Integra Project: strengthening social participation in the agenda of health policies, services, and technologies

Abstract

The 16th National Health Conference illustrated the interest of health councils to intervene in public policies in order to guarantee the right to health technologies. The INTEGRA project (Integration of policies for Health Surveillance, Pharmaceutical Care, Science, Technology, and Innovation in Health) is a partnership among the National Health Council, the National School of Pharmacists, and the Oswaldo Cruz Foundation (Fiocruz), with support from the Pan American Health Organization (PAHO), with the goal of strengthening participation and social engagement in the theme, as well as the integration of health policies and practices within different sectors of society (social movements, health councils, and health professionals), with the various stages related to the access to medicines (research, incorporation, national production, and services) being the main theme in the context of the COVID-19 pandemic. It seeks to offer training for leadership groups in the health regions and activities with a broad national and political scope, and it hopes to establish an intersectorial and integrated network of leaders capable of acting collaboratively to defend the development of science, public policies, national sovereignty, and social control of health.

Key words: Pharmaceutical Care; Health Surveillance; Science; Technology and Innovation; Social Control

Resumo

A 16ª Conferência Nacional de Saúde demonstrou o interesse do controle social em intervir sobre as políticas públicas a fim de garantir o direito às tecnologias de saúde. O projeto Integra - Integração das Políticas de Vigilância em Saúde, Assistência Farmacêutica, Ciência, Tecnologia e Inovação em Saúde -, nasce da parceria entre o Conselho Nacional de Saúde, a Escola Nacional dos Farmacêuticos e a Fundação Oswaldo Cruz (Fiocruz), com apoio da Organização Pan-Americana de Saúde (OPAS) com objetivo de fortalecimento da participação e engajamento social na temática e a integração das políticas e práticas de saúde em diferentes setores da sociedade (movimentos sociais, controle social e profissionais de saúde), tendo as diversas etapas relacionadas ao acesso aos medicamentos (pesquisa, incorporação, produção nacional e serviços) como mote principal, no cenário da pandemia de COVID-19. Oferta-se, neste projeto, capacitação para grupos de lideranças nas regiões de saúde e atividades de grande abrangência nacional e política. Espera-se alcançar o estabelecimento de uma rede intersetorial, integrada de lideranças capazes de atuar colaborativamente para a defesa do desenvolvimento da ciência, das políticas públicas, da soberania nacional e do controle social da saúde.

Palavras-chave: Assistência farmacêutica; Vigilância em Saúde; Ciência; Tecnologia; Inovação; Controle social

Introduction

Three years ago, the Brazilian society prepared to participate in the 16^th National Health Conference. Regional preparatory meetings culminated in the 8^th National Symposium of Science, Technology, and Pharmaceutical Services at the end of 2018, at which highly compelling proposals were consolidated in defense of access to medicines and to health technology and humanized services, and were characterized by their resoluteness^1,2.

Among the strategies indicated in 2018 as absolutely necessary are the expansion of investments and regulations for Brazilian scientific and technological development to attend to the very needs of the population and health services. The high costs and prices of medicines and other technologies, as well as the regulatory and intellectual property barriers^3,4, were themes that were present in the presentations and discussions. Many proposals for the directing of investments, giving priority to studies on neglected and endemic diseases, and for the improvement of service quality of services were soundly defended².

The 16^th National Health Conference reaffirmed these proposals, demonstrating the interest of the society to comprehend, discuss, and intervene in public policies that define the conditions to guarantee the right to health and the democratic state⁵.

What followed exemplified, in an unfortunate reality, the need for the measures defended at the 16^th National Health Conference. The political decision for a heavy downgrading of investments in the health system have led to the abrupt collapse of the Brazilian Health System (SUS, in Portuguese), aggravated by the COVID-19 pandemic⁶. Brazil has become one of the epicenters of the COVID-19 pandemic and is currently undergoing a public health disaster⁷. The void of federal government actions to coordinate the fight against the pandemic, the generalized processes of disinformation, including and mainly governmental, and the lack of integration between the civil society and managers aggravate the difficulty confronted in the country². The conditions of inequality of our society, with a major portion of its population in situations of extreme vulnerability, are worsened in the current scenario⁷, thus culminating in which is being called “sindemia”⁸.

It is vital to assure feasibility over the middle and long terms of the national responses to COVID-19 in order to minimize their predicted prejudicial social and health impacts⁹. It is necessary to learn through life’s experiences and prepare the society and SUS to confront the challenges of the future in a more harmonious and effective manner.

