National Policy for Health Promotion : a Vision about Operational Axes

INTRODUCTION: Operational axes are strategies that enable the achievement of health promotion actions. Studying them allows the clarification of the actions that are being performed in the community. This study aimed to analyze the national policy of health promotion of 2015 about the implementation of strategies to achieve health promotion, considering its progress and challenges. METHODS: It is a reflective study about the operational axes inserted in the public policy. There was the division of operational axes in three thematic blocks: 1. Environmental Health, 2. Community Participation and 3. Communication and Social Information, identifying their respective health promotion actions. RESULTS: It was observed in each thematic block, that the main activities were related to the Ministry of Health programs involving leisure, work, education, environment, and communication. CONCLUSION: The operational axes presented important advances that favor the approach of realities and health problems of the population. While acknowledging the improvements in this area, it is still considerable inconsistencies and disagreements in the daily life of health practices.


Introduction
The National Policy for Health Promotion (NPHP) established by the Brazilian government in 2006, aims to institutionalize health promotion principles discussed and incorporated into the Health Reform Mo-vement by the Federal Constitution of 1998 and by the Unified Health System [1,2].
From the perspective of promotion, health is perceived as a positive and participatory concept, being guided by the search for autonomy and equality of individuals and community, so they can act on the factors that influence their quality of life [3,4].
It is perceived that health promotion is seen as an organization strategy management and health practices.So it is not just a set of procedures that inform and enable individuals and organizations or who seek to control determinants of health conditions in specific population groups, but a way to the meaning of ensuring comprehensive care to the health of the population by establishing a holistic health approach, permeating the entire course of life [5].
Several studies [1,6,7] have shown the importance of the ideas of this policy in the lives of individuals and communities.However, there is a lack of scientific evidence that discourse about the need to operationalize these actions in the territories for the mobilization of the actors involved in the search for its practical realization.Thus, it demonstrates the need to reassess the impact and transformation that occurs from these actions.
In 2015, the NPHP has been redesigned with new inductors elements for its implementation.The specification of values, the definition of transversal themes and operational axes were included, as well as adequacy and update priority issues of policy.This reformulation happened due to the real need for articulation with other public policies to strengthen it and ensure equity, improving the conditions and ways of living, and the affirmation of the right to live dialogue with the reflections of the movements within the health promotion.
Therefore, it was deemed relevant to analyze the nine operational axes, which according to NPHP of 2015, aims to achieve the health promotion actions respecting the values, principles, objectives and guidelines of the policy.The operational axes inserted in the current policy were: I -Territorialization; II -Articulation and intra-sectorial and inter-sectorial cooperation; III -Health Care Network; IV -Participation and social control; V -Management; VI -Education and Training; VII -Vigilance, monitoring and evaluation; VIII -Production and dissemination of knowledge and learning; IX -Social and Media Communication [8].
Importantly, the analysis to be performed in this study started from the premise that the process of implementing a public policy is affected by diverse political, institutional and relational factors.In this sense, it can be affirmed that the implementation of public policies starts from diverse actors and the relationships guided by their experiences, values, worldview, and inserted in a given political, economic and social context.
For this, aware that the operational axes are a set of strategies that enable the implementation of health promotion, it was deemed relevant to analyze these guided axes in existing publications about the addressed issues, aiming to clarify and facilitate the applicability of these axes/strategies listed in 2015 NPHP, through discussions already performed.
Thus, the objective is to analyze the National Policy for Health Promotion of 2015 about the implementation of the strategies to achieve health promotion actions, considering its progress and challenges.

