Articulo cientifico

Analysis of information on mitigating SUS’s judicialization in digital media

Rodrigues de Siqueira, Fernanda; da Silva Müller, Carlos André; Siena, Osmar

Fernanda Rodrigues de Siqueira

fernanda4092@gmail.com

Universidade Federal de Rondônia Brasil

Carlos André da Silva Müller

Universidade Federal de Rondônia Brasil

Osmar Siena

Universidade Federal de Rondônia Brasil

Revista de Gestão

Universidade de São Paulo, Brasil

ISSN: 2177-8736

Periodicity: Trimestral

vol. 29, no. 4, 2022

rege@usp.br

URL: http://portal.amelica.org/ameli/journal/154/15435981543598003/

Non-profit publishing model to preserve the academic and open nature of scientific communication

ePub generated from XML JATS4R

Abstract: Abstract

Purpose

This research aimed to analyze how information on public policies to mitigate the judicialization of the SUS (Brazilian Unified Health System) have been disseminated via digital media to citizens and stakeholders.

Design/methodology/approach

Under a qualitative and inductive paradigm, the research was based on the search for news on the Google pages. Data were grouped into higher categories to formalize theoretical generalizations.

Findings

Data analysis showed that there are news classified into 11 codes, forming three news groups broadcast as an effort by the programs to legitimize themselves with society: Perceived Quality, Publicity Produced and Results Achieved.

Research limitations/implications

The relationship between the effectiveness of public policies and their dissemination in digital media has implications for the result/legitimacy relationship, not excluding that public marketing can make a program legitimate without having results that confirm its effectiveness.

Social implications

The work provides a means of understanding the dissemination of public policies, in particular, verifying whether these are being provided in order to establish responsible and transparent communication with the citizen or to legitimize public policies without effective results.

Originality/value

The proposed conceptual model is based on four quadrants and represents the relationship between the results achieved by public policies and legitimacy, considering a phenomenon resulting from public marketing. The association between the intensity of these constructs constitutes four themes: fake public marketing, inefficient public policy, deficient public marketing and full public policy.

Keywords: · Health judicialization · Public marketing · Digital media.

1. Introduction

Marketing strategies are being increasingly adapted in the public sector. Among the discussions in the literature, we find the concept of public marketing (Pasquier & Villeneuve, 2018; Silva & Minciotti, 2021), which has become one of the essential activities for public brand building strategies (Zavattaro, Marland, & Eshuis, 2021).

Marketing of organizations and public services, within the scope of public marketing, is aimed at planning, implementing and controlling public policies oriented to meet social needs (Alemán, Gutiérrez-Sánchez, & Liébana-Cabanillas, 2018; Silva, Bianchini, & Minciotti, 2021). For citizens to know about public services, it is essential that all coordinated actions are strengthened by broad institutional dissemination (Cezar, 2019). Therefore, communication can serve for both population's engagement and actions' transparency in the political, economic and social fields (Cezar, 2019; Ribeiro & Oliveira, 2013).

The way communication is conceived in digital media can increase the performance and the perception of brand value and the public service offered (Thomas, Fay, & Berry, 2020), allowing the management of image and reputation to facilitate achieving public sector's goals (Pasquier & Villeneuve, 2018; Zavattaro et al., 2021). Public marketing can even be associated with public brands, which represent consumers' (here citizens) perceptions and feelings about a particular product (or public solution), thus establishing a relationship among the citizen, the product offered and the organization (Kotler & Armstrong, 2015).

Every public policy effort is not only exclusively related to norms and their effectiveness (Ribeiro & Oliveira, 2013; Silva, 2015) but also, and perhaps mainly, to being recognized as legitimate by society (Meyer & Rowan, 1977; Rossoni, 2016). In this sense, marketing has the potential to create value, not only for products and services – from customer value capture, in the marketing sense (Kotler & Armstrong, 2015) – but it also has application in public policies designed to overcome obstacles faced by citizens (Silva et al., 2021; Silva & Minciotti, 2021).

In Brazil, public marketing gained fertile ground from the changes promoted by the State Reform Master Plan – PDRE, in the Portuguese acronym – based on the paradigm known as managerialist, which took place in the 1990s (Oliveira, Costa, Miranda, Mesquita, & Pereira, 2013; Silva & Minciotti, 2021), and assumed that the functions performed by the private for-profit administration could be easily transferred to public administration. This perspective received several criticism, giving rise to a set of new paradigms, known as the New Public Governance (Ronconi, 2011; Runya, Qigui, & Wei, 2015), in which marketing role is best used (Rakšnys, Guogis, & Minkevičius, 2015).

In view of the emerging need to use public marketing in different public policies, we acknowledge the importance of the Brazilian health policy. Several sources indicate an exponential growth of judicialization (Lara, Fernandes, Penteado, & Serra, 2021), whose results do not benefit both citizens and public administration (Carvalho, 2007). Due to this phenomenon, alternatives were sought to minimize the large number of demands to the Unified Health Service (SUS), such as conflict mediation programs. In general, mediation is a space where the parties and other stakeholders get together to settle potential issues, in order to prevent the conflicts’ judicialization, and, instead, to meet the citizen's demand (Conselho Nacional de Justiça [National Council of Justice – CNJ], 2016). Some programs stand out in reducing judicialization, such as “SUS Mediado” (Mediated SUS) and Chamber for Health Disputes Settlement (CRLS), in the states of Rio Grande do Norte and Rio de Janeiro, respectively and the Permanent District Chamber for Health Mediation (Camedis), in the Federal District (Silva, 2018).

