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Health promotion in primary care:
eects and limitations in conservative neoliberalism
Abstract is article aims to understand and
analyze the eects and limitations of Health
Promotion in Primary Health Care (PHC). We
conducted genealogical, qualitative research with
23 PHC workers. e analysis originated the
following datasets: eects of Health Promotion
practices performed in PHC and diculties and
limitations in conducting the practices. e re-
sults show that the main impact of Health Pro-
motion is reducing medicalization and adopting
Expanded Clinic elements in the care provided.
e main diculties arise from the poor public
policies due to the scal austerity measures ad-
opted in recent years. Strengthening the collective
nature of health demands and their responses is
a possibility of resisting in the face of the author-
itarian neoliberal rationality currently prevailing
in the Brazilian State.
Key words Health Promotion, Public Health,
Primary Health Care, Genealogy, Neoliberalism
Fernanda Carlise Mattioni (https://orcid.org/0000-0003-3794-6900) 1
Cristianne Maria Famer Rocha (https://orcid.org/0000-0003-3281-2911) 2
DOI: 10.1590/1413-81232023288.05752023EN
1 Grupo Hospitalar
Conceição. R. Conselheiro
D’Avila 111, Jardim Floresta.
91040-450 Porto Alegre
RS Brasil.
nandacmattioni@gmail.com
2 Programa de Pós-
Graduação em Enfermagem,
Universidade Federal do Rio
Grande do Sul. Porto Alegre
RS Brasil.
ARTICLE
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Mattioni FC, Rocha CMF
Introduction
In its Brazilian presentation, Health Promotion
(HP) was established as a synthesis of the con-
ceptual aspects of the movement that originated
in Canada and Collective Health in Brazil in the
1970s1. Dierent practices emerged in HP, gener-
ating heterogeneous knowledge and actions.
At the same time, we can identify the adop-
tion of dierent political strategies in HP practic-
es, whose characteristics range from a so-called
conservative stance to critical, radical, and lib-
ertarian perspectives. us, from a conservative
perspective, HP would direct individuals to take
responsibility for their health and, by doing so,
reduce the nancial burden on health care. Un-
der the reformist mode, HP would be a strategy
to create changes in the relationship between cit-
izens and the State, emphasizing public policies
and intersectoral action, or even be a libertarian
perspective seeking deeper social changes2.
Health Promotion in PHC follow the hetero-
geneous nature described above. Actions aimed
at individual behavior changes and risk control
coexist and hold a hege
monic position in this
knowledge-power eld, with practices aimed at
improving the Social Determinants of Health
(SDH). e latter, with less strength and expres-
siveness
3
. e SDH are factors in which life takes
place, ranging from the most individual aspects,
such as age and genetic factors, encompassing so-
cial and community relationships, public policies,
and ultimately reaching the macro conditions of
a country
4
.
Strategies for governing the population have
existed since the emergence of Nation States in the
15
th
century. roughout history, they have been
changing and becoming increasingly complex to
enable the regulation of the population and the
modulation of individual behavior to meet the
needs of capitalism in its dierent phases. e set
of techniques operated on the people was called
biopolitics, and governmentality is its primary
operating strategy from the 18
th
century
5
.
e Brazilian re-democratization process,
with the struggles for social rights in the 1980s,
was anchored in a new political reason called
democratic governmentality
6
. It was a historical
period of promoting citizenship, evidencing dem-
ocratic governmentality as machinery put in place
legitimized by the 1988 Federal Constitution
7
.
is rationality was accentuated in subsequent
years with the Brazilian State’s broad creation of
public policies
6
. e technical, political, and legal
bases of the Unied Health System (SUS) are built
in this context. Health Promotion became a pub-
lic policy in 2006, showing the dierent inuenc-
es mentioned above in its text.
Authors
7,8
maintain that democratic gov-
ernmentality is rooted in neoliberal rationality.
While social rights are guaranteed for the pop-
ulation, the price paid for this guarantee lies in
the need to be governed in a democratic regime.
However, extreme competitiveness, solely indi-
vidual responsibility for life issues, self-manage-
ment, and self-exploration emerge precisely from
the supposed freedom in this set of ideas.