Methods
This is a reflective study, performed from April to September 2015, based on the National Policy for Health Promotion of 2006 and the update of 2015.It was sought to know the nine operational axes included in the policy, as well as published articles involving the issue.
For a better contextualization, electronic searches were performed in the Lilacs, SciELO and MEDLINE bases by crossing the descriptors "Health Promotion", "Health Policy" and "Brazil", and the search for the place "subject" of database with the issues addressed in the operational axes: 1) Territorialization; 2) Articulation and intra-sectorial and inter-sectorial cooperation; 3) Health Care Network; 4) Participation and social control; 5) Management; 6) Education and Training; 7) Vigilance, monitoring and evaluation; 8) Production and dissemination of knowledge and learning; 9) Social and Media Communication.
The inclusion criteria for this assessment were: articles published in full-text in any language, from 2006 to 2015.It is noteworthy that studies that analyzed other thematic unrelated to operational axes were excluded.
The titles and abstracts of all articles were analyzed.If the eligibility of a study was uncertain or there was not enough information, the full-text articles were examined.40 articles were identified, which 25 articles that met the inclusion criteria were selected.Also, it was consulted information contained in ordinances of the Federal Government, about Health Promotion Policy from 2006 to 2015, documents and institutional publications of the Ministry of Health, consultations on websites, books referenced during the search.
Then, for a better analysis of the public policy, the division of operational axes was performed in three thematic blocks: 1.Environmental Health, 2. Community Participation and 3. Comunicação and Social Information, to facilitate the presentation and discussion of the results, and identified the health promotion actions inherent in each thematic block, as these are health social production strategies, which influence the quality of life of individuals [1].These health promotion actions were extracted from the selected articles and were only included in the study, in the case of answer the following question: Which health promotion actions that relate to operational axes?

Results
The first thematic block, Environmental Health, was composed of axes I to III by treating strategies that considered the specificity of the spaces/territories, involving the ways of living and working and relations conditions.

Community participation
Participation and social control.
• Shared construction of health promotion strategies.
• Development of international agendas involving democratic participation.• Simultaneous movements of listening and mobilization.
• The incentive to educational methodologies (seminars, workshops, debates) ensuring a board process of discussion, participation and dialogue between the involved different actors. Management.

Communication and social information
Vigilance, monitoring and evaluation.
• Dissemination of vigilance procedures, monitoring, and evaluation of the effectiveness of actions on the health of the individuals and collectives.• Health education aimed at the dissemination of knowledge to the population to obtain changes in habits to improve the quality of life and well-being.• Use of electronic media -SUS Portal-programs offered by the Government about health.
Production and dissemination of knowledge and learning.
Social Communication and Media.
The second thematic block, Community Participation, gathered the axis IV to VI and was related to the performance of the subjects about the complexity of health problems, in the decision process and public health policy management and the continuing education supported by active methods.
The third thematic block, Communication, and Social Information contemplated the axis VII to IX and aimed at disseminating strategies with impact on health, as well as informative and educational contents in health, to strengthen the knowledge and practices developed by the community (Table 1).

