remote, thus making it easier to carry out previous approvals for the recommendation, which did not occur.

It is not clear why remote meetings were not carried out more often, which would have enabled for documents to be issued reinforced by the Plenary Assembly decision. Nevertheless, the CSN President is not hindered from using the ad referendum institute to adopt measures that cannot wait for the regular meeting chronogram, either presential or remote: the President is allowed to do it immediately, giving science to the collegiate as soon as possible.

Graph 1 next presents the addressees of the recommendations.

The Ministry of Health was the main addressee, as it is the responsible department for the SUS direction at the Union level. However, the CSN did not disregard the recommendations to all remaining institutions, either direct or indirectly connected to the combat to the pandemic, there included even organs of the justice system.

Among the recommendations issued, one must be remarked: the one on ‘Public action specifically by the health service’, with 29 documents. Ita content involved different areas, such as health surveillance promotion, pharmaceutical assistance and primary, secondary and tertiary attention, there included measures meant to ensure the health services security. The proposal proves the CSN commitment with facing the sanitary emergency, with special attention to the most vulnerable populations affected by the pandemic.

One example is recommendation Nr. 26/2020^{2323 Conselho Nacional de Saúde (Brasil). Recomendação nº 26, de 22 de abril de 2020. Recomenda aos gestores do SUS, em seu âmbito de competência, que requisitem leitos privados, quando necessário, e procedam à sua regulação única a fim de garantir atendimento igualitário durante a pandemia. [acesso em 2023 jul 18]. Disponível em: https://conselho.saude.gov.br/recomendacoes-cns/recomendacoes-2020/1131-recomendacao-n-026-de-22-de-abril-de-2020.
https://conselho.saude.gov.br/recomendac...} , which guided SUS managers to require private beds and to promote one single regulation, thus granting equalitarian assistance. The CSN did acknowledge the importance of the national coordination to guide assistance resources, there include private property hospital beds, to fulfill sanitary priorities case to case. Such measure was an answer to the insufficiency of available beds in the health system - a clear reality as one would observe the waiting roles even in situations of epidemic control. Lack of beds turned to be a concern, revealed by data related to judicial processes against the public health system in Brazil^{2424 Ramos EMB. Argumentos dos atores processuais nas causas jurídicas sobre saúde no Estado da Bahia, Brasil. Cad. Ibero-amer. Dir. Sanit. 2017 [acesso em 2023 jul 18]; 6(1):127-138. Disponível em: https://www.cadernos.prodisa.fiocruz.br/index.php/cadernos/article/view/357/444.
https://www.cadernos.prodisa.fiocruz.br/...} .

Another guideline considered refers to actions related to health care for vulnerable groups. Recommendation Nr. 4/2021^{2525 Conselho Nacional de Saúde (Brasil). Recomendação nº 4, de 30 de março de 2021. Recomenda ações relativas aos cuidados à saúde das populações vulnerabilizadas no contexto da pandemia da Covid-19. [acesso em 2023 jul 18]. Disponível em: https://conselho.saude.gov.br/recomendacoes-cns/recomendacoes-2021/1671-recomendacao-n-004-de-30-de-marco-de-2021.
https://conselho.saude.gov.br/recomendac...} stressed the importance of anti-racist actions at health attention services and stimulated full accomplishment of the National Policy od Basic Attention. Data collection on race/color was also stimulated to reduce health inequalities and to protect vulnerable communities.

Those documents are not fully effective, as they lack normative strength and do not enforce any public authority. It is well acquainted that, considering its history and national importance, CNS counts on institutional force to bind authorities, institutions and even private persons to act for granting everyone’s health. However, unfortunately, as the recommendations lack normative force, it may every now and then be disregarded by the addressees.

Among the recommendations, those related to ‘Revocation, alterations, norms approval or guidance suspension issued by the Ministry of Health’ represent 26% of the total. Those acts have specific contents concerning governmental actions in the health area and are meant to influence public policies and rules to combat the pandemic. This theme covers a number of issues, such as the destination of financial resources to acquire materials for COVID-19 prevention procedures, emergence measures for family agriculture and compulsory license for new drugs in cases of national or international emergency, public interest or state of public calamity.