Neoliberal rationality is dened not only as
an economic doctrine but a normativity that can
structure new governmental rationality, reach-
ing all social relationships and dimensions of
life
9,10
. It presupposes State regulation favoring
the market (guaranteeing the best conditions for
competition) and negligible investment in social
policies
10
.
is sedimented rationality, accompanied by
economic crises, legitimized adopting scal aus-
terity measures in dierent countries, especially
in recent years. In Brazil, it is argued that a new
political reason has been adopted as of 2016. e
democratic neoliberal governmentality seems to
have given way to a conservative neoliberal ra-
tionality
7,8
, in which investing in social policies
is reduced to the extreme, directly aecting SUS
and its services. In this context, Health Promo-
tion practices tend to be weakened in all settings
in which they have a leading role, including PHC.
us, we proposed research to understand and
analyze the eects and limitations of Health Pro-
motion practices in PHC.
Methods
We conducted qualitative, descriptive, explor-
atory, and genealogical eld research in the
PHC context of a municipality in south Brazil.
Qualitative genealogical research identies ten-
sions, disputes, discourses, practices, and pow-
er relationships11. Research data were produced
through semi-structured interviews with work-
ers responsible for Health Promotion in twelve
Health Units (HU), which correspond to 39 Fam-
ily Health Strategy (ESF) teams and ve Family
Health Support Centers (NASF). Such Health
Units care for approximately one hundred thou-
sand SUS clients. e professional centers (and
respective number) of the participants were: So-
cial Service (06), Nursing (05), Psychology (04),
Community Health Worker (03), Medicine (02),
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Ciência & Saúde Coletiva, 28(8):2173-2182, 2023
Dentistry (02), Nutrition (01), totaling 23 partic-
ipants. e interviews were held from February
to May 2020.
e workers invited to participate in the re-
search were selected by the “snowball” method,
characterized by establishing a non-probabilistic
sample using reference chains. Sampling started
by contacting key informants, named “seeds”, to
locate some people with the necessary prole for
the research within the participating teams12. is
procedure was performed to map the workers di-
rectly involved with Health Promotion practices.
us, the key informants (or seeds) participated
in the survey by responding to it and provided
new contacts with the potential to participate.
e interviews ended when Health Promotion
practices and narratives repeated themselves, in-
dicating the saturation point, as predicted by the
“snowball” strategy12. e interviews were au-
dio-recorded and transcribed. Moreover, a eld
diary was used, which contained the impressions
of the researcher who conducted the interviews.
Data qualitative analysis consisted of the fol-
lowing steps: re
ading the transcribed interviews
and describing and analyzing the eects, di-
culties, and limitations related to Health Promo-
tion in the research setting. Empirical data were
analyzed from the Health Promotion theoretical
framework and some Foucauldian tools-concepts.
Following the research’s genealogical perspective,
we aimed to contextualize the study’s ndings in
a chain of historical events and their discontinu-
ities, which enabled the current conguration of
the researched setting and presupposed an anal-
ysis displacement, encompassing local and more
general aspects that inuence the composition
of the knowledge-power eld in the researched
background. We also aimed to describe research
ndings that escape the hegemonic Health Pro-
motion discourses that may suggest methodolog-
ical, technical-political, and practical possibilities
for this eld.
is article presents the partial results of
the research carried out for the construction of
a Doctoral esis at the Nursing Graduate Pro-
gram of the Federal University of Rio Grande do
Sul. Data were organized into two sets: eects of
Health Promotion practices conducted in PHC;
and diculties and limitations of running Health
Promotion practices in PHC. Research partici-
pants were identied with codenames, which re-
fer to artistic expressions chosen by themselves at
the time of the interviews, to preserve anonymity.
e ethical procedures recommended for Bra-
zilian human studies were observed
13
throughout
the study. e Research Ethics Committees of the
Federal University of Rio Grande do Sul and the
Conceição Hospital Group approved the research
under CAAE numbers 16078319.7.0000.5347 and
16078319.7.3001.5530, respectively.
Results
Eects of Health Promotion in PHC
e following eects were identied as a
product of Health Promotion (HP) in the re-
searched setting from the respondents’ report:
partial change of habits; user empowerment;
socialization and establishment of support net-
works; improved quality of life and lower med-
icalization; comprehensive health care; and in-
come generation.