In this context, we consider that communication, especially through digital media, plays a fundamental role in disseminating information on conflict mediation programs, so that citizens have knowledge and access to them, rather than judicializing their demands of public health. That is why communication, as the most visible part of marketing, has been associated with the constant process of knowledge, persuasion and trust on what the public sector offers, which affects citizens' decision to make exchanges with the public service (Cezar, 2019).

Studies show the importance of marketing and communication when it comes to public health (Grier & Bryant, 2005; Gurrieri, Gordon, Barraket, Joyce, & Green, 2018; Hoek & Jones, 2011); however, these authors sought to understand the marketing phenomenon for promoting social behavior changes in order to reduce health problems. Although there is evidence on the application of marketing as a State strategy to foster public policies (Kaplan & Haenlein, 2009; Zavattaro et al., 2021), there is evidence of a gap in investigating the relationship between the legitimacy provided by public policies' communication and the real effectiveness that these programs seek to achieve. It is possible, for example, to have ineffective public policies with good marketing and communication structures that provide a misleading legitimacy, just as the opposite is also true.

Given this perspective, based on the practices involving “SUS Mediado”, Camedis and CRLS, we raised the following question: how information on public policies to mitigate SUS's judicialization is disseminated in digital media to citizens and main stakeholders? Since information conveyed by digital media is a marketing strategy mechanism to establish a relationship with stakeholders (Pasquier & Villeneuve, 2018; Zavattaro et al., 2021), we understand that this is a relevant context, especially for public health, and this is the paper's contribution.

2. Theoretical background

2.1 Public marketing

The concept of marketing has undergone significant changes over the years (Kotler & Levy, 1969; Silva & Minciotti, 2021). Currently, the American Marketing Association (AMA, 2017) defines it as “a set of institutions and processes for creating, communicating, delivering, and exchanging offers that have value for customers, consumers, partners, and society in general”. Marketing applied to the public sector was driven by the universal view of the discipline for all organizations (Kotler & Levy, 1969), fitting into the objectives of public administration (Kaplan & Haenlein, 2009; Zavattaro et al., 2021).

Public marketing is the first step toward citizens' satisfaction (Alemán et al., 2018; Pasquier & Villeneuve, 2018), as it enables greater proximity between the State and citizens, if applied to meet the needs and expectations of society, either qualitatively or quantitatively (Cezar, 2019; Silva & Minciotti, 2021). It allows the achievement of the efficiency-efficacy-effectiveness triad in public services' provision (Silva, 2015; Silva & Minciotti, 2021).

However, in contrast to other practices that were more easily consolidated in public administration, marketing's route through the areas of public administration proved more difficult than expected in the early 1980s (Bouzas-Lourenzo, 2010; Laing, 2003). Even in the political changes characterized by the New Public Management, there was a strong reluctance to adopt marketing concepts as means to understand and manage the uncertainty inherent to the new paths of public administration (Laing, 2003). In general, it has been associated with pure electoral advertising (Bouzas-Lorenzo, 2010).

The literature on public marketing became better used from the paradigm subsequent to managerialism, known as New Public Governance, which assumes a strong involvement of public management with its stakeholders (Runya et al., 2015; Rakšnys et al., 2015), for higher administrative effectiveness of participatory democracy (Edelenbos, Klijn, & Steijn, 2010). This paradigm supports a new approach known as marketing in public services (Cezar, 2019; Silva et al., 2021), when public sector commitments seek to meet the needs and expectations of citizens through participation. In this case, the goal is to improve the efficiency of public service management, allowing a strategic, responsible and integrated public management, thus enhancing citizenship (Alemán et al., 2018; Silva, 2015).

In this process, communication is essential, seeking to remain closer and accessible to stakeholders (Cezar, 2019; Pasquier & Villeneuve, 2018; Ribeiro & Oliveira, 2013). Media evolution is one of the factors underlying organizations' trend to communicate more and more (Pasquier & Villeneuve, 2018; Thomas et al., 2020), which enables the development of marketing strategies through the dissemination of information and message projection. As a result, it encourages society to participate in political life and related matters (Cezar, 2018), as well as to achieve other goals, including, but not limited to, gaining trust and improving public image (Thomas et al., 2020; Zavattaro et al., 2021).

In recent years, when social media emerged as ubiquitous, governments have increasingly used different methods to convey their message (Thomas et al., 2020), allowing public communication to take on different levels (Pasquier & Villeneuve, 2018), among which stand out institutional communication and government communication. In general, communication has promoted public organizations, in order to facilitate access to their services or strengthen their legitimacy (Pasquier & Villeneuve, 2018; Rossoni, 2016). In democratic countries, communication usually has a governmental character, providing marketing campaigns and strategies about government decisions (Pasquier & Villeneuve, 2018), so that citizens can know them better and engage in spaces of public deliberation (Cezar, 2018, 2019). In the latter case, the field of public marketing goes from a communication strategy to a strategic governance initiative (Zavattaro et al., 2021).

2.2 SUS's judicialization

The SUS ensures universal and free access, providing not only assistance care, but also complete health care (Ministério da Saúde [MS], 2021). However, SUS is not always able to accommodate the demand and, as a consequence, citizens seek in court their denied right, by filing suits against the State (Carvalho, 2007; Lara et al., 2021). This issue involved resources over R$1.5bn in 2016 (CNJ, 2019; Ventura, Simas, Pepe, & Schramm, 2010).