On March 24, Recommendation Nr. 16/2000^{2626 Conselho Nacional de Saúde (Brasil). Recomendação nº 16, de 24 de março de 2020. Recomenda ao Ministério da Economia, aos Presidentes da Câmara dos Deputados e do Senado Federal e ao Presidente do Supremo Tribunal Federal a adoção de providências em razão da edição da Medida Provisória no 927/2020. [acesso em 2023 jul 18]. Disponível em: https://conselho.saude.gov.br/recomendacoes-cns/recomendacoes-2020/1078-recomendac-a-o-no-016-de-24-de-marc-o-de-2020.
https://conselho.saude.gov.br/recomendac...} , one of CSN actions, suggested the immediate revocation of Provisional Measure (PM) Nr. 927/2020^{2727 Brasil. Medida Provisória nº 927, de 22 de março de 2020. Dispõe sobre as medidas trabalhistas para enfrentamento do estado de calamidade pública reconhecido pelo Decreto Legislativo nº 6, de 20 de março de 2020, e da emergência de saúde pública de importância internacional decorrente do coronavírus (covid-19), e dá outras providências. Diário Oficial da União. 22 Mar 2020.}, which changed labor rules to combat the pandemic. However, this recommendation was not accepted, as the PM remained in force until July that same year and did only lack validity as the validity term of 60 days as established in the Federal Constitution was over^{11 Brasil. Constituição, 1988. Constituição da República Federativa do Brasil. Brasília, DF: Senado Federal; 1988.}.

The reach of all nine recommendations concerning ‘Vaccination as combat strategy’ was larger, aimed at important authorities and institutions, meant to ensure access to vaccination and widen the protection for the population. The measures proposed were sent to the Presidency of the Republic, the Ministry of Labor, the Ministry of Health, the Secretariats of Health, the National Congress, the Federal Public Ministry, the National Agency of Sanitary Surveillance (ANVISA) and other relevant entities. The measures proposed included: the withdrawal of materials that could discourage the vaccination; the accomplishment of international commitments; the enlargement of the National Vaccination Plan to reach priority groups; strengthening the Primary Health Care; the protection of pregnant women, those who had just given birth and those who were nursing; and priority to workers exposed to the virus. Such recommendations aimed at holding back the advancement of the pandemic and promoting a coordinate and effective answer for the combat of the sanitary crisis.

At last, with small number of documents issued, recommendations include contents on ‘Execution of Technical Opinion’ and ‘Budget and Finances’. Contents involve carrying out technical opinions issued by the CNS itself, as well as the guidance for budgetary and financial actions, focused on expenses execution and resources transfer for actions meant to combat the pandemic, reaching a reduced number of authorities and institutions.

One recommendation to be highlighted as ‘Execution of Technical Opinion’ was issued to the Ministry of Education, the Ministry of Health and to the Programs of Residence in Health. Considering the declaration of sanitary crisis, this recommendation would guide those departments to execute the Technical Opinion Nr. 106/2020^{2828 Conselho Nacional de Saúde (Brasil). Parecer Técnico nº 106, de 26 de março de 2020. [acesso em 2023 jul 18]. Disponível em: https://conselho.saude.gov.br/recomendacoes-cns/recomendacoes-2020/1086-recomendacao-n-018-de-26-de-marco-de-2020.
https://conselho.saude.gov.br/recomendac...} , on guidance for the work/performance of residents in health, and male and female workers in health services during the pandemic. Actually, the recommendation would reinforce the importance of technical opinions issued by the CNS, aimed at promoting more adequate and safe performance of health professionals involved in the sanitary emergence. This initiative was intended to grant an efficient answer aligned with the health protocols in a critical moment for public health in the country.

On the other hand, recommendations on ‘Budget and Finances’ produced greater impact, mainly directed to the Presidency of the Republic and the National Congress. They demanded urgent corrective measures aimed at a more agile budgetary and financial execution of the Ministry of Health, there included transfer of resources for State and Municipal Health Funds and control of health-related public expenses. Furthermore, they involved SUS sub-financing and the importance of fulfilling constitutional financing obligations to make sure the population would be properly assisted during the pandemic.

As to opinions issued by the CNS, they represent 7% of the acts produced over the period. These are about a technical-political-public pronouncement - that is, not normative -, grounded and detailed, which points out to a solution for one certain subject, consultation or administrative process the CSN is called to manifest on. The subject must be analyzed by the CSN Collegiate and may be produced by any of its organs - Directive Board, Inter-sectorial Commissions, Work Groups and Technical Chambers^{1010 Conselho Nacional de Saúde (Brasil). Resolução nº 407, de 12 de setembro de 2008. Aprova o Regimento Interno do Conselho Nacional de Saúde. Diário Oficial da União. 11 Mar 2009.}.

Considering that all opinions analyzed were issued to support CNS recommendations, these recommenda tions were organized as indicated by the Commission responsible for the act produced, the subject and the recommendation connected (box 2).

