Institutional Analysis in the Context of Collective Health in Primary Health Care: A Scoping Review

Abstract

Objective: To analyze the appropriation of Institutional Assessment in primary studies and the use of the central theoretical-methodological and conceptual framework of institution in its three moments: instituted, instituting, and institutionalization.

Methods: Scoping review conducted in the databases of the Virtual Health Library and in the databases provided by the journals portal of the Coordination for the Improvement of Higher Education Personnel and Google Scholar. The study included original articles in Portuguese, English, Spanish, and French, published from 1987 to 2021. Quantitative findings were grouped using descriptive statistics and the PRISMA-ScR checklist. Narrative data analysis was organized in the webQDA software®.

Results: Resulted in 34 articles, published from 2003 to 2020 both nationally and internationally, emerging a plurality of research, being more common those related to collective health, mental health, familyteam relationship, family health, primary care, continuing education, micro-politics of work in health. The areas that have most opted for IA are Nursing and Psychology. The various meanings and the concept of institution are confirmed in the findings, pointing to profusion in the formats and use of the concepts.

Conclusion: Presents concepts and tools with the ability to support the analysis of health practices in the context of the CH in line with the findings of the articles.

Keywords

Institutional analysis, Organizations, Collective health, Primary health care, Scoping review

Introduction

The Institutional Analysis (IA) developed in France in the 1960s counted with the contributions of René Lourau, a reference institutional analyst who defended a State thesis in 1969. The existence of other analysts of reference, such as Lapassade, has to be acknowledged. However, Lourau's recognition is due to his interventions with social collectives, named Socioanalysis, which resulted in the theoretical-methodological systematization and the construction of the IA [1].

According to L'Abbate[2] this is a field of knowledge formed from Psychoanalysis, Social Sciences and Philosophy, having emerged in Brazil in the 1970s and aimed to perform interventions in groups and institutions. Such proposal was based on some principles or "rules": order and demand analysis, group self-management, the rule of "everything to say", the elucidation of transversality, the analysis of implications, the explicitness of the analyzers, and restitution; the theoretical perspective of IA, based on the concepts of the analyzer, the triad institute/instituting/institutionalization and implication. Thus, today there is recognition that the methodological strategy of IA has influenced and been incorporated into the Brazilian health culture, which can be attested by clear evidence of its institutionalization, either in health management experiences, or in documents and regulations guiding programs and public policies in the sector. An important milestone was the recomposition of the Integrated Support proposal, starting in 2011, in the context of the implementation of health networks [3].

As for the organization and functioning of public and universal health systems, based on the proposal defined at the International Conference on Primary Health Care held in Alma-Ata (1978), Primary Health Care (PHC) became the first level of contact of people with the national health system [4]. In Brazil, the main PHC strategy was implemented in 1994 with the Family Health Program (FHP), later called Family Health Strategy (FHS) [5,6]. In the context of collective health inserted in Brazil, it can be seen that it is shaped as an ethical-political-pedagogical proposal, aiming to transform and qualify health care, training processes, and health education practices, in addition to encouraging the organization of actions and services in an intersectoral perspective also in the FHS scenario [7,8].

Meanwhile, it is reiterated that collective health seeks to understand the interrelation of knowledge nuclei to build the field of common knowledge and understand the complexity of the disease process and the appropriate professional action in this process. Thus, this mutual relationship between knowledges occurs through teamwork, an essential and necessary process in the context of collective health [9]. In the context of PHC and in Brazil, also the scope of analysis of this article, IA was incorporated as a managerial function to support the implementation and consolidation of the National Policy of Primary Care (NPPC). Anchored in [10], the methodology is under institutionalization since it was officially presented in several PHC norms. These refer both to the institutional support provided by municipal health secretariats to health regions and to PHC teams [11]. However, there is a gap in the studies systematizing the effects generated in concrete experiences of IA in the context of PHC, which hinders the possibility of reflecting critically on the scope and relevant issues for its consolidation. This article seeks answers to this gap, through a bibliographic research, Based on these concepts, it is reiterated that the implementation of social clinical interventions in the field of collective health is an innovative strategy, as it reveals how institutions act in professional [12], supporting the achievement of the goals established in PHC.

Objective

To analyze the appropriation of IA as a context of collective health in PHC, regarding the initiatives developed in primary studies in the use of the central theoretical-methodological and conceptual framework of institution in its three moments: instituted, instituting and institutionalization.

Methods

Study design method

This is a scoping study (scoping review) of the national and international literature on IA in the context of public health and PHC [13]. To this end, the methodology proposed by the Joanna Briggs Institute[14,15], described in five phases was adopted: identification of the research question; identification of relevant studies; selection of studies; data mapping; and grouping, synthesis, and reporting of results according to the PRISMA extension for scoping reviews (PRISMA-ScR).

The protocol is the best way to search for an effective question that directs the work of the review is to use the PCC strategy that stands for an acronym for Population (PHC), Concept (Institutional Evaluation) and Context (Collective Health). Thus, the following central question that guides the research was defined: 'How is IA conceptually denoted in collective health and in the context of Primary Care? The scope review is registered at OSF: osf.io/75jnz, record DOI:10.17605/OSF.IO/EXNV6.

