ABSTRACT

The present paper aims to systematize information on health leaders inserted in state and municipal governments, to reflect on technical, academic and political influences in shaping their trajectories, seeking to contribute to the design an overview of Unified Health System (SUS) management at subnational bodies. The study is supported by research from secondary sources, including official databases, government portals and commercial news. Information from the secretaries of the 26 states and their capitals, in addition to the Federal District, in office in May 2021, was processed, generating 53 resumes, that were categorized as specialists (79%), health professionals (75%), career politicians (25%) and businesspeople (19%). Despite the significant partisan influence, a process of formation of bureaucratic cadres by the parties was found, beyond the electoral dispute. Of the thirteen career politicians identified, eleven were also typified by the analysis as ‘specialized’, questioning senses about the opposition between ‘technical’ versus ‘political’ profiles, suggesting the relevance of the intersections of trajectories. An exceptionality of technical insulation of health was not confirmed. Thus, the image that political party forces are antagonistic to academic training and experience in public administration is unrealistic, suggesting that health is simultaneously specialized and politicized.

KEYWORDS
Politics; Unified Health System; Health manager; Local government; State government

RESUMO

O trabalho objetiva sistematizar informações sobre os secretários de saúde inseridos em governos estaduais e municipais, para refletir sobre influências técnicas, acadêmicas e partidárias na conformação de suas trajetórias, buscando contribuir para o delineamento de um panorama da gestão do Sistema Único de Saúde (SUS) nas instâncias subnacionais. O estudo é apoiado em fontes secundárias, incluindo bases de dados oficiais, portais de governos e notícias divulgadas pela mídia comercial. Foram processadas informações dos secretários dos 26 estados e suas capitais, além do Distrito Federal, no cargo no mês de maio de 2021, gerando 53 currículos, que foram categorizados como especializados (79%), profissionais de saúde (75%), políticos de carreira (25%) e empresários (19%). Apesar da significativa influência partidária, encontrou-se um processo de formação de quadros burocráticos pelos partidos, para além da disputa eleitoral. Dos treze políticos de carreira identificados, onze também foram tipificados pela análise como ‘especializados’, interpelando acepções sobre oposição entre perfis ‘técnico’ versus ‘político’, sugerindo a relevância das interseções das trajetórias. Uma excepcionalidade de insulamento técnico da saúde não foi confirmada. Dessa forma, não é realista a imagem de que forças político-partidárias sejam antagônicas à capacitação acadêmica e à experiência na administração pública, sugerindo que a saúde se apresenta, simultaneamente, especializada e politizada.

PALAVRAS-CHAVE
Política; Sistema Único de Saúde; Gestor de saúde; Governo local; Governo estadual

Introduction

Studies on health secretaries and secretariats, assuming the relevance of subnational bodies for the implementation of the Unified Health System (SUS), showed mismatches between the profile of the occupant and the attributions of the position<sup>11 Souza A. O perfil dos secretários municipais de saúde de Minas Gerais e a organização de programas e projetos municipais. Rev. Min. Saúde Pública. 2002; 1(1):1-10.

2 Arcari JM, Barros APD, Rosa RS, et al. Perfil do gestor e práticas de gestão municipal no Sistema Único de Saúde (SUS) de acordo com porte populacional nos municípios do estado do Rio Grande do Sul. Ciênc. Saúde Colet. 2020; 25(2):407-420.-33 Ouverney ALM, Carvalho ALBD, Machado NMDS, et al. Gestores municipais do Sistema Único de Saúde: perfil e perspectivas para o Ciclo de Gestão 2017-2020. Saúde debate. 2019; 43(esp7):75-91.</sup>. Over time, the understanding of the need to adapt professional profiles to the coordination activities of local and regional health systems has been consolidated^{44 Paim JS, Teixeira CF. Configuração institucional e gestão do Sistema Único de Saúde: problemas e desafios. Ciênc. Saúde Colet. 2007; 12(2):1819-1829.}. The analyzes on the ‘specialization’ of the secretaries took place pari-passu with the process of creating municipalities and local administrative bodies in the country, the National Council of Health Secretaries (Conass) and the National Council of Municipal Health Secretaries (Conasems). The conformation of decision-making flows and tripartite funding for health arising from constitutional precepts, organic laws and administrative norms, as well as the organization of health committees in city councils and legislative assemblies required the development of skills and competences in order to debate in sectoral forums.

In this sense, the SUS implementation process contributed to the progressive relevance and deliberative autonomy of health secretariats and their representative entities. Recently, the Conass note^{55 Brasil. Conselho Nacional de Secretários de Saúde. Nota oficial. [acesso em 2021 maio 16]. Disponível em: https://www.conass.org.br/wp-content/uploads/2020/05/NOTA-OFICIAL.pdf. 16 maio 2021.
https://www.conass.org.br/wp-content/upl...} questioning the use of hydroxychloroquine for the treatment and prevention of COVID-19 stated the need for an integrated plan to respond to the pandemic. Other initiatives, such as the articulation between Conasems, Conass and Datasus, were essential for the registration for vaccination. Undoubtedly, over time, a technical corpus was constituted and consolidated in the health secretariats. However, the hypothesis of a propensity to adhere to agendas favorable to the expansion of public health does not rule out unfavorable interests and pressures to the SUS in the composition of alliances for the exercise of positions defined by elected governors and mayors.

The present work, situated as one of the developments of the theme of interactions between the political system and health, proposes to systematize information about health secretaries inserted in state and municipal governments, resulting from choices in two unique political contexts: the defeat of center-left coalitions in 2018 - although PT, PDT and PCdoB victories were registered in Northeastern states - and changes, albeit discreet, in the political-party framework in the mayoral elections. Both political conjunctures give rise to specific questions about the conduct of health policies by states and municipalities. Although this study does not answer all these questions, its main contribution is to outline a political panorama, albeit partial, of subnational SUS bodies, based on the analysis of the secretaries’ professional and political careers.