The opinions must be analyzed by the CNS Collegiate, thus suggesting that their validity and relevance are evaluated in a wider context, involving representatives of different sectors of the Collegiate. This collaborative approach and the review by the Collegiate may help granting well grounded, balanced opinions, which represent a more comprehensive vision of health issues on screen, thus considering different points of view and specialties.

By providing solid and well-grounded technical information, such opinions may contribute for the formulation of more effective policies and actions in the public health field. Nevertheless, for not counting on normative character, they do not bind the manager. Furthermore, during the pandemic a common situation was the creation of emergency committees to deal with COVID-19 subjects and, in one certain way, the transfer of the councils to a secondary position. Thus, one may not state that those opinions for the combat of the COVID-19 did actually produce some impact.

Motions represent 6% of all acts analyzed. This is a means for the Council to manifest approval, acknowledgement or denial concerning one specific subject or fact^{1010 Conselho Nacional de Saúde (Brasil). Resolução nº 407, de 12 de setembro de 2008. Aprova o Regimento Interno do Conselho Nacional de Saúde. Diário Oficial da União. 11 Mar 2009.}. The motions issued by the CNS are described in box 3.

Two motions issued are related to projects of law that were under discussion at the National Congress. It is acknowledged that one motion to support the approval or denial of the approval of normative acts under discussion at the National Congress counts on the political force at the Council^{2929 Temoteo-da-Silva B, Lima IMSO. Análise política da atuação do Conselho Nacional de Saúde na construção da política de saúde no Brasil no período de 2014-2017. Interface (Botucatu). 2022 [acesso em 2023 jul 18]; (26):e210582. Disponível em: https://doi.org/10.1590/interface.210582.
https://doi.org/10.1590/interface.210582...} , although this may not be determinant for the proposal to be either approved or rejected by the Federal House of Laws.

The Support Motion Nr. 1/2021^{3030 Conselho Nacional de Saúde (Brasil). Moção de Apoio nº 1, de 2 de fevereiro de 2021. Manifesta apoio à população amazonense e aos trabalhadores e trabalhadoras da linha de frente de combate à Covid-19. [acesso em 2022 out 13]. Disponível em: http://conselho.saude.gov.br/mocoes-cns/mocoes-2021/1585-mocao-de-apoio-n-001-de-02-de-fevereiro-de-2021.
http://conselho.saude.gov.br/mocoes-cns/...} was motivated by press news on the situation the Amazonas population has been submitted to due to the lack of oxygen and of adequate treatment conditions. Motions Nr. 8/2021^{3131 Conselho Nacional de Saúde (Brasil). Moção de Repúdio nº 8, de 11 de novembro de 2021. Manifesta repúdio às declarações do Presidente da República proferidas em live do dia 21 de outubro de 2021. [acesso em 2023 fev 13]. Disponível em: http://conselho.saude.gov.br/mocoes-cns/mocoes-2021/2173-mocao-de-repudio-n-008-de-11-de-novembro-de-2021.
http://conselho.saude.gov.br/mocoes-cns/...} and Nr. 10/2021^{3232 Conselho Nacional de Saúde (Brasil). Moção de Repúdio nº 10, de 20 de dezembro de 2021. Manifesta repúdio às declarações do Presidente da República proferidas em live do dia 16 de dezembro de 2021. [acesso em 2022 out 13]. Disponível em: http://conselho.saude.gov.br/mocoes-cns/mocoes-2021/2260-mocao-de-repudio-n-010-de-20-de-dezembro-de-2022.
http://conselho.saude.gov.br/mocoes-cns/...} resulted from pronouncements by the President of the Republics - the later, with strong media reaction, due to statements contrary to both scientific authorities worldwide and the WHO. Due to the enormous negative repercussion of the facts, the CNS could not avoid presenting a denial motion.

As to technical notes issued, they represent 25 of CNS acts and represent one internal act, produced by the Executive Secretariat. They have instructive character and are meant to subsidize the Directive Board and the CNS Collegiate on subjects related to administrative, judicial and political processes that might require deeper analyzes as they are to guide debates and deliberations^{1010 Conselho Nacional de Saúde (Brasil). Resolução nº 407, de 12 de setembro de 2008. Aprova o Regimento Interno do Conselho Nacional de Saúde. Diário Oficial da União. 11 Mar 2009.}.

Both technical notes identified were produced in 2021, and dealt with vaccination against COVID-19 and actions related to the pandemic control, such as: immediate progress of full vaccination; active search for people who had not received full vaccination; transparency and access to information on the rhythm of doses disaggregated per social markers; implementation of a national plan on surveillance and testing of the population; and implementation of a national plan on monitoring of the epidemiological status in order to identify risk groups to premature reduction of immunity for serious infections etc.