One of HP’s central dimensions is education-
al practices to change individual habits and be-
haviors. We found the following reports in the
research setting, which refer to educational activ-
ities aimed at changing eating habits, sedentary
lifestyle, and the proper use of medications:
We realized that people don’t change their
habits. ey report that it is dicult to change
because these are cultural things. ey must have
so drinks to receive the grandchildren. You have
to oer a cupcake when visiting neighbors. So, even
having understood the relationships between food
and health, they continue with the same habits
(Pintura).
Participants in this activity are selected from
a list of clients with decompensated Hyperten-
sion or Diabetes Mellitus. Although participation
in the activity is not mandatory, the health team
encourages them to participate. Many even show
interest in engaging because of the possibility
of interacting and meeting (with the team and
neighbors), but only in a genuine desire to change
their way of life.
Below is another report of activity aimed at
changing eating habits:
We measured [the results] on some occa-
sions. We observed when asking whether they had
changed some habits. All had changed at least one
habit […] such as drinking more water, eating
more vegetables, or stopping eating heavy meals…
(Música).
e factor that seems to interfere with the
outcome of the practices described above is the
objective and motivation of the participants re-
garding the activity. In the rst, clients are un-
willing to change their habits, or their life context
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Mattioni FC, Rocha CMF
is not favorable for this. Moreover, approaches
centered on achieving goals established by health
protocols may be very distant from these people’s
life trajectories. Establishing the notion of what
will or will not be a risk/threat for someone de-
pends on more than what experts determine with
studies and evidence. People build their habits
from dierent inuences, which operate in the
subjective eld and the material aspects of life. In
other words, adopting a habit is independent of
access to health information. It is complex and
conditioned by social, cultural, psychological,
and economic factors14.
In the second report, the activity is performed
with people who spontaneously seek space; they
understood that it would be time to change some
habits. e appr
oach adopted considers people’s
life context and the possibilities for change. Not
all habits are expected to be modied, but some-
thing ends up being changed and improves health
under a singular construction, considering the
individual possibilities. is perspective aligns
with the Expanded Clinic, a strategy found in
the Collective Health framework. In this strate-
gy, subjects in the care relationship gain centrality
with their underlying individual aspects, wheth-
er subjective or objective factors. is approach
enables the care relationship to produce results
under shared care plans built from the clients’ de-
sires and possibilities
1
.
Regarding empowerment, we can identify an
example of how it can be made in the report refer-
ring to the group of pregnant women:
Women are strengthened for issues related to
their “delivery” [sic]; they become more attentive to
the onset of labor signs and breastfeeding issues in
baby care. With access to this information, women
and their families are more empowered to question
biomedical behaviors that oen disrupt the birth
process through normal delivery and breastfeeding
(Ovelha, our emphasis).
Empowerment underlies the Health Promo-
tion theoretical-methodological framework. It is
widely disseminated in its eld of action and has
multiple meanings1. Attention is paid to using this
concept as a strategy to delegate responsibility
for individual care to clients, as they are “taught”
care methods through the transfer of information.
e informed choice that occurs from the prem-
ise that subjects can decide about their health per
their desires and priorities can be understood
from the neo-subject notion, according to which
free choice is not an option but a rule of conduct
in neoliberal ideas. By being free to choose ac-
cording to their will, people assume to the same
extent all responsibility for that choice10. On the
other hand, empowerment can be established as
a tool to produce eects that go against neoliberal
rationality. As information is shared in health ser-
vices, which allows questioning established prac-
tices and guarantees the rights (as in the case of
pregnant women, the choice of childbirth, refusal
of invasive procedures, and the presence of a com-
panion), empowerment takes on another mean-
ing, inscribed in historical feminist struggles. A
good question to assess the eects of empower-
ment and the direction in which it is being oper-
ated is to identify how much such eects impact
the correlation of forces in the existing power rela-
tionships in health services, changing outcomes in
the decisions taken in these relationships.