Excessive judicialization of health hinders the effectiveness of judiciary and has a decisive impact on the execution of this and other public policies (Barroso, 2009). The increase in spending on lawsuits causes budgetary and financial changes in health programs and other government actions (Bianca & Damascena, 2015; Gomes, 2019), affecting the execution of public policies (Kukul, 2018). Therefore, it was necessary to look for alternatives to minimize the large number of demands that burdened the courts, and to avoid distortions arising from health judicialization, such as the adoption of arrangements for solving conflicts, through Mediation and Conciliation Chambers (Lara et al., 2021; Silva, 2018).

One of the pioneers was the “SUS Mediado” program, created in 2012 through technical cooperation among various agencies, to ensure higher effectiveness to public health policies in the State of Rio Grande do Norte; it mitigates legal claims and ensures access of SUS's users to products and services (Defensoria Pública do Estado do Rio Grande do Norte [Public Defender's Office of the State of Rio Grande do Norte – DPE-RN], 2020).

Following the example, the CRLS, also created in 2012, whose scope is to attend parties assisted by the State Public Defender's Office and the Union's Public Defender's Office, demands the provision of health services in order to avoid lawsuits filing. It seeks an administrative solution for medication offer, scheduling a surgical or clinical procedure, hospitalization or a medical exam (Convênio [Agreement] SN71, 2012).

The Permanent District Chamber for Health Mediation – Camedis – was created later, in 2013, as the result of a partnership between the State Health Secretariat and the Public Defender's Office of the Federal District, whose mission is to prevent new lawsuits and propose solutions to those that already exist, through the mediation of public health demands (Portaria Conjunta [Joint Ordinance] nº 01, 2013).

3. Methodology

The research sought to check how information on public policies for mitigating SUS's judicialization is disclosed on digital media to citizens and key stakeholders. We chose the programs SUS Mediado, Camedis and CRLs, since Innovare Institute indicated them as innovative actions to find solutions in the Brazilian Judiciary (Instituto Innovare, 2020).

The research method was essentially qualitative, although supported by descriptive statistical analysis in the exploratory phase (Saunders, Lewis, & Thornhill, 2016). We started from a theoretical set and empirical literature; later, as data revealed patterns, we conducted new theoretical search and returned to data sources, in order to understand and generalize results, thus characterizing an abductive method.

To carry out the exploratory phase, we chose to use webometric procedures. The term “webometrics” was initially coined by Almind and Ingwersen in 1997 (Silva, 2016; Vanti, 2002), meaning the application of the infometric method to the world wide web, considered an extension of bibliometric analyses, as it covers “the study of production modes of information and communication in non-academic communities” (Vanti, 2002, p. 155). Bibliometrics handles quantitative studies involving both the development and use of the web in the following areas: content analysis of web pages, link structure, web use and technologies (Thelwall, Vaughan, & Björneborn, 2006). The method can also be applied to checking “the evolution of the presence of a certain institution […] in the network […]” and “to quantify the growth or loss of a theme or matter relative importance […]” (Vanti, 2002, p. 157).

One of the ways to capture data for webometric studies is using search tools to index as many web pages as possible (Lang, Gouveia, & Leta, 2008). In this study, we carried out searches using one of the search engines available to locate and characterize institutional publications on the web referring to mediation programs for mitigating health judicialization, without time limits. To do that, we have used Google search engine, which has a high percentage of indexed pages, and is the most used in Brazil and worldwide (Rioja, 2020).

In the Google page, we did the following search strings:

1. SUS Mediado: (“SUS MEDIADO” + “NATAL”); (“SUS MEDIADO” + “NORTE”); (“SUS MEDIADO” + “RN”);

2. Camedis: (“CAMEDIS” + “DF”); (“CAMEDIS” + “Brasília”); and

3. CRLS: (“Câmara de Resolução de Litígios de Saúde” + “RJ”); (“CRLS” + “Rio de Janeiro”).

We tried other strings, but found no additional information. We finished data collection when we noticed successive repetition of pages already visited. The final sample consisted of 131 data, among which 60 referred to SUS Mediado, 24 to Camedis and 47 to CRLS.

We filed data in electronic spreadsheets, whose contents we fully read, and discarded those that did not have information aligned to our objectives, which are publications in digital media that somehow seek communication with citizens and/or stakeholders. As mentioned, initially we conducted a descriptive analysis of these data, through coding according to the conveyed message (Bardin, 2004).

Coding began by considering the purpose of each message about programs transmitted in digital media, from which we identified and classified groups of codes, based on the research context. In order to assign a higher internal validity to the procedure, we reviewed the codes among the authors (Saunders et al., 2016). Then we grouped the factors found by similarity and meaning into higher categories (Flick, 2013). From then on constructs emerged, generalizing a conceptual model that relates legitimacy and effectiveness of public policies.

4. Results

4.1 Characterization of public marketing of programs for mitigating SUS's judicialization in digital media

We fully read the news published in digital media, and it was possible to group them into 11 different codes, according to the proximity of their attributes. Table 1 shows the description and frequency of each message.

As shown in Table 1, the vast majority of information in digital media were releases – original or replicated by third parties – from public agencies that handle judicialization mitigation programs; they focused much less on news about the program or the public policy itself, mainly consisting of institutional communication.

In general, the characteristics of the publications were similar in all programs analyzed. One of the most frequent news is about “reducing judicialization” (18.32%), associated with the main purpose of these programs: to avoid the filing of actions related to public health policies. In this group, we found information such as “it avoided judicialization in 50% of the services against the State in the first semester of 2018” (extracts from pages cod38 and cod39) on SUS Mediado; or “in the first half of 2016, 40% of demands received were solved without a legal process” (extracts from pages cod77 and cod79) about Camedis or even indirectly, like “more than 15 thousand people chose not to go to court to complain that their demands were not met by the public health system in Rio de Janeiro” (extract from page cod130), about CRLS.

