Dinâmicas participativas e processo deliberativo : uma análise sobre a atuação dos Conselhos Municipais de Saúde da Macrorregião dos Vales (RS).

Abstract

This thesis analyzes the influence of the dynamics and institutional designs adopted by Municipal Health Councils on the implementation of health policy on a local scale. Starting from the assumption that the public policy formulated within the scope of the Federal Government undergoes a series of changes throughout its implementation process in different territories, in this case in municipalities, we seek to understand the local conditions that influence its implementation. In this sense, we investigated the designs and dynamics of health councils in four main municipalities in the regions that form the Macroregion of Vales/RS, namely: Cachoeira do Sul, Santa Cruz do Sul, Estrela and Lajeado. Furthermore, we sought to analyze the perceptions of its members, coming from different social segments, regarding their responsibilities and the conflicts and demands that arise during decision making moments in the deliberative process. Health Councils constitute a space for struggle, negotiation and articulation full of limitations and ambiguities, but also of opportunities and challenges. Due to the importance of social participation in health management, as a possibility of reinforcing the democratic character of the State, and the need to investigate the effectiveness of new forms of contractuality between the State and civil society, this study focused on the influence of the Municipal Health Councils in the implementation of health policy at the municipal level. To achieve the proposed objectives, the research used the neo institutional approach and studies on the implementation of public policies, which were fundamental for understanding the institutional and territorial constraints of the actors linked to the implementation of public health policy in the municipalities. As a methodological path, the investigation and data collection procedures were based on the following strategies: a) Document analysis (legislation related to health policy and documents from the Health Councils of each municipality, such as minutes, reports, internal regulations, lists attendance, etc.); b) Participant observation, carried out based on observations at municipal council meetings; c) Application of questionnaires to all participants in the municipal health councils surveyed, aiming to understand the profile of the councilors and their perceptions about the functioning and performance of the Council in the implementation and control of health policy at the local level, and, d) carrying out semi-structured interviews with members of the municipal health councils of the municipalities investigated considering the period from 2010 to 2020 as a time frame, comprising several administrations. The choice of interviewees respected the parity composition of each Council (50% users, 50% between management, service providers and health workers) after preliminary analysis of the number of participants, as there were variations between municipalities. The analysis of the results indicated some challenges for the more effective performance of municipal health councils, among which the following stood out: insufficient resources to provide adequate functioning of the councils, which added to the councilors' scarce financial resources, bring difficulties to the social participation of the different sectors represented; insufficiency and discontinuity of training activities aimed at a more qualified performance of counselors (in all councils investigated). As positive factors, the counselors pointed to greater community participation, which produced improvements in access and quality of health services at the local level, as well as the promotion of actions more in line with the needs of users of health policies. In this sense, the importance of municipal councils in producing greater confluence between the actions implemented by the municipal executive and the demands coming from civil society organizations in relation to health policies is highlighted.