Relations between the political system and health policies

Research on the profiles of health secretaries adopts assumptions according to which many elements that determine health are located outside the health care system^{66 Oliveira MAC, Egry EY. A historicidade das teorias interpretativas do processo saúde-doença. Rev. Esc. Enferm. USP. 2000; 34(1):9-15.} and within the political system<sup>77 Mishori R. The Social Determinants of Health? Time to Focus on the Political Determinants of Health! Med Care. 2019; 57(7):491-493.

8 Beckfield J, Krieger N. Epi + demos + cracy: linking political systems and priorities to the magnitude of health inequities - evidence, gaps, and a research agenda. Epidemiol. Rev. 2009; 31(1):152-177.-99 Mackenbach J. Political determinants of health. Eur. J. Public Health. 2014; 24(1):2.</sup>. Policy analyzes from this perspective tend to blur the demarcation lines between political science and health, admitting ‘theft’ between the fields of knowledge^{99 Mackenbach J. Political determinants of health. Eur. J. Public Health. 2014; 24(1):2.}. It is worth remembering that analyzing politics, in turn, has political implications, because, as Wright Mills^{1010 Mills CW. A imaginação sociológica. Rio de Janeiro: Editora Zahar; 1975.} states, even if implicitly, carrying out such research and disseminating it is also a form of political action. For Muntaner et al.^{1111 Muntaner C, Borrell C, Ng E, et al. Locating politics in social epidemiology. In: O’Campo P, Dunn JR. Rethinking social epidemiology: towards a science of change. London: Netherlands Springer; 2012. p. 175-202.}, public health scientists who deny their political action and claim to be ‘value-free’ adopt an incongruous stance, as they “are explicitly committed to improving the population’s health and reducing health inequalities”^{1111 Muntaner C, Borrell C, Ng E, et al. Locating politics in social epidemiology. In: O’Campo P, Dunn JR. Rethinking social epidemiology: towards a science of change. London: Netherlands Springer; 2012. p. 175-202.(178)}. When discussing the relationship between politics and health, the commitment to democracy is reaffirmed, by systematizing subsidies for the conduct of health policies and exposing limits and links between living conditions and political representations.

The positions of health secretaries in 2021

The secretaries are the leaders chosen by mayors and governors elected by suffrage, composing the executive power. In this way, they share responsibilities with the government, being commonly referred to as ‘managers’, that is, leaders of bureaucracies, drivers of public policies in thematic divisions - the ‘cabinets’ -, with health being one of the highlighted. Therefore, a comprehensive analysis of how the executive of states and municipalities has the capacity to implement policies demands an analysis of who these managers are. However, empirical analysis of secretariats are usually less common than ministries at the federal level, which is especially limiting in a country with a federalist order such as Brazil, in which subnational entities, including the 5,570 municipalities, are endowed with autonomy.

Therefore, the context of Brazilian public health can be summarized in an analytical matrix that summarily considers underfunding and the political conjuncture of advancing anti-establishment, populist, if not overtly anti-democratic, proposals as determinants of the health crisis in Brazil. When looking for nuances to detail the equation of cutting resources and refusing to adopt better scientific evidence, the subnational spheres acquire importance, pointing out the secretaries of health as key players in the implementation of health policies across the country^{1212 Coelho TCB, Paim JS. Processo decisório e práticas de gestão: dirigindo a Secretaria da Saúde do Estado da Bahia, Brasil. Cad. Saúde Pública. 2005; 21(5):1373-1382.,1313 Santos ADO, Lopes LT. Coletânea direito à saúde: boas práticas e diálogos institucionais, Brasília: Conass; 2018.}.

Considering the need to deepen knowledge about decision-making dynamics within the SUS, this work explores an angle of this vast theme: the profile of leaders at the state and municipal levels (restricted, for reasons of scope, to capitals).

In dialogue with the literature, the article has as its guide the outlining of the profiles of these managers, considering demographic, academic, party and societary components, seeking to identify striking traits in the definition of the trajectory of health management leaders in Brazil, under the critical juncture of the health crisis. The investigation seeks to complement existing research on the profile of the secretariat, emphasizing the political components of public administration. This is a complementary contribution to the analysis of the topic carried out by more extensive and in-depth research whose methods are supported by the application of questionnaires or interviews directly to the secretaries^{33 Ouverney ALM, Carvalho ALBD, Machado NMDS, et al. Gestores municipais do Sistema Único de Saúde: perfil e perspectivas para o Ciclo de Gestão 2017-2020. Saúde debate. 2019; 43(esp7):75-91.,1212 Coelho TCB, Paim JS. Processo decisório e práticas de gestão: dirigindo a Secretaria da Saúde do Estado da Bahia, Brasil. Cad. Saúde Pública. 2005; 21(5):1373-1382.}.