In the context of the COVID-19 pandemic, the social control of health has played a key role, through the protagonism of health councils, of research and teaching institutions, and of organized movements in civil society, and have sent out efforts in the sense of informing the population; monitoring the actions of the public institutions; provoking the establishment regarding necessary public policies, by means of key legal instruments (Resolutions, Recommendations, Notes, Letters); and giving incentive to the development and defense of the credibility of science.

In this context, the INTEGRA project (Integration of policies for Health Surveillance, Pharmaceutical Services, Science, Technology, and Innovation in Health) in a partnership joining the National Health Council, the National School of Pharmacists, and the Oswaldo Cruz Foundation (Fiocruz), with support from the Pan American Health Organization (PAHO), was born. INTEGRA’s core aim is the strengthening and integration of health policies and practices within different sectors of society (social movements, health councils, and health professionals). To achieve this, it seeks to offer training for leadership group activities in the health regions and activities with a broad social outreach. It hopes to establish an intersectorial and integrated network of leaders capable of acting collaboratively to defend the development of science, public policies, national sovereignty, and social control of health.

For this, some of the guiding principles of the project are described below.

Intersectoriality in SUS

The Brazilian Federal Constitution of 1988 introduced significant advances to the Brazilian legal order, extending rights, correcting inequalities, and guaranteeing the general population’s participation in the drafting of public policies. SUS arose within this context, innovating by adopting the core principles of the ideas of complementarity and intersectoriality as compared to the historical legacy of centralized and vertical public health policies. The management, planning, control, and assessment moved closer to SUS users, recognizing them as citizens and holders of fundamental rights, not only because of the effective institution of community participation in Councils and Conferences, but also in the enhancement of SUS’s Ombudsmanships and Audits. In this light, the decentralization proposed in the organization of SUS opened the door to a more participative and democratic management¹⁰.

However, in compliance with the process of the implementation of public services after the ratification of the Federal Constitution of 1998, one can identify the theme of intersectoriality and of articulation as elements that are still challenging, since, although the organizations are often decentralized, they are still sectorialized, with no integrated search to truly attend to demands. Thus, the need for intersectoriality became evident inasmuch as the efficiency, effectiveness, and efficacy expected in the implementation of the political sectors has not been observed, primarily in that which concerns attending to the demands of the general population and to the resources made available for the execution of such actions^10,11.

Intersectoriality can be defined as a consequence and product of the articulation of a wide range of knowledge, perceived as a new process in the governmental dynamic to achieve integrated results when faced with combatting complex problems, with actions geared toward collective interests, permeated by the participation of the civil society, and that result in a greater efficiency of the political management and of the services provided^11-13.

Regarding health, the specific interlocution among public policies is problematized due to the common challenge that unifies them around the complex social determination of the conditions of life and health of the population. Moreover, such policies share a design of territorialized implementation, formulated through principles of hierarchization and regionalization, which results in the fact that they are in one single territory, attending to the same population, with different specific objectives, and yet inseparable¹³. Intersectoriality incorporates the idea of integration, territory, equality, and, in the end, social rights; it is a new means through which to approach the problem, since one can observe that each social policy moves down its own path toward a solution, without considering the citizen in its totality, nor the actions of the other social policies, which are also seeking improvements in the quality of life. Intersectoriality has been defended for some time as an alternative applied to solve problems, as it indicates a group’s perspective of the problems and offers possible solutions, through the optimization of the scarce resources and considering the complexity of the social reality, which inevitably will not remain only in the implementation of a single public policy¹⁴. However, even today, implementation has been rare in the field of health.

Intersectoriality is not something that occurs spontaneously or naturally within public institutions without provoking resistance and a call for substantial change in the organizational model^12,15. A paradigmatic change in the intersectorial direction does not presuppose the omission of the disciplines in their singularities, but rather the triggering of a communication process, not only to reframe the public management practices, but also to enrich the comprehension of the differences in knowledge. Sectoriality, therefore, is not necessarily suppressed by intersectoriality, since the wide range of disciplines should be synthesized through communication^11,16,17.