Inclusion and exclusion criteria

As inclusion criteria, the empirical and theoretical studies were chosen, having as initial limit of temporality the year 1987, being the definition of this period of the search based on the pioneer publication on the theme in Brazil, the collection IA in Brazil [16], and extending until 2021 the articles published in Portuguese, English, Spanish and French, since IA had its first studies conducted in France. We chose as exclusion criteria duplicate works, ordinances, editorials, opinion articles, studies in project phase, as well as documents and summaries of seminars, congresses, courses, those not found in full and those that did not address relevant content to achieve the objective [17].

Data extraction

Therefore, the search strategy and selection of the publications was carried out in stages. The first stage was limited to MEDLINE for an analysis of the titles, abstracts, and descriptors used in the articles. The second stage of the search used all identified keywords and descriptors in all databases included in the study. In a third step additional studies were added. The database search was performed between September and October/2020 by two independent reviewers and included studies up to October/2020. Regarding the databases, the publications were collected from the Virtual Health Library (VHL): LILACS, MEDLINE, BDENF. The search was also conducted in the databases available at the CAPES (SciELO) journal portal; Cochrane, Web of Science, SCOPUS/Elsevier and CINAHL and Google Scholar.

The descriptors for the search were selected from the structured vocabulary of controlled descriptors of the DeCS/MeSH, in Portuguese, English, Spanish and French The Boolean operator (AND) was used and, according to each database, the signs of parentheses ( ), asterisk * or quotation marks "" were also used to assist in the search. The following keywords were used: 'avaliação institucional', 'institutional evaluation', 'evaluación institucional', 'évaluation institutionnelle', 'saúde coletiva', 'collective health', 'santé collective' 'saúde pública', 'public health', 'salud pública', 'santé publique', 'atenção primária', 'atenção primária à saúde', 'primary health care', 'atención primaria de salud', 'soins de santé primaires'.

It is noteworthy that even though this review aims to highlight the current knowledge on the topic of IA in the context of collective health and developed in PHC, the choice of the descriptor 'public health' was present due to the conceptual confusion existing with the term collective health, consequently, by the inappropriate use in texts and scientific articles. To compile the articles, the combination of terms was performed and adapted for each database. EndNote X9® (Thompson Reuters, New York, NY) software was used to manage the references and remove duplicate articles. The selection of studies was performed in two stages. In the first step, two reviewers independently evaluated the titles and citation abstracts of all databases. The web application Rayyan® (Qatar Computing Research Institute, Doha, Qatar) [18] was used for this purpose. In the second step, the same reviewers independently applied the inclusion criteria to the full-text readings of the articles. Another reviewer critically reviewed the list of selected studies. Any disagreement in the steps was resolved with the consensus of the authors.

Data analysis

The mapped data were entered into a specific form, with general and specific information about the study, such as the population, the type of intervention, the outcome measures and the study design. Data regarding authors' names and professions, year of publication, country of origin, country of the journal, type of production (uni- or multiprofessional), type of study, objectives, main themes of the study (health area), and results were identified, The quantitative findings were grouped using descriptive statistics, and for the narrative data the software webQDA® was used [19].

Results

Based on criteria established in the search strategy in the databases, the search resulted in 2,326 occurrences, and from the analysis of the references, 623 more texts were included, totaling 2,949 studies. Among these, 112 duplicates were found. After reading the titles, abstracts and descriptors, 2,837 were excluded, resulting in 224 texts submitted to full reading, whose analysis resulted in 34 studies, which make up the scope review. The exclusion of studies was guided by the exclusion criteria. Figure 1 specifies the results of each step of the analysis, following the PRISMA model [20].

The 34 studies selected to be part of this review were mapped using an Excel® spreadsheet in a form, following the model of [21], for the extraction and management of information, being carried out according to the aspects of an observation and mapping script, with the following information: author(s), year of publication, title, country of origin and excerpts, describing the main results of interest to this review. For the step of summarizing the essential elements of each study, a descriptive analytic structure was used to examine the text of each article. To this end, a qualitative analysis of all content was performed, which enabled the creation of narratives that emerged from the deeper analysis of the publications, which were able to illustrate topics of interest.

In the final step, the results were compiled and communicated, with the intention of presenting an overview of all the material, by means of a thematic construction, organized according to the elements that influence the answer to the question of this research. Almost all the studies were conducted in Brazil, with the exception of two in France, one in Argentina and one in Canada, in 24 different journals in the areas of Psychology, Nursing, Collective Health and Education, as shown in Table 1. As for the year of publication, it was evidenced in the year 2003, 1% (1); the year 2011, 1% (1) the years 2012 (6) and 2013 (6) presented 33%; in the sequence, the following distribution occurred: in 2014, 15% (4); in 2015, 23% (6); in 2016, 6% (2); in 2017, 10% (4); in 2018, 1% (1) 2019 1% (1); 2020 and 1% (1). With regard to language, most studies were published in Portuguese, with one in Spanish and two in French.

Table 1. Evidence table.