The “institutional information” code (18.32%) also stands out, given the importance of a wide dissemination of activities in order to reach more and more citizens and other stakeholders. At Camedis and CRLS, the messages contained in this group are strictly oriented to the publication of official acts, such as the creation of these programs through Joint Ordinance No. 01/2013 (cod64 and cod67) and the Agreement SN71/2012 (cod86 and cod88), respectively. On the other hand, the profile of SUS Mediado messages differs from the other programs, as it sought to advertise its operation to the community with news such as “Tuesday is the day of SUS Mediado in the Public Defender's Office” or “SUS Mediado is now working in the new DPE building” (extracts from pages cod06 and cod29).

Another obvious code is “model for other states” (15.26%), which is a way for the public administration of trying to show that the public policy was recognized as a benchmark model for other regions of the country. SUS Mediado was the one that contributed the most to this type of public marketing, as it was the only program that showed in its institutional channels the interest of other states in knowing its actions; we found news such as “SUS Mediado implemented in RN is a model to other states” or “authorities from Bahia come to know the SUS Mediado project in RN” (extracts from pages cod26 and cod23). CRLS and Camedis did not show this profile, and we found information of this type in third-party publications. This is still more evident in CRLS, whose releases were published in institutional channels of other states that visited the program; we found news such as “PGE-RS visits PGE-RJ to learn about experiences in compensating registered warrants and solving health disputes” (extract from page cod114).

Among the data, also common are those whose main message is presenting programs' actions and results at some events, mainly involving the health area, which we put under the code “presentation at event” (13.74%). Therefore, the experiences of SUS Mediado, Camedis and CRLS programs were shared in events such as the Second Seminar on the Right to Health (cod08), Second Seminar on Law and Health (cod75) and Seminar on Social Security: the challenges of the Judiciary and related entities (cod113), respectively.

The code “program launching” (8.4%) differs from “institutional newsletter”, as it is exclusively oriented to advertising their beginning, as in these highlights: “State Public Defender's Office makes partnerships and launches the SUS Mediado program” (extract from page cod07), for SUS Mediado; “Health wins Mediation Chamber” (extract from page cod66), for Camedis and “RJ government creates agency to streamline health demands” (extract from page cod91), for CRLS.

SUS Mediado and CRLS programs expanded to other cities within their area of action; therefore, both have messages assigned to the code “expansion to other municipalities”. According to the collected data, SUS Mediado expanded to the cities of Caicó (cod04), Angicos (cod05) and Parnamirim (cod14), in the State of Rio Grande do Norte; and CRLS started to assist in the cities Campos dos Goytacazes (cod106), Magé (cod111), Mesquita (cod120) and Petrópolis (cod128), in the State of Rio de Janeiro.

Of the three programs, SUS Mediado has the greatest variety of news, as unlike the others it sought to spread information regarding the consolidation of new partnerships, and even about routine meetings of its representatives to strengthen the program. As a result, we assigned two codes exclusively to this program: “partnerships strengthening” (3.05%), which was mainly due to disseminating the reintegration of the city of Natal to the program, through the Municipal Health Secretariat (cod4) and “meeting of members” (5.34%), with messages such as “Sesap and the Public Defender's Office discuss strengthening SUS Mediado” (extract from page cod36).

Considering that the three programs were nominated for the Innovare Award, as innovative actions for finding solutions in the Brazilian judiciary (Instituto Innovare, 2020), the code “award” refers to the dissemination in digital media of information related to this nomination.

Although the vast majority of codes deal with positive aspects of the analyzed programs, we also identified a small part of messages with opposite content. One of them reveals “increased judicialization” (2.29%), which may be indirectly related to the low effectiveness of the programs, or the lack of knowledge or access of citizens who have health demands. On CRLS, even acknowledging the program's efforts, news were “RJ has more than 52,000 lawsuits in court for health failures” (extract from pages cod124). On SUS Mediado, this happened with the City of Natal leaving the program, which resulted in messages such as “SUS Mediado does not advance and judicialization increases” (extract from page cod34). Similarly, the code “criticism/complaint” (2.30%) relates to some difficulties faced or criticism regarding its operation. On CRLS, for example, there is criticism from citizens regarding the delay in assistance (cod131).

4.2 Building public marketing constructs of programs for mitigating SUS's judicialization in digital media

By ranking the codes obtained at the level of categories and constructs, we analyzed those regarding public marketing strategies. In general, such publications seek to enhance citizenship as a way to facilitate access to information and to offer public services with greater transparency and responsibility (Alemán et al., 2018; Ribeiro & Oliveira, 2013). Data revealed grouping of codes in four categories that make up three major constructs: Perceived Quality, Advertising Produced and Results Achieved (Figure 1).

The “Perceived Quality” construct is the result of the category “result evidence”, composed by the codes “model for other states”, “award” and “criticism/complaint”. While the first two indicate that public policies have institutional quality, the last goes in an opposite way, and comprises third-party publications. Perceived quality refers to consumers' assessment of the general excellence or superiority of a product (Gotlieb, Grewal, & Brown, 1994). In this case, not a consumer, but mainly a citizen. It is an external criterion of legitimacy very important for public policy recognition (Meyer & Rowan, 1977; Suchman, 1995). Hence, public marketing present in institutional releases does not intend to capture the consumer, but to influence the citizen's perception of reality, not of a factual quality.