Working in an intersectorial manner means overcoming the fragmentation of knowledge and practice, which also involves the population, who experiences the problem in search of shared solutions. Therein lies its role to overcome fragmentations, not only in the structure of the state apparatus, but also in the knowledge, overcoming assistentialist practices and piecemeal management. Moreover, intersectoriality is a channel through which to deal with the resistance from workers, guarantee a greater participation and social control, and finally, conduct the management, assessment, and surveillance of the intersectorial actions aimed at achieving broader integrality and equality in providing the public policies in question^11-13.

Social control in health and the public policies in question

The cycle of a public policy encompasses the stages of the formation of the agenda, the drafting of the policy, decision-making, implementation, and assessment. The pre-decision process, prior to the drafting of the policy, consists of enumerating the problems and defining the possible alternative of intervention. Different actors are involved in the process of understanding and defining the problem, in the agenda stage, which will define the entire consequent debate in the process of drafting the policy¹⁸.

The civil society, in Brazil, participates in the drafting and control of public health policies through health councils. The Health Councils and Conferences, regulated by the Organic Law of Health 8.142/90, as well as other institutionalized spaces in the legal framework of SUS, are means used to exercise social control through dialogue with different segments of users, workers, and service providers¹⁹.

Although it still has not formally assumed this participation¹⁹, the health council has matured since the creation of SUS, establishing a greater representativeness and influence over public policies²⁰. Evidence shows the limits and capabilities of the Municipal Health Councils, highlighting the importance of the qualification of the board members and that, for many of the authors studied, the lack of participation on the part of some board members is due to the lack of knowledge that these people have regarding their own role and how to execute it²¹, as well as the lack of knowledge concerning the policies that guide public health actions and services.

The National Policy of Science, Technology, and Innovation in Health (PNCTIS, in Portuguese), the National Policy of Pharmaceutical Care (PNAF, in Portuguese), and the National Health Surveillance Policy stem from the fight carried out by organized social movements, due to the health needs of the population. Therefore, one can affirm that they were the result of the socially representative segments of society, and seek to bring equality and reason in access to and the providing of health care⁴.

The integration of these areas of health: science, technology, pharmaceutical care, and health surveillance constitute a core element of the Triannual Work Plans, 2019/2022, of the Intersectorial Commissions of the National Health Council, which are related to these themes, which are the Commissions of Science, Technology, and Pharmaceutical Care, of Health Surveillance, and of Health Care for Individuals with Pathologies.

The debate with the population about the PNCTIS, PNAF, and Health Surveillance policies is essential for these to achieve a greater involvement in different sectors of civil society in the health council and can reflect the interests of the Brazilian society as a whole. The greater the knowledge of these policies and the perception of how they are interconnected will unleash an even greater involvement of the population in the creation of the agenda of public policies that are assertive and based on the clearest understanding of the determinants and conditioning factors for health promotion in Brazil.

The pandemic as a concrete case to identify the fragilities and capabilities of the system

The COVID-19 pandemic has been challenging health systems worldwide, clearly showing their fragilities and exposing the need for a greater integration and system structure of the SUS guidelines expressed in article 198 and the urgency of society’s appropriation of the concept extended to health, as set forth in the 1998 constitution.

This health emergency brought the need to reflect on the situation and to implement new strategies for the organization of the supply of services within the country; planning of purchases of inputs for health care in an environment replete with an increase in demand and a scarcity of supply; attraction of human resources to perform these services, and, to sustain all of these actions, social and economic policies that would guarantee the reduction of socioeconomic vulnerabilities among the Brazilian people. For these actions to be effective in combatting the pandemic, the coordination between the federal agencies and the diverse public policies was crucial for the success of these strategies. Unfortunately, this was not what we saw, especially in the sharing of planning and in decision-making among the management levels and the health council of SUS.

At the onset of the pandemic, the main problem was to guarantee a strategic decision-making, with priorities over the purchase of diagnostic tests, their inputs, and Personal Protective Equipment (PPE)²². At the same time, it was also important to consider the health system so as to attend to the population’s demand for health care, both for COVID-19 symptoms, as well as in the maintenance of care for other natural health problems and those incorporated within the daily routine of health services. It was necessary to contemplate the restructuring of the working processes of primary health care, health surveillance, urgencies and emergencies, and hospitalization units, where the elective health processes were halted due to the health emergency related to the new epidemic.