Socialization and the establishment of sup-
port networks can be identied in the report of
the interactive group, which exists in almost all
HU surveyed:
We are constantly referring older adults to the
group because their lives improve; they are less sad,
manage to communicate, and make new friends
aer losing loved ones. us, they need to have
other relationships and build new networks (Cri-
atividade).
Another eect of Health Promotion was gen-
erating income through the prod
uction of handi-
cras in the interactive group:
ey meet other people here and create bonds.
ey go on trips that they would not be able to do
with their income with the money generated by the
handicra produced (Artecriativa).
e constitution of community support
networks is a Health Promotion15 operational
framework strategy. e organization of spaces
that promote the construction of support ties
indicates that such health work identies and
transforms the vulnerabilities of residents into
motivation for developing and strengthening in-
dividual and group potential16. Again, attention is
paid to the risks of neoliberal rationality attacking
such spaces to the extent that governments and
health services may consider them replacements
for social protection policies to provide primary
conditions of life; in other words, community
support and solidary relationships are benecial
and necessary for maintaining health. However,
they do not relieve the State of its responsibility
to provide public policies to create environments
conducive to health.
e improved quality of life – and the conse-
quent declining medicalization – were identied
in reports referring to Integrative and Comple-
mentary Health Practices (PICS):
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Ciência & Saúde Coletiva, 28(8):2173-2182, 2023
Meditation oers a quality of life. We have re-
ports of people who felt less pain and started to use
less medication aer meditating (Pérola).
A study points out that using PICS can
strengthen and weaken medicalization in health
according to the practices used and the profes-
sional or worker operating such activity. Howev-
er, in PHC, the authors maintain that using PICS
leads to lower life medicalization17, promoting
health and quality of life.
On the other hand, comprehensive care is
produced from an expanded view of health,
which can be identied both in the Children’s
Group, which seeks to promote health without
medicalization, and in the activities of the Health
at School Program, which reach other dimen-
sions of life than just illness, such as learning,
through intersectoral partnerships, for example:
We followed the children through the group
and identied situations that needed early inter-
vention. Intervening in situations that can gener-
ate trauma in the child is something crucial. We
work in partnership with the school, which helps in
these situations (Mandala).
When we can follow up on the demands, PSE
actions impact the child’s learning possibility. e
learning process will be favored when we identify
a visual acuity problem, and that child can access
the glasses (Cinema).
e expanded concept of health, comprehen-
sive care, and intersectoriality are the underlying
HP assumptions of its operationalization strat-
egies15. Coordinated actions between dierent
public administration sectors, in which the de-
mands generated are provided for, can positive-
ly aect people’s lives, oering a comprehensive
approach by the health sector, provided that they
can meet the identied needs.
Diculties and limitations for conducting
Health Promotion in PHC
e diculties and constraints reported by
the respondents regarding conducting HP in
PHC refer to changes in the care model and lack
of legitimization/prioritization of the HP in the
PHC teams’ work process; poor public policies;
lack of infrastructure and physical space; lack of
user participation in activities; complex dialogue
and articulation with other sectors; and territory
violence.
Changes in the care model and the lack of
legitimization/prioritization of HP in the PHC
teams’ work process are pointed out in the fol-
lowing reports:
e lack of 100% coverage of PHC teams in the
city limits us because we identify demands with the
PSE actions that end up not being followed up be-
cause the student does not have a reference Health
Unit (Cinema).
Loss of the care model based on the Family and
Community Health model. We have the loss of the
ACS who worked with this articulation between
the team and the community. Hence the impor-
tance of reviving the [Local Health] Council as a
place of defense for the Health Unit itself (Capoei-
ra).
e Family Health Strategy (ESF) model was
elected in the rst editions of the National Pri-
mary Care Policy (PNAB)18 as a priority strategy
for the organization of PHC in Brazil. Initial-
ly, adopting this model was strongly induced
in the municipalities. Aer the publication of
the PNAB in 201119, the Ministry of Health in-
creased nancial incentives for expanding and
qualifying the number of ESF teams. Moreover,
other strategies were made available to the mu-
nicipalities, such as the Requalica UBS (PHC
Unit) program to improve the physical structure
of the Health Units; the health gyms program to
create physical activity spaces close to the HUs,
and under the coordination of the Family Health
Support Centers (NASF), which are also a PHC
qualication strategy in the country since 200820.