Discussion
Related to the first thematic block: environmental health, it was noted that the Brazilian experiences in health promotion anchored in the territory have been a constant challenge due to regional-locate reality and the issues related to social inequities.It is emphasized the healthy municipalities as local health plans with a focus on equity and quality of life to face this problem and ensure the right to health [9].
In the health sector the territories are places that go beyond the physical space, constituting social relationships, spatially organized, rather than tangible and concrete spaces [9].The territorial process is something continuous, under construction.The particularities that emerge at each place should be contemplated so that interventions can be anchored in the living conditions of the population and not, in particular interventions.In the meantime, interventions based on specific problems should be performed, to achieve the conditioning and determining that emerge from a general plan.
It should be also noted, the intensification, over the past decade, of the interaction processes between the federal entities -Municipalities, States and Union -and between sectors and intra-municipal actors, to guarantee the constitutional rights [10].
This theme is present in the previous policy, being mentioned as a transversal, but is currently an operational axis, seen as a form of concrete actions, given the fact that the inter-sectorial and intra-sectorial has as one of its objectives, the horizontality of relations between the sectors, based on the interdependence of services.
About the work environment, health promotion actions have been proposed to encourage healthier habits of professionals within organizations, providing improved productivity, with satisfied and confident professionals, generating a positive impact on the quality of life of workers.There are the following interventions: healthy eating, increased physical activity, weight control, decreased stress levels and decreased smoking [11].
It can be seen that the decrease in exposure of professionals to risk factors for health has been the focus of public and private sectors, seeking an increase in the quality and efficiency of service, being fundamental the investments to promote health, to the success of these actions.
Facing the challenges related to ways of living, the Ministry of Health has assumed the leading role in actions to encourage the practice of healthy habits in the population, such as the Health Academy Program, an initiative that provides for the establishment of centers with infrastructure, equipment and qualified professionals for the guidance of health and physical activity [12].
Also, aiming to structure information to management support, this federal agency has implemented the Actions Plan of Chronic Non-communicable Diseases Coping (2011-2022), defining inter-sectorial strategies and resources to confront these diseases in the country [13].
There is a health policy that must be well delineated and go through a set of actions in health that offers a continuous, comprehensive, cooperative and multidisciplinary care to the population.Thus, health care networks if well structured and organized can improve the clinical quality, health outcomes, users satisfaction and reduce the cost of health care systems.[14] Regarding the second thematic block: community participation, initiatives that allow the democratization among the involved subjects, such as the construction of policies and plans aimed at health promotion, has excelled over the last five years, providing effective changes in the perception of welfare, favoring the construction of autonomy and the search for equity through action on social determinants of health [1].
With regard to the management, the development of international agendas such as the United Nations Conference about Sustainable Development -Rio +20 (2012), the 8th International Conference on Health Promotion in Finland (2013), and the World Economic Forum in Switzerland (2015) present urgent and overall improvements involving democratic and participatory processes and establish guidelines for the implementation of the approach "Health in All Policies" due to the inability of the health sector to respond alone to face the determinants and health conditions [8].
Besides, studies involving the active participation of the population strengthened the construction of autonomy, rising new solutions on the complexity of facing health problems.The first used multiple simultaneous movements of listening and mobilization being a key for the reformulation of this policy [6].Then there was the discussion of Bamboo Method [15], applied as a validated tool to prioritize planning local actions grounded in affirmative approaches that value the individual and collective potential of the individual and community through subjective transformations as mechanisms for social changes [1].
Events such as II National Seminar on the National Policy for Health Promotion, Online Distance Learning Courses (ODL) in Health Promotion and the National Seminar on Popular Education in Health Education, stand out as listening strategies, mobilization and knowledge production ensuring a broad process of discussion, participation and dialogue between the different involved actors, including those involving the participation of managers and health professionals of the Unified Health System (SUS) and other involved sectors, researchers and teachers linked to universities, civil society representatives and users [6,16].
It is observed that the recent valorization of active methodologies and problem solving in health education has expanded space for the presence of vocational training processes, but rather critically, in which very little is discussed the differences between the various pedagogical perspectives that emphasize these methodologies.The pedagogical practices among the population and its social movements, in informal educational contexts, have also hampered its application in the health-training field [17].
Aiming to democratize the decisions, it was used the "Taking Stock" procedure suggested by Fetterman, in the "Empowerment Evaluation" methodology [18].It is a model that prioritizes events, facts or results in a democratic manner, with the demystification of a potentially redemptive education and reaffirming the subject, socially determined, aware and responsible for their health.[6] It can be affirmed before the aforementioned scientific evidence that there was increasing social participation and in the relevant decisions that affect the lives of individuals and communities, with the perspective that a unique segment or point of view was not sufficient to meet the needs and provide transparency and democratic participation.
Citizenship should guide the subjects in the measurement of welfare processes and quality of life, favoring autonomy to the individual, criticality, and reflection, making it a thinking being, far away, so, from the individual mass [9].Therefore, it is needed to give voice to the subjects, because it is through the principles and health promotion values linked to individual and community empowerment that the population recognizes their problems advocating for healthy public policy.Thus, public policies of equitable character must be prioritized, to support collective reflections and look for alternatives in socio-political contexts, encouraging creative and feasible solutions to health problems in our country.It is considered necessary; therefore, a change of initiative by the different segments to achieve the transformation of practices based on paradigmatic perspective.
The last thematic block: communication and social information bring indicators monitoring strategies to promote health that were inserted into actions that composed the National Health Plan (2012-2015) and the Strategic Planning of the Ministry of Health (2011-2015) as well as the insertion of health promotion in the Multi-annual Plan.Also, regulation and control actions have also been implemented to monitor the health promotion projects funded by the government, encouraging the Brazilian population to acquire healthier habits [1].
In this context, the Ministry of Health has adopted several measures to evaluate the implemented programs and strategies to measure the effectiveness and impact of these actions about the health of the population.Methodological strategies have been used as an analytical history of implementation of the programs at the local level, identification of the logic model of each program, systematic observation of performed actions, collecting qualitative data of professionals and involved managers, quantitative studies with users, as well as conducting studies by telephone survey and home [19,20].
The process of evaluation, monitoring and vigilance are key concepts in health promotion and noteworthy in NPHP because through the systematization, monitoring, and evaluation, observation, and recording of the process of an evaluation model for a given population are performed for a specific location, allowing an effectively adequate monitoring.Although the assessment is paramount, there is a deficit of this process within the SUS, because of the challenge in the scope of interventions and monitoring of the target audience [21].
The communication of this information through works performed in public health is an alternative to improve and expand knowledge, and to evaluate the effectiveness of programs that are being implemented providing a feedback to the population [22].
Another way to share and divulge the results broadly, with the community, is through health education.To encourage a reflective and resolute attitude about problems needs and potential of individuals, it can be applied to health education as an educational process of building health knowledge, from the needs and unknowns of certain subjects.There are practices that aim to empower people in their self-care, in the dissemination of knowledge and relationships with professionals, making effective its action [5].
Health education is one way in which professionals, from their knowledge and experience, can spread to their community, in their place of work, to get changes in habits and improved quality of life and well-being.Thus, it is necessary that health professionals develop working methods that seek to promote health in the community, trying to establish links between scientific knowledge and popular knowledge, developing among them, values of quality of life and well-being, always encouraging engagement, participation, and partnership between professionals, managers, and community.
It is notorious that community communication is intended to seek the community strengthening in the social participation, decision-making and autonomy of the population.One of the artifices used for the insertion of health promotion in the media is the SUS health portal (www.saude.gov.br) of the Ministry of Health [23], which has all the programs of the Government about health, assuming the Law No. 12.527, which regulates the constitutional right of citizens' access to public information.To regulate this right, the Law guarantees access to information and should be performed with the basic principles of public administration, such as information disclosure, use of the communication media of information technology and social development [24].
In health education, should also be emphasized the continuing education of health professionals, that direct to the qualification of health working processes, taking into account the needs and local circumstances [25].
Therefore, to develop a health education focused on the democratization of information, there must be breaking paradigms, seeking symmetry of knowledge, valuing knowledge and the scientific and popular knowledge, approaching, increasingly all spheres that make up this scenario [26].