The “Advertising Produced” construct covers the category “program advertising”, represented by the codes “meeting of members”, “program launching”, “institutional newsletter” and “presentation at events”. It refers to all actions that allow the implementation and organizational strengthening inside and outside an institution. Communication facilitates shared understanding with its stakeholders about the organization itself, its values, its brands' identity and the specific benefits of its products and services (Proctor, 2007). With SUS Mediado, Camedis and CRLS programs it is not different: it is through this communication, mandatory or voluntary, that public policy achieves greater social acceptance for legitimizing itself in its environment, or to keep its legitimacy before society (Beuren, Gubiani, & Soares, 2013; Rossoni, 2016).

Finally, the construct “Achieved Results” comprises two categories: “negative results”, with the code “increased judicialization”, and “positive results”, with the codes “partnerships strengthening”, “expansion to other municipalities” and “reduction of judicialization”. These are quantifiable conveyed facts and represent real public policy results, as the presented numbers and data show concrete actions. Considering the interorganizational characteristics of the program, the positive results stem from good public governance, transmitting the concept of cooperation and participation (Denhardt & Denhardt, 2000).

5. Discussion

5.1 Configuration of the conceptual model of public marketing of programs for mitigating SUS's judicialization in digital media

As found in the results, constructs represent mechanisms that make a public policy recognized by citizens. According to Suchman (1995), these mechanisms are important for legitimacy, defined as the generalized perception that actions are appropriate within any socially built system of norms, values and beliefs.

Currently, media is one of the main indicators of legitimacy (Rossoni, 2016), considering that reports on the organization through mass communication influence the general public's opinion. Therefore, an organization becomes legitimate when its elements are supported by structural principles accepted in the social system (Rossoni, 2016; Suchman, 1995). In this sense, legitimacy becomes a key construct and a goal that the whole public administration must achieve, as it can increase an organization's resources and survival capacities (Meyer & Rowan, 1977; Rossoni, 2016).

According to Beuren et al. (2013), as organizations are accepted, they move from the state of legitimacy to that of required legitimacy and, from there, they work to keep this legitimacy or to recover the undermined or lost legitimacy. To do that, their main strategic ally is communication with the public, considered in the literature as the greatest potential of marketing for public administration (Kaplan & Haenlein, 2009; Zavattaro et al., 2021). For this reason, official organizations launch in their communication channels several marketing strategies to indicate trust in their public policies (Thomas et al., 2020).

Given the findings, the construct “Legitimacy” emerged in this research, whose causal relationship arising from the proposed model is shown in Figure 2.

In Figure 2, the four constructs relate to each other in a nomological network, where legitimacy is the most exogenous variable, that is, what any public policy pursues. Both Results Achieved and Advertising Produced are intended to influence public health policy through information for stakeholders (Proctor, 2007), which gives levels of legitimacy. This means that bad publicity or negative results reduce legitimacy, and the opposite is equally true (Rossoni, 2016).

However, Perceived Quality mediates both constructs, since perception is something that involves individuals' subjectivism, in this case citizens'. Thus, legitimacy can pass through this filter, which grants higher complexity to public policies' legitimation.

These findings corroborate Henneberg, Scammell and O'Shaughnessy (2009), who claim that the major concern for the implementation of public policies regards ensuring legitimacy and stability of the democratic system as a whole. Therefore, the adoption of marketing strategies in the public sector and, especially, in the programs under study, consolidates a democratic legitimacy (Henneberg et al., 2009; Zavattaro et al., 2021).

It is possible to imagine that in medium to long term, legitimacy will also affect the constructs Achieved Results and Perceived Quality. Service provision is not complete with a single action, but with the sum of actions in the sequence of its cycle, by constantly monitoring the degree of satisfaction of the target audience (Silva et al., 2021).

5.2 Degree of achieved results and legitimacy

Based on the fact that Achieved Results represent real data on what mitigation programs for SUS's judicialization have achieved, it is possible to understand this construct as a result of the capacity for dialogue of complex interorganizational operations to provide quality services for the citizen (Denhardt & Denhardt, 2000; Oliveira et al., 2013; Silva, 2015).

On the other hand, Perceived Quality and Advertising Produced are institutional forces that promote the legitimacy of public policy. Figure 3 shows four quadrants formed by placing them as an ordered pair, with one axis representing Achieved Results (real data disclosed) and the other Legitimacy, the goal of public marketing (Henneberg et al., 2009).

Based on Figure 3, when there is fake public marketing, there is investment in marketing of a public policy that grants a high degree of legitimacy that does not correspond to a project's real results. Under this possibility – using marketing to deceive the citizen –, several authors in fact condemn it; therefore, they do not agree with the use of advanced marketing techniques in the public sector (Bouzas-Lorenzo, 2010). Especially given the evolution of fields such as neuromarketing, through which influences can be subtle and imperceptible (Murphy, Illes, & Reiner, 2008).

On the contrary, the inefficient public policy dimension assumes that most of the results of a public policy, as well as marketing, are below expectations, which affects the recognition and social acceptance of the brand (Pasquier & Villeneuve, 2018). In this case, managers must rethink the continuity and reformulation of a certain public policy, since the efficiency and effectiveness of public administration is essential in all activities (Silva & Minciotti, 2021).

The deficient public marketing dimension is due to the existence of a well-conducted, efficient and effective public policy, which attains its established objectives; however, somehow society does not recognize it as legitimate. These cases are those where public marketing could be better explored, since communicating the citizen regarding the quality of products and services provided is a fundamental marketing goal (Cezar, 2019; Thomas et al., 2020), as well as developing strong political brands on top of equally strong services provided (Kaplan & Haenlein, 2009; Ribeiro & Oliveira, 2013).