The work is doubly justified by relevance and opportunity. The importance of the study is defined because the reflection on the institutional architecture of the SUS is subordinated to the Brazilian federative model, which is guided by decentralization, establishing responsibilities of states and municipalities in the formulation and execution of health policies. In turn, regional and intra-regional heterogeneities and inequalities foster new tensions^{33 Ouverney ALM, Carvalho ALBD, Machado NMDS, et al. Gestores municipais do Sistema Único de Saúde: perfil e perspectivas para o Ciclo de Gestão 2017-2020. Saúde debate. 2019; 43(esp7):75-91.,1414 Souza C. Governos e sociedades locais em contextos de desigualdades e de descentralização. Ciênc. Saúde Colet; 2002; 7(3):431-42.}. As a result, subnational entities develop relationships of interdependence, especially in the provision of services, with significant disparities in capabilities, configuring relationships of competition and cooperation^{1515 Lima LD, Queiroz LFN. O processo de descentralização e regionalização do SUS no contexto do Pacto pela Saúde. In: Machado CV, Baptista TWF, Lima LD, organizadores. Políticas de saúde no Brasil: continuidades e mudanças. Rio de Janeiro: Editora Fiocruz; 2012. p. 229-251.}. The 1988 Constitution, which advocates decentralization as synonymous with democratization, provided shared responsibilities, necessarily inducing coordinated and, therefore, cooperative action. However, this institutional structure has been subjected to tests by the advance of COVID-19, which can be considered a Complex Intergovernmental Problem (CIP), as it requires a high level of intergovernmental coordination and cooperation for an effective response^{1616 Paquet M, Schertzer R. COVID-19 as a Complex Intergovernmental Problem. Can. J. Polit. Sci. 2020; 53(2):1-5.}. Therefore, Brazil can be interpreted as an example ‘in reverse’ in the fight against the health crisis, since the measures to combat it were characterized by intergovernmental lack of coordination^{1717 Abrucio FL, Grin EJ, Franzese C, et al. Combate à COVID-19 sob o federalismo bolsonarista: um caso de descoordenação intergovernamental. Rev. de Adm. Pública. 2020; 54(4):663-677.}, with the confrontation between two federative models: the cooperative, recommended by the Constitution, versus the Bolsonarist conception of centralizing and dualistic bias, reducing the role of the Union in helping subnational entities, unbalancing the institutional pillars, as became visible by the conflicts between the president and governors and mayors about authority over social isolation measures. The ‘bolsonarist federative tripod’, based on compartmentalization, autocracy and confrontation, threatened the health area, which best represents the institutional arrangement desired by the 1988 Constitution (CF/88)^{1717 Abrucio FL, Grin EJ, Franzese C, et al. Combate à COVID-19 sob o federalismo bolsonarista: um caso de descoordenação intergovernamental. Rev. de Adm. Pública. 2020; 54(4):663-677.}. The institutional robustness of the SUS collided with the component of the political conjuncture, marked by the operation based on conflict, pointing out that the conduct of the health crisis, at the federal level, was based on the transfer of responsibilities^{1818 Fleury S, Mafort A. Confronto no federalismo brasileiro durante a pandemia aumenta riscos sanitários e ameaça à democracia. Rio de Janeiro: CEE-Fiocruz; 2020. [acesso em 2021 abr 18]. Disponível em: https://cee.fiocruz.br/?q=Confronto-no-federalismo-brasileiro-durante-a-pandemia-aumenta-riscos-sanitarios-e-ameaca-a-democracia.
https://cee.fiocruz.br/?q=Confronto-no-f...} - and resulting in high mortality and lethality rates.

Methodological Approach

The study has an exploratory nature, being supported by research from secondary sources. Information was collected from the secretaries of the 26 states and their respective capitals, in addition to the DF, totaling 53 resumes. The selection of secretaries considered those who were in office during the month of May 2021.

The research was based on consulting publicly available information on the internet, including government portals, news sites, especially regional ones, curriculum databases (Escavador and Lattes), legal bases (JusBrasil) and data on participation in companies (Diretório Brasil). The information that made it possible to delineate the health secretaries’ profile was organized into five blocks: demographic characteristics; training and profession; party affiliation; participation in companies; and suspicions or evidence of involvement in scandals.

For the basic demographic data, as well as the list of secretaries, the official pages of Conass and Conasems were used, with checks on news portals about possible exchanges not yet updated on the websites of the referred councils. For age, media interviews or data from the websites of the respective city halls and state governments were used. These sources also provided part of the data from previous experiences and academic training. The latter was mainly based on the Lattes curriculum database, when available.

With regard to training and profession, research was carried out in databases and media portals available on the internet. It should be noted that the information contained on sites such as Escavador and the Lattes curriculum database is largely based on self-reported information. Regarding journalistic articles, it is also noted the existence of texts whose bias of favoring secretaries is explicit, especially in small vehicles of the local press^{1919 Diário X. Coxinense e médico ortopedista José Mauro Filho assume a secretaria municipal de Saúde de Campo Grande. 2019. [acesso 2020 ago 1]. Disponível em: https://www.diariox.com.br/estado-ms/coxinense-e-medico-ortopedista-jose-mauro-filho-assume-a-secretaria/18954/.
https://www.diariox.com.br/estado-ms/cox...} .

To register the secretaries’ party affiliation, the TSE (Superior Electoral Court) Repository - Party Affiliation System, public consultation^{2020 Brasil. Tribunal Superior Eleitoral. Sistema Consulta Filia. [acesso em 2021 maio 16]. Disponível em: https://filia-consulta.tse.jus.br/#/principal/menu.
https://filia-consulta.tse.jus.br/#/prin...} was used. Based on the name of each secretary, it was sought if they had a certificate of party affiliation, with care for homonyms, checking the municipality of affiliation. Then, by the voter’s title, the Affiliation Certificate was generated - Historic type^{2121 Brasil. Tribunal Superior Eleitoral. Sistema Consulta Filia - Gerar certidão. [acesso em 2021 maio 16]. Disponível em: https://filia-consulta.tse.jus.br/#/principal/certidao-gerar.
https://filia-consulta.tse.jus.br/#/prin...} , which records the affiliation movements. It is important to note that there is a difference between ‘politicians’ and ‘affiliates’. While the first group is fully inscribed in the second, the converse is not true, that is, not all members of political parties can be considered ‘politicians’, that is, those who occupied (or, for this work, at least, ran, although without victory) for positions through elections, in the legislature and in the executive. Thus, while politicians in general, especially those who actually held positions in the legislature or executive, can be easily detected with a simple internet search, affiliates needed a detailed search in the TSE repository. Career politicians, due to their intrinsic public visibility, were identified in a quick search on internet search engines, many with profiles on the websites of the houses they occupied (Legislative Assemblies, Chamber of Deputies, etc.), in addition to appearing in media headlines and interviews.

Data on involvement in suspicions and scandals were obtained from news portals, with preference given to public legal institutions, such as the respective Public Ministry.

The shareholding was identified on the website ‘Diretório Brasil’ and complemented by news that eventually characterized the secretary as a businessman.