Furthermore, we highlight the teams’ territori-
al linkage and the Community Health Workers’
(ACS) linkage to a specic number of clients/
households in that territory.
e care model used in the ESF should pri-
oritize health promotion, prevention, and re-
habilitation actions, focusing on promotion in
the teams’ work process. e performance in
the territories and the link provided by the ACS
work organized the teams’ actions according to
community needs. Moreover, it allowed debating
these issues in the territories, seeking a collective
confrontation of the problems and holding the
State accountable.
However, we observed a massive weakening
of the State’s role in conducting public health pol-
icies and the emergence of a conservative or au-
thoritarian neoliberalism8 in recent years, which
has led to adopting scal austerity measures,
which, by withdrawing public investments from
the social area, reduce its capacity to act. e
reection of such measures can be seen in the
publication of the 2017 PNAB, in which aspects
such as the team territorial binding, the number
of ACS, and the nancing of services are more
relaxed21. Furthermore, the non-accreditation of
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Mattioni FC, Rocha CMF
new NASF teams also limited the work of PHC
teams, especially regarding Health Promotion
practices.
e NASF teams are staed by profession-
als who are not part of the minimum ESF team
(namely, Medicine, Nursing, and Community
Health Workers). eir work is based on the prin-
ciples of matrix support and Continuing Educa-
tion. ese teams’ support to the ESF teams has
a signicant pedagogical dimension. It expands
the scope of the ESF’s activities, including Health
Promotion, along with the territories for which
they share the responsibility. We emphasize that
the setting in which the research was conducted
still has active NASF teams. Most workers inter-
viewed are NASF members and responsible for
most reported HP actions. Another professional
center responsible for driving many HP actions is
the ACS. us, we can relate the weakened NASF
teams and the lower number of ACS in the teams
to declining and disqualied HP actions in the
territories where such measures are being adopt-
ed. is situation tends to be generalized in the
country since the primary way of maintaining
these services depends on the funding oered by
the federal and state governments21.
Another aspect pointed out as a diculty re-
fers to the secondary space occupied by Health
Promotion in the organization of the teams’ work
process:
Care activities have a protected space. ings
could be more spontaneous for others, such as
Health Promotion and Health Education. ey
remain in this limbo of “if I have time, I’ll do it”;
“if I feel like it, I’ll do it”. is situation overloads
workers because you must always convince your-
self it is essential (Dança, emphasis in the original
statement).
We identied the marginal place of Health
Promotion actions in the teams’ daily work. Care
activities have well-established routines and insti-
tutional guidelines, including goals and indicators.
Prevention occurs more frequently and is intend-
ed to prevent specic diseases and conditions. On
the other hand, Health Promotion demands more
comprehensive actions, requiring workers’ time
availability and participant involvement. HP has
less and less space regarding care activities with
the changes in the care model adopted.
Other precarious intersectoral policies direct-
ly related to healt
h besides the poor public health
policies also weaken the actions that can achieve
the SDH:
e weakened network of services, health,
social assistance, and education in the territory
limits the possibilities of thinking comprehensively
about the territory and the possibilities of produc-
ing practices and meanings in Health Promotion.
When we must look at the most urgent, we cannot
do Health Promotion. We stay in the line of treat-
ment (Bacurau).
Fiscal austerity measures, legitimized by Con-
stitutional Amendment No. 9522 in 2016, already
show the signs of the devastation of the Brazil-
ian social protection standard. e eects so far
observed in the short time reect a disastrous
downgrading of the living conditions of Brazilian
citizens, nullifying historical achievements23. In
health, dismantling the Unied Social Assistance
System (SUAS) aects the full approach to situa-
tions identied in the territories and the reach of
HP. Consisting of intersectoral policies, includ-
ing SUAS policies, the Social Protection Network
is essential to expand the approach of the care
provided by health teams in the territories to
achieve the SDH minimally and, thus, produce
comprehensive care. is fact can be exempli-
ed by the weakened Reference Social Assistance
Centers (CRAS) in the researched teams’ oper-
ational territories due to the substandard work
bonds of professionals working in these spaces,
the lack of minimum working conditions (tele-
phone line and internet, for example), and the
few possibilities to oer inclusive policies for the
population served.