Finally, the full public policy dimension is the goal of any public policy, where results are high, as well as legitimacy. It is the scenario in which public marketing aligns with positive results and, consequently, with the guarantee of legitimacy. This quadrant corroborates the perception of Edelenbos et al. (2010), who concluded that the better the inclusion of stakeholders is designed and organized, the better the results (content and process) will be achieved in complex governance processes.

6. Final remarks

The analysis has shown that disclosing public policies that involve SUS Mediado, Camedis and CRLS through digital media has three distinct purposes. The messages contained in Advertising Produced seek to disseminate information on the programs' characteristics, while in Perceived Quality they go beyond this perspective, as the aim is to get favorable assessments from the community, regarding its effectiveness. However, we found the concreteness of their actions in the messages that make up Achieved Results, because they present numbers and data on the reality of public policy's efficiency.

All constructs found in this research refer to public marketing strategies that seek to achieve and keep, directly or indirectly, the legitimacy and stability of the public policy as a whole. Thus, elaborating a generalizable structure that comprises the four dimensions of the relationship between results achieved and legitimacy represents a theoretical progress, as it has allowed investigating potential characteristics of public marketing for any form of public policy's action.

As a social implication, this article recognizes this structure as a means of providing better social control of public policies, especially if, in fact, public marketing is establishing a responsible and transparent communication with the citizen, and not just promoting an ineffective public policy. Therefore, it leads to questioning when the application of marketing is feasible, since there are possibilities of building legitimacy without concrete results.

Specifically regarding health judicialization, we identified different communication efforts among conflict mediation programs for citizens and other stakeholders, in search of legitimacy. However, as data collected in this study were based exclusively on digital media, we could not check the real effectiveness of the programs, but only their communication, which is a limitation of this research.

Considering the difficulty in getting a filter between government releases and dissemination on news sites, we emphasize the need to improve impartial informative stories to validate institutional news.

Finally, this paper presents directions for future research, regarding how public marketing planning has been carried out or evaluated in terms of its effectiveness, and how to use public marketing to interpret citizens' perception in search for legitimacy.

Figure 1
Categories and constructs of reported news

Figure 2
Conceptual model for SUS's public marketing

Figure 3
Comparison between the degree of achieved results and legitimacy

Table 1

Codes regarding message transmission

Codes | Description | Frequency
Institutional newsletter | Purely informative messages to communicate the operation of the program or the publication of administrative acts related to it | 24
Reduction of judicialization | Disclosure of the health-related lawsuits’ amount reduction over a given period, due to the effectiveness of the program's operation | 24
Model for other states | Characteristics of the program for mitigating SUS's judicialization, recognized as a potential administrative solution to reduce judicialization in the health area for other federation states | 20
Event presentation | Presentation on the program's actions and results in health events, and as successful practices in meetings of the National Council of Public Defenders of the States, the Federal District and the Union – CNCG | 18
Program launching | Launching of the SUS program for mitigating judicialization, with the presentation of its purpose, operation and partnerships | 11
Expansion to other cities | Expansion of programs for mitigating SUS's judicialization to other municipalities within its sphere of action | 11
Meeting of members | Meetings of the representatives, in order to seek new actions to strengthen and expand the program | 7
Award | Indication of SUS's program for mitigating judicialization to the Innovare Award, as a practice that contributes to improving Justice in Brazil | 5
Strengthening partnerships | Partnerships of SUS's program for mitigating judicialization with other public bodies, to enhance actions' effectiveness | 4
Judicialization increase | Presentation of the increase on number of health-related lawsuits, even with the existence and operation of SUS's program for mitigating judicialization | 4
Criticism/Complaints | Program's weaknesses related to difficulties faced, or criticism about its operation or effectiveness | 3

References

Alemán, R., Gutiérrez-Sánchez, R., & Liébana-Cabanillas, F. (2018). Determinant factors of satisfaction with public services in Spain. Australian Journal of Public Administration, 77(1), 102–113. doi: 10.1111/1467-8500.12252.

American Marketing Association (2017). Definitionsof marketing. Available from: https://www.ama.org/the-definition-of-marketing-what-is-marketing/.

Bardin, L. (2004). Análise de conteúdo (3a. ed.). São Paulo: Edições 70.

Barroso, L. R. (2009). Da falta de efetividade à judicialização excessiva: Direito à saúde, fornecimento gratuito de medicamentos e parâmetros para a atuação judicial. Jurisprudência Mineira, 60(188), 35–50. Available from: https://bd.tjmg.jus.br/jspui/bitstream/tjmg/516/1/D3v1882009.pdf.

Beuren, I. M., Gubiani, C. A., & Soares, M. (2013). Estratégias de legitimidade de Suchman evidenciadas nos relatórios da administração de empresas públicas do setor elétrico. Revista de Administracao Pública, 47(4), 849–876. doi: 10.1590/S0034-76122013000400003.

Bianca, A. S., & Damascena, A. L. (2015). Os impactos do excesso de judicialização da saúde sobre o orçamento público. Revista Eletrônica da Faculdade Metodista Granbery, 18, 1–26. Available from: http://re.granbery.edu.br/artigos/NTM5.pdf.

Bouzas-Lorenzo, R. (2010). Publicsector marketing, political science and the science of public administration: The evolution of a transdisciplinary dialogue. International Review of Public and Nonprofit Marketing, 7, 113–125. doi: 10.1007/s12208-010-0057-2.

