Intersectorial health-related policies: the use of a legal and theoretical framework to propose a typology to a case study in a Brazilian municipality

DOI: 10.1590/1413-812320141911.19282013 Políticas Intersetoriais Relacionadas à Saúde: uso de marcos legais e teóricos para a proposição de uma tipologia aplicada a um estudo de caso em um município brasileiro Beatriz Helena Tess 1 Fernando Mussa Abujamra Aith 1 Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo. Av. Dr. Arnaldo 455/2º andar, Cerqueira César. 01246-903 São Paulo SP Brasil. 1 Abstract This article analyzes intersectorial health-related policies (IHRP) based on a case study performed in 2008-2009 that mapped the social policies of the city of Piracicaba, State of Sao Paulo, Brazil. The research strategy comprised quantitative and qualitative methodologies and converging information sources. Legal and theoretical conceptual frameworks were applied to the Piracicaba study results and served as the basis for proposing a typology of IHRP. Three types of IHRP were identified: health policies where the health sector is coordinator but needs non-health sectors to succeed; policies with a sector other than health as coordinator, but which needs health sector collaboration to succeed; and thirdly, genuine intersectorial policies, not led by any one sector but by a specifically-appointed intersectorial coordinator. The authors contend that political commitment of local authorities alone may not be enough to promote efficient intersectorial social policies. Comprehension of different types of IHRP and their interface mechanisms may contribute to greater efficiency and coverage of social policies that affect health equity and its social determinants positively. In the final analysis,, this will lead to more equitable health outcomes. Key words Intersectorial action, Health equity, Public policies, Social determinants of health, Brazil Resumo Este artigo analisa as Políticas Intersetoriais Relacionadas à Saúde (PIRS), com base em um estudo de caso realizado em 2008 e 2009 que mapeou as políticas sociais do município de Piracicaba, São Paulo, Brasil. A estratégia de pesquisa compreendeu metodologias qualitativa e quantitativa. Marcos legais e teóricos foram aplicados aos resultados do estudo de Piracicaba, servindo de base para a proposição de três tipos de PIRS: políticas de saúde coordenadas pelo setor saúde e que necessitam de outros para serem bem sucedidas; políticas coordenadas por outro setor, diferente do da saúde, mas que necessitam da participação deste para serem efetivas; e as políticas intersetoriais genuínas, que não são lideradas por um único setor mas sim por um órgão intersetorial criado especificamente para sua coordenação. Os autores sustentam que somente a vontade política do gestor pode não ser suficiente para a promoção de políticas intersetoriais eficientes, e que a compreensão dos tipos de PIRS, e seus diferentes mecanismos de articulação, podem contribuir para o aprimoramento e a cobertura das políticas sociais que afetam positivamente a equidade em saúde e os determinantes sociais. No final, isto irá conduzir a resultados com maior equidade em saúde. Palavras-chave Intersetorialidade, Equidade em saúde, Políticas públicas, Determinantes sociais da saúde, Brasil ARTIGO ARTICLE Intersectorial health-related policies: the use of a legal and theoretical framework to propose a typology to a case study in a Brazilian municipality 4449 Tess BH, Aith FMA 4450 Introduction Over the past two decades, Brazil has been experiencing an increase in the number and coverage of national and local social policies aimed at improving Brazilian social indicators. Although the national social and economic situation has been improving steadily, Brazil still has to overcome one of its most striking problems: inequity1,2. The 1988 Brazilian Constitution states that the objectives of the Republic are to eradicate poverty and marginalization and to reduce social and regional inequities. To achieve these goals, the Constitution recognizes health, education, food security, social assistance, social security, housing, healthy environment, leisure, security and work as social rights for all citizens3. The main strategy of the Brazilian government to support social rights, and to take action against inequity, has been the promotion of social and economic public policies3. These policies have been formulated, executed and coordinated by sectoral ministries, secretariats and other organizations of the public administration in all federative levels, particularly in the states and municipalities. The administrative organization based in sectors has been a common feature of modern federative nations, but it may, per se, jeopardize the sharing of governance power, consensus building and funding of intersectorial policies. Additionally, in Brazil, political issues may contribute to this unfavorable scenario because different political parties usually occupy different administrative levels and different institutions within a level. As a result, institutional fragmentation in social protection policies has led to poor outcomes in tackling complex problems, such as health inequity1. From the health sector point of view, social rights should not be understood as rights to be fulfilled separately, but instead, as determining factors of the health-disease process. In a recent publication, Spiegel et al.4 highlighted that, to fight health inequity, it is imperative that public policies address social determinants of health intersectorally. The authors noted that regular engagement of different sectors in dealing collaboratively with health determinants at the municipal level in Cuba contributed to a reduction in health inequity and to provision of high standards of health. In a similar vein, Franco-Giraldo and Álvarez-Dardet5 had emphasized the perspective of public health policies based on human rights. This kind of approach might shed light on the relationship between public policies and the practice of human rights, beyond the right to health. It is the fulfillment of human rights considered as a whole that allow a better protection of the right to health itself and the promotion of social equity. The importance of intersectoral policies for health equity was reiterated in the Rio Declaration on Social Determinants of Health, signed by all World Health Organization (WHO) members in 20116. The principles affirmed by the Declaration of Alma Alta7 were then reinforced, i.e., integrated practices aiming at health promotion, health protection and health recovery and rehabilitation should consider the interrelations between the bio psycho social determinants of the health-disease process. Putting public policies with integrated purpose into practice poses substantial challenges. Several studies have discussed different experiences of intersectoral practices8-13, but knowledge about the mechanisms that may facilitate interrelations across sectors is scarce. Based on a two-phase study, this paper aims to analyze and to discuss intersectoral hea (...truncated)