Considering the set of information, a ‘photograph’ of the health secretaries’ profile was obtained, that is, information restricted to the specific time point of data collection, shortly after a year after the emergence of the COVID-19 health crisis. However, there were changes in the structures of the health secretariats, which were not contemplated. Therefore, the analysis did not include changes in secretaries, which are frequent.

It is necessary to note limits resulting from the scope, reliability and quality of the secondary sources consulted. Although several conferences were used for each record, it is possible that the information contains inaccuracies, especially with regard to the attempt to apprehend participation in companies (which can occur through different means) and suspicion/involvement in scandals (whose news and processes, when they come to light, do not correspond to the management period).

Despite the intrinsic beacons of a cross-sectional study organized from empirical documentary bases, the investigation contributes to delineating less anodyne profiles of the health secretaries of states and capitals in a very complex context of national life.

Results

Demographic characteristics

In the survey of the CVs of the secretaries of the states, of their respective capitals and of the Federal District (DF) (n = 53), we found a predominance of males (75%), with 1 secretary for every 3 secretaries. It is also noteworthy that only two women are elected heads of state executives and the respective capitals, being a governor and a mayor. Analyzing them separately, the states and the Federal District have only 10% of health secretariats headed by women, while the capitals have 37%.

Not all CVs provide accurate information about age, but, as this information is important for the biographical characterization of secretaries, an estimate was made for 24 cases (45%), necessarily of little rigor, using age groups in order to to alleviate imprecision. Among the 29 cases of precisely known age, the average reached is 53 years of age, a minimum value of 37 and a maximum of 57 years. Thus, we have the following age distribution for the complete set of profiles, including approximations: 30-40 years: 19%; 40-50 years: 17%; 50-60 years: 35%; 60-70 years: 28%.

Regarding the origin and geographic displacements of the secretaries, 30% were born in a different state than the one they work. It is important to consider that the change can occur at different times of its trajectory, whether already graduating in the new state, in which he or she develops their entire professional career, or moving precisely because of the appointment to work as secretary.

Academic education

Of the 53 CVs searched, all had higher education, with the single exception of incomplete higher education. Forty secretaries are health professionals, making up 75%. Within this category, graduates in medicine predominate, corresponding to almost 80% of those trained in health, with practically half of the secretaries (24, or 46% of all secretaries) being doctors and men, followed by graduates in nursing (four), pharmacy (two), dentistry (two) and social service (one). The remaining 25% have different degrees, such as History, Agronomy and Engineering, with Law being the predominant course (6) for non-health professionals, making up 11% of the CVs.

POSTGRADUATE STUDIES

35 secretaries (66%) had at least one postgraduate course, and there are even secretaries with several courses in their curriculum, such as masters, doctorates, professional residency specializations and MBAs (Master of Business Administration). The Lattes curriculum was the main source for this information, which allowed the selection of 74 courses, including 48 specialization courses, and it is common to find CVs with more than one specialist title. Medical residencies correspond to 20% of the analyzed courses. Eight (15%) of the secretaries have a doctorate, and almost a quarter (12, or 23%) have a master’s degree. There are 17 (32%) secretaries with at least one postgraduate degree in public management or public/collective health. Only 23 (about 30%) of the courses are in the fields of public/collective health or public management, demonstrating that graduate studies are justified by professional qualifications, often in self-employed activities, such as medical specialties, especially in cardiology and surgery (thirteen courses, or 18%).

Of the certifying institutions, 65% are public, with the most present being federal universities, Fundação Oswaldo Cruz (Fiocruz) and University of São Paulo (USP). Private institutions - including philanthropic, charitable, etc. - certify 28% of the courses analyzed in the curricula, in addition to titles obtained abroad, in Portuguese, English and American universities.

Past experiences and trajectory

Relevant to the analysis of the health secretariat is to know their previous experiences, shaping the trajectories. The Lattes curriculum was the source that returned the most results and in an organized way, with 30 CVs analyzed (56%), but it is necessary to consider the primarily academic purpose of the platform, which ended up giving greater weight in the analysis to the experiences in Universities and Higher Education Institutions (HEIs) than other professional or government experiences, but this information was also sought on other websites and in the media. At least 30% (16) of the secretaries worked as higher education professors, with private HEIs prevailing. Twenty-nine (55%) held some other position in another secretariat or had previous experience in the secretariat itself.

Party affiliation

The analysis was started by all secretaries who had affiliation at the time of the research (consultation with the TSE Repository). Assuming that not all members of a political party are career politicians or candidates, it was found that half of the secretaries (27) are affiliated with one of the 15 political parties, but half of these members are not career politicians nor do they ran in the last three elections. DEM and PSDB have 4 affiliated secretaries; Cidadania has 3; PDT, PT and PSB, 2 each; PSD, PCdoB, Solidariedade, PMN, MDB, Pode, PP, Patriota and Republicanos have 1 secretary each.

Here, those who are currently affiliated with a party that is either the same as the incumbent or are in the elected coalition will be classified as ‘party-aligned’. Fourteen (26%) meet at least the criterion of affiliation to the coalition, with 10 (19%) being affiliated, at the time of analysis, with the same party as the ruler who appointed them. Of the latter, which range from career politicians to those who have never run for office, but are affiliated, are members of the following parties: PSDB (3 secretaries and governors); PT (2 secretaries and governors); MDB, Cidadania, DEM, PP and PDT (1 secretary and 1 governor, each party). They are the secretaries of the municipalities of São Paulo, Teresina, Macapá, Palmas, and the states of PI, RN, MS, MT, AC and AP.

At least a quarter (13 or 25%) of secretaries are career politicians, that is, notorious politicians. They are distributed among the following parties: PSDB (3 secretaries); PT, with two secretaries; and DEM, Citizenship, PSD, PCdoB, PDT, PMN, PSL, PP, Republicans (1 secretary each).