Despite the wide range of international evidence that demonstrated the importance of the structure of primary health care in the tracking and control of COVID-19 infections in Brazil, mass testing, follow-up, and isolation of the positive cases and their contacts^23-25, as well as the correction activation of the services of immunization linked to basic health care, little was done or implemented in this sense. Much to the contrary, what we witnessed was the preference for such strategies as the purchase of medicines with no proven therapeutic efficacy²⁶, as well as the opening of health campaign hospitals and/or new hospital beds that, although necessary to provide medical care to the population, when implemented in an isolated manner and disconnected from other actions, were incapable of preventing the overload of hospital units²⁷.

In a cross-sectional manner to all of the problems of the organization of the healthcare network within the Brazilian states, what became evident was the fragility of the national productive base in offering the necessary inputs to combat the pandemic. The heavy dependence of Brazil upon the importation of pharmaceutical drugs, medicines, and other inputs for health^28-30 compromised our capacity to respond to the pandemic due to the difficulties to buy diagnostic tests and their inputs, PPEs, equipment, and medicines necessary for health care.

The pandemic also demonstrated the importance of SUS for Brazilians, which, even with all the fragilities, continued to provide medical care to their citizens during the pandemic, even to those who have a supplementary private health insurance and saw their rights denied by health insurance companies. Without SUS, the current scenario would most certainly be even worse. Nevertheless, it is important to return, in a practical manner, to the legal guidelines of SUS, in such a way that we can consider health policies within a broader scope, one that is participative and interconnected with the other public policies. For this, and in homage of the thousands of deaths suffered due to the pandemic, we must use the problems that occurred as a lesson and analyze them in such a way as to improve our healthcare system, implementing strategies and actions that can reduce these fragilities and guarantee SUS’s mission in Brazil.

Therefore, it is based on the constitutional principles, inspired by the experience of the creation of the 8^th SNCTAF² and driven by the questions evidenced by the Coronavirus pandemic that this project proposed to conduct a debate, joining the following areas of health: science, technology, pharmaceutical care, and health surveillance, together with social mobilization, the proposal of political actions and the creation of leaderships within public health policies with which they are intrinsically interlinked. This Proposal seeks to work on the integrality and integration of the aforementioned public policies, based on the needs described by the health council, fruit of extensive and rich debates, through conference processes that deliberate on the specific themes.

Proposed Methodology

The Integra project

The proposed methodology in the Integra Project aims to provide the conditions for a more solid and structured creation of leaderships theoretically and conceptually prepared to develop actions related to the proposed theme, with the creation of more long lasting links and commitments among the participants and between them and the local and national health institutions. In addition, it proposes the development of activities of education and social mobilization, in an open and encompassing manner; the construction of references for the integration of the policies; and the concrete proposition of political actions in this sense. For this reason, it proposes a construction in stages (Figure 1):

Figure 1
Development stages of the Integra Project.

1st Stage - Train leaderships: Creation of regional leaderships regarding the public policies in question;

2nd Stage - Educate and engage the society and the institutions: Hold preparatory regional meetings for the 9^th National Symposium of Science, Technology, Health Surveillance, and Pharmaceutical Services.

3rd stage - Consolidate proposals: Hold the 9^th Symposium and approve the report with the constructed reference.

4th stage - Promote political action: Hold debates and public hearings in the Federal House and Senate, in the Legislative Assemblies, in the City Councils, at Universities, and in the Regional Boards of Fiocruz (where they exist) to present the approved Final Report at the 9^th Symposium.

For the 1st stage, strategies and interactive resources are developed for the recognition, analysis, and reflection on the main axes (Science, Technology, and Innovation in Health, Pharmaceutical Care, Health Surveillance, and Health Council), issues that will be treated in depth at the 9^th Symposium. The methodology for this stage consists of synchronous and asynchronous activities in groups of up to 20 participants, under the mentoring of an experienced professional dedicated to this activity. Each group of participants will be engaged in these activities for a period of two months and will have their attendance monitored.

The training of the leaderships is carried out based on the formation of competencies that involve knowledge, abilities, and attitudes. The necessary competencies for the leaders to act in the integration of policies in Science, Technology, and Innovation in Health (CT&I); Pharmaceutical Services, and Health Surveillance (HS) together with the institutions and the social movements were defined based on the objectives proposed in the Integra Project and in agreed upon workshops with the participation of members of the National Health Council, from Fiocruz, and from the National School of Pharmacists, and are described in Figure 2.

Figure 2
Development of the competencies in the INTEGRA Project’s leadership education - Stage 1.