Finally, the resolution represents the kind most seldomly used by the CNS (1%). It is a general act with normative character, resulting from deliberations in the Council that must necessarily be homologated by the State Ministry of Health within 30 days, at most, to assign it the respective official publicity. Should the resolution not be ratified or should no alteration or rejection proposal be sent to the CNS by the manager, the Council may try to validate it judicially and/or by means of the Prosecuting Council, if so required^{3333 Conselho Nacional de Saúde (Brasil). Resolução nº 453, de 10 de maio de 2012. Aprova as diretrizes para instituição, reformulação, reestruturação e funcionamento dos Conselhos de Saúde. [acesso em 2022 out 12]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/cns/2012/res0453_10_05_2012.html.
https://bvsms.saude.gov.br/bvs/saudelegi...} .

Actually, the CNS issued Resolution Nr. 671, as of April 2022^{3434 Conselho Nacional de Saúde (Brasil). Resolução nº 671, de 05 de abril de 2022. Dispõe sobre as diretrizes referentes à definição de prioridades para as ações e serviços públicos de saúde nos processos de planejamento da saúde para 2023. [acesso em 2022 out 12]. Disponível em: http://conselho.saude.gov.br/resolucoes-cns/2421-resolucao-n-671-de-05-de-abril-de-2022.
http://conselho.saude.gov.br/resolucoes-...} , on directives concerning definitions of priorities for health actions and public services in planning processes in the health area for 2023, determining that budgetary and financial programs by the Health Ministry should assign sufficient resources for both the combat do the COVID-19 and other actions and health services. Nevertheless, that resolution was not homologated by the Minister of Health, probably due to insufficiency of time for the sanitary authority to provide the President of the Republic with information to produce the competent Project of Law of Budgetary Directives (Projeto de lei de Diretrizes Orçamentárias - PLDO). According to 1988 Constitution^{11 Brasil. Constituição, 1988. Constituição da República Federativa do Brasil. Brasília, DF: Senado Federal; 1988.}, the National Congress must receive that Project of Law every year until April 15, maximum.

As the resolution was published five working days before that deadline, its nor homologation is justified for untimeliness. However, that does not reflect low effectivity of an act issued by the CNS in actions meant com combat the COVID-19, nor does it reflect lack of prestige, as the PLDO and even the Annual Budgetary Law (Lei Orçamentária Anual - LOA) - included the proposal in the Resolution Nr. 671^{3434 Conselho Nacional de Saúde (Brasil). Resolução nº 671, de 05 de abril de 2022. Dispõe sobre as diretrizes referentes à definição de prioridades para as ações e serviços públicos de saúde nos processos de planejamento da saúde para 2023. [acesso em 2022 out 12]. Disponível em: http://conselho.saude.gov.br/resolucoes-cns/2421-resolucao-n-671-de-05-de-abril-de-2022.
http://conselho.saude.gov.br/resolucoes-...} .

Conclusions

A number of acts have been issued by the CNS, a locus of permanent deliberation when confronting the COVID-19 pandemic, as long as ESPIN was in force.

The CNS site is outdated, particularly browser tabs meant to inform on normative and ethnic-political acts, putting all together files referring to years 2020 and part of 2021. Furthermore, the way those tabs are organized makes quite difficult the interaction with the user, requiring much time to find acts like those analyzed in this paper (opinions associated with recommendations, technical notes on tabs referring to public notes).

During the most critical period of the pandemic, the CNS focused on its non-normative performance, those acts that do not oblige the public manager. Besides, the only resolution issued was passed as late as 2022, no longer feasible due to the lateness and the lack of homologation by the Minister. Considering its national importance, the CNS should have used more often this normative expedient, as this is the only one with binding effect. But it did not.

Over the period from 2020 and 2022, the CNS was quite profitable when issuing recommendations that, although not binding, could be delivered to any public department, even simultaneously. Almost all recommendations issued over that period were ad referendum - an alternative that, although accepted in the rules, points out to some difficulty for the members to get together, which is not desirable, mainly considering the possibility to carry out remote meetings, which is duly accepted.

One must consider that social control is a complex process that faces a number of obstacles to turn effective. However, we must keep in mind the priority of health conscience as an indivisible asset that requires the commitment and the cooperation of all actors involved - health authorities in special. It is therefore suggested that other studies should be carried out, so as to give rise and divulge issues concerning the CNS operation, aiming at strengthening the participation of the community in the health context, so that it may hold on and support itself over time.

References

Publication Dates

History