The government officials who nominated a career politician to occupy their health secretariat belong to the following parties: PT (3); PSDB, PSL, PP (2 each); MDB, PSD, CAN, DEM (1 each).

There are also secretaries who are not notorious politicians but have recently ran. They can be considered candidates for a political career - strictu sensu - if a restricted meaning is adopted, at this moment, of the term ‘politician’ as a representative of an elective legislative or executive position. Three profiles were identified, based on consultation with the TSE bases, who ran in the last three elections (2016, 2018 and 2020), affiliated with PCdoB, Cidadania and DEM, the last two belonging to the same party as the ruler who nominated them.

Involvement in scandals and suspicions

It is noteworthy that most of the scandals and convictions do not affect the secretaries in office, but the former managers. This can be explained by the time that judicial processes and investigations demand, due to delay or not, being slower than the speed of political processes. Therefore, replacements, which only depend on an act by the mayor or a request for dismissal by the secretary, take place much faster, and often just before possible scandals. Therefore, the ‘complaints’, ‘suspects’ and ‘scandals’ were raised that mentioned the secretaries in office at the time of the research, both in the media and on portals of the judiciary, returning 19 secretaries still in office.

Profiles

It becomes clear that there is unequivocally no single possible trajectory to rise to office. Given the myriad presented by the dozens of cases analyzed, we resort to the Weberian strategy of building ideal types^{2222 Freund J. O tipo ideal. In: Sociologia de Max Weber. Rio de Janeiro: Forense Universitária; 2000. p. 47-55.}, that is, a representation derived from rationalization that accentuates the characteristic traits of the trajectories, in order to make the results intelligible and enable the analysis. Finally, it should be noted that typification is by no means an objective, but a research instrument.

The typification was built by the authors in order to contemplate the influence of the main forces acting in the trajectory of a secretary, from the combination of literature and data collected in the CVs. We sought to find, in each trajectory, the influence: of the public administration, based on previous experience in public management (of health or another field of public policy); from the academy, based on training, especially in postgraduate studies; from the political-party sphere, based on affiliations; and the private sector, based on the role of secretaries as entrepreneurs<sup>2323 Junqueira TS, Cotta RMM, Gomes RC, et al. As relações laborais no âmbito da municipalização da gestão em saúde e os dilemas da relação expansão precarização do trabalho no contexto do SUS. Cad. Saúde Pública. 2010; 26(5):918-928.

24 Brandão CC, Scherer MDDA. Capacidade de governo em Secretarias Municipais de Saúde. Saúde debate. 2019; 43(120):69-83.

25 Palotti PLM, Cavalcante PLC. Articuladores políticos e dirigentes da burocracia - ministros de Estado no Brasil e em perspectiva comparada. In: Pires R, Lotta G, Oliveira V. Brasília, DF: Enap; 2018. p. 161-174.

26 Teixeira CF, Molesini JA. Gestão municipal do SUS: atribuições e responsabilidades do gestor do sistema e dos gerentes de unidades de saúde. Rev. baiana saúde pública. 2002; 26(1):29-40.-2727 Costa AM, Bahia L, Scheffer M. Onde foi parar o sonho do SUS. Le Monde Diplomatique Brasil. 2013; 69(30):1.</sup>. Thus, the following types were constructed: ‘specialized’, ‘health professional’, ‘career politician’ and ‘entrepreneur’.

The typification was generous when considering previous experiences, even in other secretariats, and for allowing an interdisciplinary action in health, considering training and professional experiences both in the area of public management and public/collective health. There was also no preference regarding academic training in relation to professional experience or vice versa, that is, a postgraduate degree in the area of public management, for example, is enough to endow the profile of the classification of ‘specialized’. Despite the public Lattes Curriculum, as the main source of this information, it is understood the preponderance of ‘specialized’ profiles over ‘entrepreneurs’, for example, but there is a skeptical reservation about the possible corporate underrepresentation, since Income and property data are largely confidential.

SPECIALIZED

The managers in this profile have academic training and experience in the field of bureaucracy, often serving in the public administration, sometimes within the health department itself, ascending ‘from within’ to the position of secretary.

We analyzed, mainly from the Lattes Curriculum, experience in public management and professional coordination, as well as experience and academic training.

Twenty-nine secretaries (55%) held some other position in another secretariat, or had previous experience in the secretariat itself; 34% (18) of the secretaries have already been responsible for managing a health unit, such as hospital directors, coordinating the health team, including in the private network; 15% (8) were part of Health Councils, whether municipal, state, Conass, Conasems, Councils of Municipal Health Departments (Cosems); Fifteen secretaries (28%) did not present any of these analyzed experiences. Regarding academic training, 28% (15) have a specialization in Public Management or Public/Public Health, 9% (5) have a master’s degree and 6% (3) have a doctorate in one of these areas.

HEALTHCARE PROFESSIONAL

Typical professional of one of the health professions (social workers; biologists; physical education professionals; nurses; pharmacists; physiotherapists; speech therapists; physicians; veterinarians; nutritionists; dentists; psychologists and occupational therapists) in the capital itself, working in clinics and offices, sometimes as partners or owning these establishments. They can also be civil servants, but they differ from specialized ones because they work directly in health care, and when they occupy management positions, they remain in health units, in coordination roles. When candidates, they usually use the designations ‘MD’, ‘nurse’ in their names... Sometimes, they occupy prominent corporate positions, such as in associations, councils, professional class bodies, such as identified in five cases (13% of health professionals).

CAREER POLITICIAN

They are public figures, sometimes traditional cadres of the party to which they are affiliated, who have already been elected to the executive or legislative power, at municipal, state or federal level. They have different academic backgrounds and, not infrequently, have already held the position of secretaries in different public policy areas. It is also important to identify those who aspire to a political career, such as secretaries who ran in recent elections but did not win.

There are thirteen secretaries: Porto Alegre, São Paulo, Salvador, São Luís, Rio Branco, SC, PR, PI, CE, RN, MS, AC, RR, who were elected, at some point, to the positions of councilor, mayor, state and federal representatives and vice governor.