Carvalho, R. K. (2007). A judicialização do acesso à saúde no Brasil: O caso HIV-AIDS (Trabalho de Conclusão de Curso de Especialização). Criciúma, SC: UNESC.

Cezar, L. C. (2018). Reflexões sobre a comunicação em políticas públicas: Proposta de um modelo de avaliação da comunicação governamental. Revista de Administração Pública, 52(1), 52–70. doi: 10.1590/0034-7612165920.

Cezar, L. C. (2019). Comunicação e marketing no setor público: Diferentes abordagens para a realidade brasileira. Brasília: ENAP. Available from: http://repositorio.enap.gov.br/handle/1/4279.

Conselho Nacional de Justiça (2016). Manual de Mediação Judicial (6a ed.). Brasília: CNJ. Available from: http://www.cnj.jus.br/files/conteudo/arquivo/2016/07/f247f5ce60df2774c59d6e2dddbf ec54.pdf/.

Conselho Nacional de Justiça (2019). Judicialização da saúde no Brasil: Perfil das demandas, causas e propostas de solução. CNJ/INSPER. Available from: https://www.cnj.jus.br/wp-content/uploads/conteudo/arquivo/2019/03/f74c66d46cfea933bf22005ca50ec915.pdf.

Convênio SN71, de 15 de junho de 2012 (2012). Convênio de cooperação visando a criação da Câmara de Resolução de Litígios de Saúde – CRLS. Rio de Janeiro. Available from: http://www4.tjrj.jus.br/biblioteca/index.asp?codigo_sophia=156599.

Defensoria Pública do Estado do Rio Grande do Norte (2020). Programa SUS Mediado. Available from: https://defensoria.rn.def.br/programa/sus-mediado/.

Denhardt, R. B., & Denhardt, J. V. (2000). The new public service: Serving rather than steering. Public Administration Review, 60(6), 549–559. doi: 10.1111/0033-3352.00117.

Edelenbos, J., Klijn, E. H., & Steijn, B. (2010). Does democratic anchorage matter? An inquiry into the relation between democratic anchorage and outcome of Dutch environmental projects. American Review of Public Administration, 40(1), 46–63. doi: 10.1177/0275074009332064.

Flick, U. (2013). Introdução à metodologia de pesquisa: Um guia para iniciantes. Porto Alegre: Penso.

Gomes, J. T. (2019). A União e o fenômeno da judicialização da saúde: Uma análise empírica dos possíveis impactos nas políticas públicas de saúde. Dissertação de mestrado. Campina Grande, PB: Universidade Federal de Campina Grande. Available from: http://dspace.sti.ufcg.edu.br:8080/jspui/handle/riufcg/4551.

Gotlieb, J. B., Grewal, D., & Brown, S. W. (1994). Consumersatisfaction and perceived quality: Complementary or divergent constructs? Journal of Applied Psychology, 79(6), 875–885. doi: 10.1037/0021-9010.79.6.875.

Grier, S., & Bryant, C. A. (2005). Social marketing in public health. Annual Review of Public Health, 26, 319–339. doi: 10.1146/annurev.publhealth.26.021304.144610.

Gurrieri, L., Gordon, R., Barraket, J., Joyce, A., & Green, C. (2018). Social marketing and social movements: Creating inclusive social change coalitions. Journal of Social Marketing, 8(4), 354–377. doi: 10.1108/jsocm-12-2016-0078.

Henneberg, S. C., Scammell, M., & O'Shaughnessy, N. J. (2009). Political marketing management and theories of democracy. Marketing Theory, 9(2), 165–188. doi: 10.1177/1470593109103060.

Hoek, J., & Jones, S. C. (2011). Regulation, public health and social marketing: A behaviour change trinity. Journal of Social Marketing, 1(1), 32–44. doi: 10.1108/20426761111104419.

Instituto Innovare (2020). Prêmio Innovare. Available from: https://www.premioinnovare.com.br/.

Kaplan, A. M., & Haenlein, M. (2009). The increasing importance of public marketing: Explanations, applications, and limits of marketing within public administration. European Management Journal, 27(3), 197–212. doi: 10.1016/j.emj.2008.10.003.

Kotler, P., & Armstrong, G. (2015). Princípios de marketing (15a ed.). São Paulo: Pearson Education do Brasil.

Kotler, P., & Levy, S. J. (1969). Broadening the concept of marketing. Journal of Marketing, 33(1), 10–15. doi: 10.2307/1248740.

Kukul, I. M. (2018). Gestão da política de saúde municipal e os impactos da judicialização da saúde: Uma análise das percepções do gestor da saúde em um município do Paraná. Dissertação de mestrado. Universidade Federal da Integração Latino-Americana, Foz do Iguaçu, PR. Available from: https://dspace.unila.edu.br/123456789/4328.

Laing, A. (2003). Marketing in the public sector: Towards a typology of public services. Marketing Theory, 3(4), 427–445. doi: 10.1177/1470593103042005.

Lang, P. B., Gouveia, F. C., & Leta, J. (2008). Relações intra-institucionais na Internet: Um estudo exploratório com base em metodologias webométricas. Perspectivas em Ciência da Informação, 3(3), 137–150. Available from: https://www.scielo.br/pdf/pci/v13n3/a09v13n3.

Lara, M., Fernandes, C. M. S., Penteado, V. P., & Serra, M. C. (2021). Rightto health and judicialization in access to medium and high complexity treatments through the Unique Health System (SUS). Research, Society and Development, 10(3). doi: 10.33448/rsd-v10i3.13091.