Also, besides the diculties, limitations re-
garding the physical space to perform the activi-
ties were reported in almost all US:
Our main diculty is the physical space. e
group had to be interrupted because we need-
ed somewhere to do it. Now we get a community
space to do the activity (Pérola).
is limitation is inscribed in the poor health
services, whose physical structure would need
renovations and investments to expand and
improve ambiance. Along the same line, public
spaces also have weaknesses:
We have a space issue to do the activity. We
usually walk in the neighborhood’s squares. Some
have an irregular surface, which is terrible. We
also have the safety issue. We are afraid of robber-
ies (Movimento).
e team and the community endeavor to
solve issues that would be the responsibility of
the Public Administration. Accompanying neo-
liberal rationality, the State exempts itself from its
obligations and delegates to health workers and
clients the search for alternatives, according to
their possibilities, which is not always the most
appropriate and safe23.
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e lack of participation in the activities was
also pointed out as a limitation.
e most signicant diculty is participation.
Making people participate in a group to change
lifestyles (Música).
e problem is getting people [to participate].
Some people always go, but they are few. We do
not give due value to social participation spaces
(Teatro).
Poor participation in health promotion spac-
es can also be understood as a reection of the
expanded neoliberal rationality that, as we de-
scribed earlier, builds subjectivities that people
need to face their problems alone, without iden-
tifying their collective dimension1,10.
Another hardship refers to the realization of
intersectoral actions:
Sometimes it is dicult to get a good articu-
lation with the school. Be able to sit together and
plan activities in a shared way. It seems we cannot
have the same goals and give the same importance
to the activity (Nataraja).
In intersectoral action, the lack of commu-
nication and the discontinuous articulations be-
tween the stakeholders and sectors are pointed
out as the most fragile aspects of intersectoral
action. Planning inconsistent actions with the
population’s health needs can lead to overlap-
ping actions in the territory and limit the reach
of interventions. On the other hand, intersectoral
initiatives were broader when dened as an in-
tegrated policy of the municipal government for
the construction of interfaces and cooperation
between the several sectors24.
Finally, the issue of violence in territories is
a signicant diculty, as it aects both workers
and residents:
We were robbed, leaving the group. We were
driving, with the computer, cell phone… ey took
everything! Aer that, we decided not to carry our
resources with us. So, the teachers lent us their re-
sources (Dança).
In the community, we have diculties re-
garding parallel power and tracking. People are
afraid to meet and expose themselves (Capoeira).
e violence in the PHC territories can also
be understood as a product of the strong on-
slaught of neoliberal rationality about these plac-
es. Abandoned by the State, the most impover-
ished territories are occupied by parallel power,
which imposes its operational rules. e popula-
tion residing in the communities is le to accept
such rules, considering the danger of breaking
them up. Likewise, regarding the violence suf-
fered by team workers, the precariousness de-
riving from the current economic logic can be
a predominant factor. By using their resources,
such as computers, cars, and mobiles, to enable
activities, teams become easy targets and suer
losses, they assume, not to mention the harmful
psychological eects for these people.
It is necessary to qualify the qualitative and
quantitative characterization of armed violence
and its consequences based on an intersectoral
approach with broad community participation to
seek coherent and signicant responses. It is also
necessary to ensure professionals’ protection,
safety, and working conditions so that health ser-
vices are continuously in place in the spaces and
supported by the State25. Besides these emergen-
cy measures, such issues should be debated with
the State so that public security measures are im-
plemented, with adequate public policies within
the communities, oering opportunities for their
members.