ENTREPRENEUR

They have business activities, sometimes widely known, with large equity or shareholdings in the health sector, or have equity interests in various companies. It is important to emphasize the difficulty of accessing such types of data, some of which are confidential by law. Small societies of clinics and offices (Enterprises registered as ‘Medical Clinic activity restricted to consultations’, with generally up to 3 partners, if not the only one), were not included in the analysis, in order to differentiate from health professionals.

From the consultation of the public portal Diretório Brasil, the sieve was adopted to select those who were part of companies with 5 or more partners, in addition to notorious businessmen, through information from the media, returning 10 secretaries (about 20%), being more common participations in hospitals, laboratories and other private health establishments, but companies of various economic activities were also found, such as travel agency, sanitation company, events, retail trade.

Table 2, below, summarizes the complete classification of the profiles, combined with other data collected.

The sum of the ratings exceeds the number of CVs, as the same CV can receive more than one rating when fulfilling the requirements.

Discussion

The results show that career politicians commonly have experience in management, marking a counterpoint to the conception of an opposition between ‘technical’ and ‘political’ profiles^{2828 Folha de São Paulo. Haddad anuncia os ‘técnicos’ de sua gestão. 2012 nov 12. [acesso em 2021 set 29]. Disponível em: https://www1.folha.uol.com.br/cotidiano/2012/11/1184589-haddad-anuncia-os-tecnicos-de-sua-gestao.shtml.
https://www1.folha.uol.com.br/cotidiano/...} - with an evaluative preference for the former -, and with the attempt, in particular, on the part of candidates, to assert themselves as ‘apolitical’, since, in fact, “politics and technique are two sides of the same coin, impossible to be demarcated in practice”^{2929 Peci A. O “político” e o “técnico” na burocracia pós-democrática brasileira: um debate ideológico?. Rev. de Adm. Pública. 2018; 52(5):1-3.(22 Arcari JM, Barros APD, Rosa RS, et al. Perfil do gestor e práticas de gestão municipal no Sistema Único de Saúde (SUS) de acordo com porte populacional nos municípios do estado do Rio Grande do Sul. Ciênc. Saúde Colet. 2020; 25(2):407-420.)}, since politics and bureaucracy are no longer separable, in overcoming the Weberian paradigm. It has already been shown^{2525 Palotti PLM, Cavalcante PLC. Articuladores políticos e dirigentes da burocracia - ministros de Estado no Brasil e em perspectiva comparada. In: Pires R, Lotta G, Oliveira V. Brasília, DF: Enap; 2018. p. 161-174.} that the idea of political ‘allotment’ of positions is more based on stereotypes than it is empirically grounded, since, over partisan disputes, professional trajectories, federative issues, race and gender profiles and even personal ties to the ruler matter. Within the SUS management itself, in turn, in addition to technical and administrative skills, the literature points out that political competence is equally necessary for the municipal manager^{2626 Teixeira CF, Molesini JA. Gestão municipal do SUS: atribuições e responsabilidades do gestor do sistema e dos gerentes de unidades de saúde. Rev. baiana saúde pública. 2002; 26(1):29-40.}. The typification corroborated the notes in the literature by finding an intersection of 34 secretaries (64%) classified as both ‘specialized’ and ‘health professional’. Seven secretaries (five of them state secretaries) also received the third classification of ‘career politician’. In this way, secretaries can collect academic training in the area of health/public management, experience in public administration and political career in their trajectory.

The party affiliation of the secretaries, a component not addressed in other researches, was investigated in order to understand if there is an allocation of internal cadres of the governing parties in the secretariats, which is expected, since it is the first level of the executive. Party influence is significant: half (26) of the secretaries are affiliated. The data found, showing that half of these members are not career politicians nor have they been candidates recently, may illustrate the reality that parties prepare internal members for bureaucratic action^{2525 Palotti PLM, Cavalcante PLC. Articuladores políticos e dirigentes da burocracia - ministros de Estado no Brasil e em perspectiva comparada. In: Pires R, Lotta G, Oliveira V. Brasília, DF: Enap; 2018. p. 161-174.}, not always candidates for the mandates of the legislature or chief executive. This finding is even notable for studies in the field of political science and public administration, as it rethinks the role of political parties and their affiliates as essentially competitors for positions in legislatures and mandates. Again, it is clear that the notion of the ‘technical’ profile as opposed to the ‘political’ profile is a separation that does not have such a clear dividing line: of the thirteen (25% of secretaries) identified career politicians, eleven (that is, 85% of career politicians) were also classified in this analysis as ‘specialized’. Only one secretary (RR) classified as a career politician was not categorized either as a ‘specialist’ or a ‘health professional’ - however, he was classified as an ‘entrepreneur’.

The political-partisan sphere also has an impact on the management of health policies if we accept the assumption that changes in the management of secretariats represent probable ruptures in the conduct of policies, which is especially worrying in a scenario of health crisis. Although they were not systematically evaluated, as the analysis took place in a time frame, demarcated punctually in the month of May 2021 (and not in a period), it is worth mentioning that the changes of secretaries have a very irregular frequency, and, therefore, unpredictable. For example: while the State Health Department (SES) of Rio de Janeiro accounted for at least five exchanges during the COVID-19 pandemic alone, SES-BA remained headed by the same secretary for more than six years. The exchanges can be interpreted as expected political movements, such as the mobilization of partisan forces, the ruler’s self-protection when scandals are broadcast in the media, etc., in addition to other imperatives, such as even cases of the secretary’s death by COVID-19, as found in Maceio. Finally, due to electoral legislation requiring the exoneration of public office holders to launch their candidacies, causing the deadlines determined by the TSE to ‘shake the seats’ of the secretariats, it is pertinent to mention the political exposure brought about by the conduct of responses to the pandemic, the 2022 election year being a crucial moment to measure the political capitalization^{3131 Miguel LF. Capital político e carreira eleitoral: algumas variáveis na eleição para o Congresso brasileiro. Rev. Sociol. Polit. 2003; (20):115-134.} of secretaries who eventually run.