Meyer, J. W., & Rowan, B. (1977). Institutionalized organizations: Formal structure as myth and ceremony. American Journal of Sociology, 83(2), 340–363. doi: 10.1086/226550.

Ministério da Saúde (2021). Sistema Único de Saúde (SUS): Estrutura, princípios e como funciona. Available from: http://www.saude.gov.br/sistema-unico-de-saude.

Murphy, E. R., Illes, J., & Reiner, B. (2008). Neuroethicsof neuromarketing. Journal of Consumer Behaviour, 7(4–5), 293–302. doi: 10.1002/cb.252.

Oliveira, A. L., Costa, A. P., Miranda, A. R., Mesquita, D. L., & Pereira, J. R. (2013). O marketing público no contexto da reforma gerencialista do estado. Desenvolve Revista de Gestão do Unilasalle, 2(2), 103–116. doi: 10.18316/1206.

Pasquier, M., & Villeneuve, J. P. (2018). Marketing Management and Communications in the Public Sector (2nd ed.). London: Routledge.

Portaria Conjunta nº 01, de 26 de fevereiro de 2013. (2013). Institui a Câmara Permanente Distrital de Mediação em saúde (Camedis). Diário Oficial do Distrito Federal Brasília, (43), 19. Available from: http://www.sinj.df.gov.br/sinj/Norma/74163/2d029b30.html.

Proctor, T. (2007). Public Sector Marketing. London: Prentice Hall.

Rakšnys, A. V., Guogis, A., & Minkevičius, A. (2015). The problem of reconciliation of new public governance and postmodernism: The conditions of returning to communitarianism. Trames, 19(4), 333–353. doi: 10.3176/tr.2015.4.02.

Ribeiro, M. P., & Oliveira, E. R. (2013). Comunicação e marketing no setor público: Uma prática que permite o fortalecimento da cidadania e a modernização da gestão pública. Revista Gestão Pública: Práticas e desafios, 4(7), 170–191. Available from: https://periodicos.ufpe.br/revistas/gestaopublica/article/view/901.

Rioja, A. (2020). Top 9 Motores de Busca: Revisão do Ranking, Prós e Contras. Available from: https://alejandrorioja.com/pt/top-search-motores/.

Ronconi, L. (2011). Governança pública: Um desafio à democracia. Emancipação, 11(1), 21–34. doi: 10.5212/Emancipacao.v.11i1.0002.

Rossoni, L. (2016). O que é legitimidade organizacional? Organizações and Sociedade, 23(76), 110–129. doi: 10.1590/1984-9230766.

Runya, X. U., Qigui, S. U. N., & Wei, S. I. (2015). The third wave of public administration: The new public governance. Canadian Social Science, 11(7), 11–21. doi: 10.3968/7354.

Saunders, M., Lewis, P., & Thornhill, A. (2016). Research Methods for Business Students (7nd ed.). Pearson.

Silva, E. C. (2015). Marketing público: uma plataforma de “trocas” no setor público. Revista Eletrônica de Administração, 14(1). Available from: http://periodicos.unifacef.com.br/index.php/rea/article/view/748.

Silva, I. O. (2016). Webometria e a análise de redes sociais. Revista ACB: Biblioteconomia em Santa Catarina, 21(2), 294–308, available at: https://brapci.inf.br/index.php/res/download/87594.

Silva, R. E. G., Bianchini, R. M. S., & Minciotti, S. A. (2021). Public services marketing: A means of meeting the contributors' benefit expectations. International Journal of Development Research, 11(4), 46480–46484. doi: 10.37118/ijdr.21643.04.2021.

Silva, R. E. G., & Minciotti, S. A. (2021). Publicmarketing as a facilitator of the exchange process in public administration. Research, Society and Development, 10(5). doi: 10.33448/rsd-v10i5.15597.

Silva, T. B. A. (2018). Métodos autocompositivos na governança pública para resolução de conflitos na saúde pública no município de Ariquemes/RO. Dissertação de mestrado profissional. Porto Velho: Universidade Federal de Rondônia.

Suchman, M. C. (1995). Managinglegitimacy: Strategic and institutional approaches. Academy of Management Review, 20(3), 571–610. doi: 10.5465/amr.1995.9508080331.

Thelwall, M., Vaughan, L., & Björneborn, L. (2006). Webometrics. Annual Review of Information Science and Technology, 39(1), 81–135. doi: 10.1002/aris.1440390110.

Thomas, M. B., Fay, D. L., & Berry, F. S. (2020). Strategicallymarketing Florida's cities: An exploratory study into how cities engage in public marketing. The American Review of Public Administration, 50(3), 275–285. doi: 10.1177/0275074019897599.

Vanti, N. A. P. (2002). Da bibliometria à webometria: Uma exploração conceitual dos mecanismos utilizados para medir o registro da informação e a difusão do conhecimento. Ciência da Informação, 31(2), 152–162. Available from: https://www.scielo.br/pdf/ci/v31n2/12918.pdf.

Ventura, M., Simas, L., Pepe, V. L. E., & Schramm, F. R. (2010). Judicialização da saúde, acesso à justiça e a efetividade do direito à saúde. Physis, 20(1), 77–100. Available from: https://www.scielo.br/pdf/physis/v20n1/a06v20n1.pdf.

Zavattaro, S. M., Marland, A., & Eshuis, J. (2021). Public branding and marketing: Theoretical and practical developments. Public Administration Review, 81(4). doi:10.1111/puar.13372.