Final Considerations
From the performed analysis, there were advances and challenges related to the nine operational axes.It highlights advances in involving inter-sectorial arrangements in the management, the inclusion of health promotion in the workplace and urban public spaces, public participation, education, training and access to communication.
As a challenge, it still needs to make progress in the everyday actions of the health services, jointly, involving the various involved actors and sectors.Thus, the user should be as a co-participant subject and co-responsible for their health to promote empowerment with emphasis on autonomy and professional-user dialogue.Another challenge is the deficit in the evaluation process of the actions under the SUS, because of the great challenge in the scope of interventions and monitoring of the target audience.
Consequently, the operational axes present important gains that favor the approach of health realities and health problems of the population.While recognizing the improvements in this area, it is still considerable the incongruities and misfit in the daily life of health practices for the implementation of health promotion actions in the SUS.
It was found that the grouping into thematic blocks allows a direct and objective view, contemplating a political-economic-social context of the current health promotion actions, inserted in public policies.The establishment of the operational axes is fundamental for public health of quality and priorities to confront the challenges presented for SUS integration, a process not yet consolidated.
It is emphasized that the present research has limitations on the fact that they have explored three databases, as well as being a theme inserted in 2015 in the policy, limiting the search for interventions related to each operational axis, suggesting a new research in all databases electronically available in the medium term.
Therefore, as contributions to this study is expected to sensitize managers and health professionals to support collective reflections and to seek practical alternatives to stimulate creative and workable solutions to the health problems and cause changes in the way of planning, organizing, perform and evaluate the work in health.

Table 1 .
Thematic blocks, operational axes and health promotion actions.