The analysis of mentions of secretaries in scandals proved to be delicate, requiring some considerations. Given the visibility, in general, the involvement of state secretaries gains greater repercussions than that of municipal secretaries, due to the dictates of the media audience, which do not correspond to the federative principle. In addition, many news reports speak of ‘suspicions’, without detailing the origin of this information. Although the journalistic principle of protecting the source is valid, we know that the political game often misuses the media. Thus, we arrive at the paradigm that emerges as one of the greatest challenges both to democracy and to communication: the phenomenon of fake news, which, specifically in health, has become an infodemic, that is, a phenomenon of disinformation generated precisely by the excess of available information^{3232 Henrinques CPM, Vasconcelos W. Crises dentro da crise: respostas, incertezas e desencontros no combate à pandemia da Covid-19 no Brasil. Estud. Av. 2020; 34(99):25-44.}. Thus, a dose of skepticism, as befits scientific taste, makes us relativize and not readily accept all mentions of ‘(suspected) involvement’ of secretaries in criminal schemes.

It is also important to point out the risk of interpreting reports of complaints that mention the secretariat attributing them, albeit indirectly, to the secretary in management, which is not necessarily true. Or, in complaints of fraud in hiring, for example, it is always necessary to take into account the possibility that the secretariat has been harmed by the contracted company, and there is not necessarily a collusion with the public power: the skeptical posture grants admitting the possibility of private organizations assaulting the public power, and the latter being the victim.

Finally, still on the involvement in scandals and suspicions, it is noted that, as a counterpoint to public weariness, secretaries are often listed to constitute a suitable image for the government, as in the emblematic case of the state of RJ, which had successive health secretaries mentioned in scandals - which even cost the governor the job -, appointing a new secretary with the nickname ‘sheriff’, for his role in inspection bodies^{3333 O Globo. Médico com fama de xerife pode ser novo secretário de Saúde do Rio. O Globo 2020 set 25. [acesso em 2021 maio 16]. Disponível em: https://oglobo.globo.com/rio/medico-com-fama-de-xerife-pode-ser-novo-secretario-de-saude-do-rio-24659712%20.
https://oglobo.globo.com/rio/medico-com-...} . In Curitiba, the secretary is known as the ‘iron lady of health’^{3434 Gazeta do Povo. Márcia Cecília Huçulak: A dama de ferro da saúde no Paraná. 2021 ago 9. [acesso em 2021 maio 16]. Disponível em: https://www.gazetadopovo.com.br/vozes/reinaldo-bessa-vozes/a-dama-de-ferro-da-saude/.
https://www.gazetadopovo.com.br/vozes/re...} . It is also worth noting that the pandemic context has provoked great attention on the part of the population regarding the investigations promoted by the Pandemic parliamentary committee and regarding vaccination, especially on the ‘jumpers’. In this sense, the use of the position of secretary of health is perceptible, especially with the public attention attracted by the pandemic, for the construction and protection of the public evaluation of the state or municipal government, justifying exchanges^{3333 O Globo. Médico com fama de xerife pode ser novo secretário de Saúde do Rio. O Globo 2020 set 25. [acesso em 2021 maio 16]. Disponível em: https://oglobo.globo.com/rio/medico-com-fama-de-xerife-pode-ser-novo-secretario-de-saude-do-rio-24659712%20.
https://oglobo.globo.com/rio/medico-com-...} .

Moving on to the analysis of demographic data, the total number of secretaries trained in higher education found is in line with the number of 81% collected by Ouverney et al.^{33 Ouverney ALM, Carvalho ALBD, Machado NMDS, et al. Gestores municipais do Sistema Único de Saúde: perfil e perspectivas para o Ciclo de Gestão 2017-2020. Saúde debate. 2019; 43(esp7):75-91.}, contrasting with research that points to a scenario of lower education in small municipalities^{2323 Junqueira TS, Cotta RMM, Gomes RC, et al. As relações laborais no âmbito da municipalização da gestão em saúde e os dilemas da relação expansão precarização do trabalho no contexto do SUS. Cad. Saúde Pública. 2010; 26(5):918-928.}, revealing inequalities in qualification of SUS managers. It is important to note that this research analyzed which were the postgraduate courses, returning a large majority of medical specialization courses, little related to public health, and more to the professional performance of the self-employed professional. The male predominance (75%) found in this research is also not similar to similar studies^{22 Arcari JM, Barros APD, Rosa RS, et al. Perfil do gestor e práticas de gestão municipal no Sistema Único de Saúde (SUS) de acordo com porte populacional nos municípios do estado do Rio Grande do Sul. Ciênc. Saúde Colet. 2020; 25(2):407-420.}. Considering that, separating the analysis only for the states and DF, we have 90% of men, in line with the absolute minority of women governors (a single elected), it is understood that the spaces for female participation are narrower as the political capital^{3131 Miguel LF. Capital político e carreira eleitoral: algumas variáveis na eleição para o Congresso brasileiro. Rev. Sociol. Polit. 2003; (20):115-134.} required for the position increases. This investigation could not accurately collect race/color data, as only the candidacy records present this information, but it is clear that the vast majority of the secretariat is white, which can be seen from the audiovisual records made available in their exhibitions in the press, verified during data collection.