The education, in 40 hours of activities, has the underlying foundation of cases based on real experiences or similar to real situations that had or have some form of social impact (relative to COVID-19 patients, for example), these cases being tools of awareness and triggers for debate. In all cases, the narrative is an integral part of the concrete cases that are close to the reality lived by people in the present-day reality, and it develops to achieve a relationship with the policies that it intends to treat: Science, Technology, and Innovation in Health (PNCTIS), Pharmaceutical Services (PNAF), and Health Surveillance (PNVS). The description of the content and activities are presented in Chart 1 below.

Chart 1
Themes, contents, and activities for the leadership education course - Integra Project’s - Stage 1.

Week	Theme	Overall Objective	Intervention activity
1	Right to health, universal access, and equality	Recognize health as an essential right, with universal access and equality	Sociodemographic mapping of the country: Identification of data sources; Recognition of the research institutions and development in the region
2	Production and access to vaccines	Understand how the policies of Health Surveillance (PNVS), of Science, Technology, and Innovation in Health (PNCTIS) and of Pharmaceutical Services (PNAF) contribute to the guarantee access to vaccination	Strategy of vaccination adopted by the municipality
3	Testing and tracking of contacts during the COVID-19 pandemic	Recognize the potential of Brazil to implement measures to combat pandemics and to develop health technologies by establishing policies of Science, Technology, and Innovation; Health Surveillance, and Pharmaceutical Care	Strategy of health surveillance, considering COVID-19 and other communicable diseases
4	Reliable health information	Understand the importance of the use of scientific evidence in the use of medicines, vaccines, and other products in the area of health	Sources of reliable health information and information for access to medicines in the country
5	Shortage of medicines	Reflect on the relationships of the policies (PNAF and PNCTIS) with the situation of the shortage of medicines during the pandemic	Organization for access to medicines in the country
6	Basic Health Care and Health surveillance	Understand the centrality of Basic Health Care, and its territorial interconnection with health surveillance	Analyze the fragilities and capacities in the organization of primary health care in the country
7	Innovation and incorporation of medicines	Understand the importance of the innovation of medicines and how their incorporation occurs in SUS	Exercise of the prioritization of problems in the lived reality
8	Role of Anvisa and its importance in the articulation among PNCTIS, PNAF, and PNVS	Understand how Anvisa contributes to the implementation and articulation of PNVS, PNCTIS, and PNAF in the daily routine of the population	Draft proposals and attract resources to the country

• Source: Authors elaboration.

After having completed this first stage for all participants in each of the regions, then the Project will proceed to stage 2, with the organization and holding of Preparatory Regional Meetings fort the 9^th Symposium. The proposed methodology for the meetings is based on the experience with the active participative methodology with the presentation of problem scenarios in the form of “cases” with narratives that are real, fictional, or adapted to reality, similar to the proposal adopted prior to the Preparatory Meetings for the 8^th Symposium² and leadership education in Stage 1 of the Integra Project. This stage will be conducted in both online and in-house forms (when the epidemiological conditions allow). The proposals constructed in each meeting will subsidize the construction of the 9^th National Symposium.

For the stage of the 9^th National Symposium, leaderships in all regions and from the main national institutions will be invited to debate the systematized proposals and to define the priorities, which will be part of the planning of the health council’s actions at all management levels. In the final stage, the network of collaboration should be established and consolidated so as to make it feasible for an enduring connection and coordinated action of leaderships within the theme of the project. Considering the importance of the assessment of educational strategies to guide decision-making and future investments in training/education^31,32, the results of the Project will be assessed in each stage.

An invitation for engagement in the defense of health

Education, motivation, and preparation of the population to qualify the participation in the health council, in the collective thought-process and action, to communicate with all of the sectors and to face the ever-increasing challenges, are investments toward a more democratic and healthier society.

The resolute defense of SUS as a public policy of recovery of citizenship and the social right to health is a pressing need. The credibility in both science and public policies is in crisis and brings profound impacts for the Brazilian population. The capacity to discern information, build bridges of collaboration, and communicate appropriately are competencies that need to be developed by the leaderships of different sectors of society so that they can act in a coordinated and more effective manner - which is what this ambitious project seeks to promote.

Acknowledgements

We would like to thank the partner institutions in this Project, the organization and production team, and the tutors of the INTEGRA project.

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Edited by

• Chief editors:
  Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva

Publication Dates

• Publication in this collection
  26 Nov 2021
• Date of issue
  Nov 2021

History

• Received
  13 Sept 2021
• Accepted
  16 Sept 2021
• Published
  18 Sept 2021