Le dilemme de la promotion de la santé en Amérique latine : les cas de l’Argentine 
et du Brésil

From the 1980's, the theorization of health promotion and its implementation are part of the agenda of international health organizations and governments. However, from the beginning, there is a tension in its understanding. Indeed, health promotion in general is conceived from a behavioral approach as a strategy for changing individual or group behaviors, with emphasis on risk factors. It is rarely conceived from a structural approach that includes action on the social structural determinants of the societies.  This qualitative research, a multiple case study conducted in Argentina and Brazil, aims to analyze the location and the understanding of health promotion in the national health policies of both countries through the analysis of the public policy development process. We aim to distinguish the approaches to health promotion, behavioral or structural, and explain the reasons why is understood in one way or the other. Finally, we try to identify opportunities for a structured approach to health promotion to be adopted in national health policy.  The data analyzed come from semi-structured interviews (n = 28) and from the following sources: government websites, documents provided by the interviewees, and official documents from governments, cooperation agencies and funding organizations. Our conceptual framework was inspired by three models: the Model of Policy Change of Sabatier & Jenkins-Smith (1999, 2009), the Multiple Streams Model of policy-making defined by JW Kingdon (1984) and the conceptual framework proposed by Walt (1994) for analyzing the role of international organizations.   We identified two levels of analysis: the organization of the State and the subsystem of health. We have also taken into account the influence of external events and of international organizations for technical cooperation and financing. We propose to observe, analyze and understand how these levels influence the place and the understanding of health promotion in national health policy. A time horizon of more than a decade allowed us to conduct a comprehensive analysis and get a better understanding of the health policy change in different historical moments of the countries studied, as well as identifying the most important actors and coalitions in the public health field.  The results of our analysis show that health promotion, conceived according to a structural approach, is not yet part of the mainstream of national health policy in any of the two countries. However, the explanations are different; in Argentina we see a fragmented subsystem of health with predominance of the medical model, where the actions taken reinforce this functioning and do not allow for discussion, neither on the values underlying the organization of the health system, nor concerning their change according to the country's health needs.  In Brazil, the health care reform of the 1980’s challenged the pre-existing model and achieved instituting health as a right at the State level. By putting emphasis on the organization of health services it reduced the understanding of health promotion to a "National Policy for Health Promotion" aimed at behavioral change. The analysis of the role of international organizations shows different situations in both countries: Argentina has a very strong dependence on both the agenda and the funding of these organizations; the lack of a national agenda on health promotion facilitates the adoption of the international agenda, almost without questioning.  In the case of Brazil the situation is different and a strong capacity to negotiate with international cooperation is observable. The interest of this country to adopt the agenda of international organizations has the objective, among others, to gain recognition and participation in international bodies. Thus, for different reasons, we observe that the two countries adopt the international agenda of health promotion from a behavioral approach.  In our research, we considered five considerations that should guide the analysis of health promotion in Latin America: 1) The processes of state reform of the 1990’s and the current consequences (type of reform, social values, constitutional arrangements), 2) the reforms of health systems with particular attention to the decentralization component (health or administrative reform?), which model dominates the field of public health?, 3) the revaluation of the APS of the late 1990’s (what impact did it have on the country?), 4) the tendency to reduce both the scope of policy and program proposals and, 5) current challenges facing health systems (collaboration with other sectors to improve health, incorporate and enhance the understanding of social and structural determinants of health).     The results of our analysis allow us to identify an important role for the national government in regards to the development and understanding of health promotion. Our research shows that the organization of the State, with its basic values, will be crucial in creating the conditions for developing a structural health promotion, even when there is influence of context and government ideology on the understanding of promotion of health and the inclusion of its social determinants. While the literature on health promotion still dedicates very little attention to the role of national level and State for their development, our research shows that these two levels have a fundamental impact on the place of health promotion in national policy and on how to understand and implement it.   The theories used for this research allowed us to build our conceptual framework and carry out a process of public policy analysis. This process improves the knowledge about the change in national health policy with regard to health promotion taking into account the relatively unexplored field of government dynamics. This conceptual framework is both flexible and rigorous, and may be appropriate to carry out similar research on the promotion of health in national health policies of other countries in Latin America.

Keyphrases: Étude qualitative, Latin America, structural health promotion, public policy analysis, international health, qualitative research