While Junqueira et al.^{2323 Junqueira TS, Cotta RMM, Gomes RC, et al. As relações laborais no âmbito da municipalização da gestão em saúde e os dilemas da relação expansão precarização do trabalho no contexto do SUS. Cad. Saúde Pública. 2010; 26(5):918-928.} found only about 10% of health professionals in the East of South macro-region (MG), Ouverney et al.^{33 Ouverney ALM, Carvalho ALBD, Machado NMDS, et al. Gestores municipais do Sistema Único de Saúde: perfil e perspectivas para o Ciclo de Gestão 2017-2020. Saúde debate. 2019; 43(esp7):75-91.} pointed to nursing as the most common profession (for 26% of respondents), but which occupied, in the present work, the second place: doctors (and men) gather half of the profiles of state and capital secretaries. From the well-known elitization that permeates the medical class, the hypothesis is attested that the positions with greater political capital, that is, those that demand greater social recognition for ascending in the structures of power^{3131 Miguel LF. Capital político e carreira eleitoral: algumas variáveis na eleição para o Congresso brasileiro. Rev. Sociol. Polit. 2003; (20):115-134.}, are less reached by categories historically subordinated in terms of color, gender and social class, revealing an inequality in the profiles of managers of states, capitals and other municipalities. Such cleavages are caught by the contrast of analyzes from different geographical circumscriptions^{33 Ouverney ALM, Carvalho ALBD, Machado NMDS, et al. Gestores municipais do Sistema Único de Saúde: perfil e perspectivas para o Ciclo de Gestão 2017-2020. Saúde debate. 2019; 43(esp7):75-91.,2323 Junqueira TS, Cotta RMM, Gomes RC, et al. As relações laborais no âmbito da municipalização da gestão em saúde e os dilemas da relação expansão precarização do trabalho no contexto do SUS. Cad. Saúde Pública. 2010; 26(5):918-928.}, revealing the importance of this component to think about the profile of SUS managers, refuting the construction of an image of the ‘SUS manager’, in the singular, whether in demographic terms, or in terms of the profile of the career and training trajectory.

The data collected and the construction of the profiles reveal a multiple and complex scenario of possible trajectories for the ascension to the post of secretary, which present crossings, such as: academic training in the areas of public management and/or public/collective health, experience in the secretariat itself (bureaucrat who ‘climbs’ a position until he is appointed), experience in other secretariats (some almost ‘secretaries by profession’). Among health professionals, many gain visibility by occupying public or private management positions, such as hospital management, or positions with a corporatist structure, such as management in unions, professional councils, in general, dependent on elections within these structures, which demand visibility. These trajectories can also be crossed by the party field, which should not be ignored. In this sense, the research is an empirical basis for what the literature on public administration has already pointed out: that the ‘technical’ and ‘political’ opposition, in addition to not corresponding to reality^{2525 Palotti PLM, Cavalcante PLC. Articuladores políticos e dirigentes da burocracia - ministros de Estado no Brasil e em perspectiva comparada. In: Pires R, Lotta G, Oliveira V. Brasília, DF: Enap; 2018. p. 161-174.,2929 Peci A. O “político” e o “técnico” na burocracia pós-democrática brasileira: um debate ideológico?. Rev. de Adm. Pública. 2018; 52(5):1-3.,3030 Pacheco RS. Mudanças no perfil dos dirigentes públicos no Brasil e desenvolvimento de competências de direção. In: VII Congreso Internacional del CLAD sobre la Reforma del Estado y de la Administración Pública, 2002 out 8-11; Lisboa: [Sem local]; 2002. p. 8-11.}, hides the complexity of the multiple factors that determine the rise to the post of secretary of health.

Conclusions

The results presented after the empirical incursion into the curricula of the state secretariat and the country’s capitals confront a widespread idea about such public offices as a mere political ‘allotment’^{2525 Palotti PLM, Cavalcante PLC. Articuladores políticos e dirigentes da burocracia - ministros de Estado no Brasil e em perspectiva comparada. In: Pires R, Lotta G, Oliveira V. Brasília, DF: Enap; 2018. p. 161-174.}. As it usually happens, when elaborating a detailed analysis of an object, the complexity stands out and makes binarisms difficult, showing intersections and other relevant components in the composition of the profile of health secretaries.

The typification constructed is just a possibility, after all, ideal types are not the product, but an instrument of an analysis. Thus, the work does not present as a result a typology to be replicated automatically, but a subsidy to reflect public management and the high level of subnational executive powers as permeated by a complexity that goes beyond the limits that only bureaucratic impersonality and partisan disputes would be the antagonistic forces acting in the definition of cabinets.

More than 30 years after the approval of the SUS, in the CF/88, there is not a predominance of only ‘professionalized’ leaders in the health secretariats^{3535 Cohn A, Viana AL, Ocké-Reis CO. Configurações do sistema de saúde brasileiro: 20 anos do SUS. Rev. Polít. Planej. Gest. saúde. 2010; 1(1):57-70.}, which are led by professional profiles that admit a more or less dense party gradient. Thus, the meanings about the exceptionality of technical insulation of health due to the tripartite configurations of the SUS were not confirmed. The criteria for choosing health leaders do not seem to differ from those that guide the allocation of positions of trust in the public administration^{2626 Teixeira CF, Molesini JA. Gestão municipal do SUS: atribuições e responsabilidades do gestor do sistema e dos gerentes de unidades de saúde. Rev. baiana saúde pública. 2002; 26(1):29-40.}. Deviations from the standards, such as the presence of secretaries whose career seems to have been demarcated by invitations from governors and mayors to ‘successful managers’ in other regions or cities were detected. But perhaps they are not a sign of change, as they may result from political negotiations within the alliances themselves to define positions in the Conass and Conasems bureaucracies.

In summary, the profiles suggest that there have been simultaneous advances in two directions: many of the selected secretaries are specialized in health and linked to political parties. The analysis, therefore, demonstrates that not only the academy or the bureaucratic structures themselves form the trajectory of these managers, since the parties also provide bureaucratic frameworks. Thus, the image that party-political forces are antagonistic to academic training and experience in public administration is unrealistic. In other words, health has become specialized and politicized - which does not represent a contradiction, as we have seen. A finding that, in itself, is not new or unprecedented, but that can contribute to the shift from statements about ‘depoliticization’ to the reflection on which specific political forces gain ground in the management of public health policies.

Referências

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