Discussion
According to the results, health promotion prac-
tices’ main eect is reducing medicalization and
adopting Expanded Clinic elements in the care
provided. We can infer that this outcome is in-
scribed from the perspective of democratic neo-
liberal governmentality5,6, whose main feature is
establishing public policies to modulate behav-
iors, make people live, and, more than that, live
under specic parameters so that the capitalist
system nds the conditions to develop itself.
is description meets the concept of biopolitics5
used by Foucault to maintain that Western soci-
eties have built strategies to enable the advances
of capitalism through life and, more specical-
ly, by modulating behaviors (governmentality)
throughout history5.
e results indicate that the main diculties
for HP actions in PHC originate from the poor
public policies due to the scal austerity mea-
sures adopted in recent years. is nding meets
the idea of authoritarian neoliberal governmen-
tality6, developed by Silvio Gallo from the gov-
ernmentality described by Foucault5. us, pub-
lic policies, among them health, are weakened
when adopting scal austerity measures, dramat-
ically reducing investments in the public arena,
leaving extremely vulnerable populations with-
out coverage of health services, so that in many
situations, especially in the COVID-19 pandem-
ic, it meant the death of thousands of people.
is State reason, called conservative neoliberal
2180
Mattioni FC, Rocha CMF
governmentality, aligns with the notion of nec-
ropolitics26, which, unlike biopolitics5, comprises
a set of strategies that operate to cause the death
of specic undesirable population groups in the
most conservative societies and where capitalism
achieves its extreme characteristics of capital su-
premacy vis-à-vis any life form.
Also, from the perspective of Foucauldian
analyses, we nd resistance and counter-conduct5
where there is power. If we can say that, in the
researched setting, we see the product of the per-
formance of public policies inscribed in a dem-
ocratic neoliberal governmentality6, in this same
eld, some practices escape this governmental-
ity, expressing the tensions resulting from the
actions inscribed in governmentality and those
that stand as resistance and counter-conduct. e
latter can be described as the actions that tension
the biomedical model. We also nd practices that
tension conservative neoliberal governmentality,
which encourages collectivized health demands
and seek to debate issues involving the SDH,
explaining the importance of preserving and
expanding the Unied Health System as a state
public policy and other intersectoral public poli-
cies that directly aect people’s lives.
Final considerations
HP practices reported in the researched setting
have their most signicant eect as resistance to
medicalization processes. ey oppose the med-
icalizing trend that reinforces industry and the
health market. However, they fail to reach the
SDH due to weakened intersectoral public poli-
cies, evidenced by the escalating scal austerity
measures in Brazil, especially in recent years.
e analyses of this research point out that
health promotion assumes a heterogeneous na-
ture, which characterizes it with conceptual pol-
ysemy and the multiple practices performed in
the studied setting. Some align themselves with
the aspect of the behavioral approach found in
the oldest and more conservative health promo-
tion currents. Other practices assume the nature
of resistance and counter-conduct against the
perspective of the absolute medicalization of life
and propose expanding the clinic to promote dif-
ferent ways of life. e latter are inscribed and
nd their technical-operational basis in Brazilian
public health, which has an intrinsic relationship
with the struggles the Brazilian health movement
waged in establishing the SUS.
Structured HP strategies at the macro level
and identied in the research setting are char-
acterized and reach the two HP strands de-
scribed above, the behavioral and the reformist.
One focused on changing individual habits and
behaviors, and the other proposed structuring
public policies favorable to establishing healthy
living environments. Although we nd, in the
discourse of groups and collectivities organized
in Collective Health, the identication and de-
sire that signicant structural changes in Bra-
zilian society will be operated as imperative for
people to have a life of better quality eectively
and that this is permanent, without being at the
mercy of the government change and econom-
ic instability inuences, we could not nd any
historical accounts that point to any investment
in this regard, at least in recent decades. At the
local level, we see this same setting, perhaps even
more fragile, because the reach of health promo-
tion actions identied in the research has a little
collective impact. Reviving the collective nature
of health demands and the possibilities of real
achievements for communities is a possibility to
resist neoliberal rationality, which imposes com-
petitiveness, blame, and individual responsibility.
2181
Ciência & Saúde Coletiva, 28(8):2173-2182, 2023
Collaborations
FC Mattioni and CMF Rocha worked on the de-
sign of the study and the preparation, elabora-
tion, and review of the manuscript.
2182
Mattioni FC, Rocha CMF
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Article submitted 20/10/2022
Approved 28/03/2023
Final version submitted 20/04/2023
Chief editors: Romeu Gomes, Antônio Augusto Moura da
Silva
is is an Open Access article distributed under the terms of the Creative Commons Attribution License
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