It was found in the analyzed studies that they were conducted from this theoretical-methodological perspective, are of the qualitative type, given the nature of their objects of study, as shown in Table 1. In this sense, we understand that the IA offers a theoretical framework that allows us to explain how the objects of study are constructed, move and transform themselves according to the political, economic, social and cultural panorama of the context in which they are inserted, constituting various social productions. Furthermore, the concepts of IA offer a contribution that allo ws visualizing the modes of operation of a given social reality, promoting a movement of complexity of analysis, as well as interventions in the context. Among the authors of the selected articles, the Psychology area prevails, with 45.4% (14), followed by Nursing, with 43.6% (11). In smaller numbers, there were graduates from Medicine, with 9% (5), Dentistry, with 5.4% (2), Pedagogy, with 1.8% (1), and Social Sciences, with 1.1% (1). Two authors had more than one degree: one of them had degrees in Nursing and Medicine and the other in Law and Psychology.

Regarding the distribution of studies by region in Brazil, the majority was from the Southeast (24) (São Paulo-12, Minas Gerais-7, Rio de Janeiro-5), followed by the South (4) (Paraná-2, Rio Grande do Sul-2), then the Northeast (2) (Natal-1, Rio Grande do Norte-1), Center-West (2) (Mato Grosso-2) and the North (0). It is worth mentioning that four articles had foreign authors: one from Canada, one from Argentina, and two from France. Based on the concept of IA it was possible to realize that in the scientific analysis of research occurred a multiplicity of concepts of IA that served as a foundation for the production of knowledge in health, however the most used was the concept chosen to compose this scope review, i.e., the concept of institution, always considering the three moments that compose it: instituted, instituting and institutionalization. In the selected articles, the following words were highlighted: IA (611 citations), public health (498 citations), collective health (348 citations), instituted (343 citations), institution (298 citations), institution (236 citations), intervention research (181 citations), instruments and tools (175 citations), primary care (165 citations) and education (143 citations), among others, as can be seen in the word cloud prepared with the support of WebQDA software (Figure 2).

Discussion

The scope review enabled the conceptual understanding of institution in its three moments, being analyzed in the study from the perspective of concept as a tool, that is, which aims to understand the way to operate the concept and to perceive it as life in movement that expands the possibilities to experience, a tool to live the concept [22]. A number of challenges to the development of IA in the area of collective health and in the context of PHC are also identified. Most studies included the lack of connection between the two dimensions of care as the main barrier to IA. However, the studies present a significant body of several other aspects that limit and/or hinder IA, such as lack of institutional support; inability to search and select scientific evidence; semantic and pragmatic misunderstanding of IA; deficiency in research funding; and inadequate communication of research results.

IA and the becoming of the concepts

The results reveal that some studies established approximations with the IA referential, without opting for specific affiliation to its aspects. Others, as perceived in the results of the studies, decided to use exclusively the concepts of socioanalysis or schizoanalysis, without permeating them. Another group sought approximations to the lines of socioanalysis and schizoanalysis. It is pondered that in Brazil, there is no consensus between the approximations of the strands of IA. There are authors who affirm that there are epistemological differences between them, but choose to approximate the concepts, understanding that they coexist and dialogue among themselves to intervene. They are: institution - instituted, instituting and institutionalization - implication, analyzer, flows, forces, agency, control, territorialization and deterritorialization. The IA is inserted in the institutionalist movement, constituted by "a heterogeneous, heterological and polymorphous set of orientations, among which it is possible to find a common feature: its aspiration to trigger, support and improve self-analytical and self-management processes of social collectives" [23]. On the other hand, even though the two strands come from the same social conception - having their beginnings in France in May 1968, there are other authors who discuss the existence of relevant differences in the theoretical genesis between them, which are known as mixture (mélange), as these productions are called [24].

It is reiterated that the studies analyzed for their theoretical and methodological foundation made use of several IA works and authors. The IA compendium [24], was used as the vanguard of this process, followed by the IA work [25]. It is believed that the choice for the first work is perhaps linked to the more cognizable format of the writing, especially for those who will have a first experience with the theme. It is observed that the AI work seeks to reflect about the concept of institution, permeating several theoretical perspectives of the social sciences, making it a fertile text, however, intense in the sense of making a first contact. Lourau R [25] stated six years after writing the book, that "under the pretext of theorizing, of generalization, of conceptual ordering, it is a cold book about a scorching subject" [26]. It is worth noting that the institutional analyst enters the scene when called upon, or when society and/or social institutions are in crisis. Thus, the IA movement itself took advantage of the various social crises to advance its assumptions and theorizations.

In this scope review, when dealing with the analysis of the concept of institution, its centrality is given to the theoretical referential of IA. In the researches under this analysis, it is evident that the concept was opposed in line with the inevitability of use of the theme in question, demonstrating the plurality of uses and ways to operate practices in collective health, confirming the polysemy around the concept and the object under analysis. It is noteworthy that most of the models and uses were close to Rene Lourau's perspective. For the IA, the institution has an apparent dimension, which materializes in the organization and/or establishment, and an immaterial dimension, constituted by norms, rules, and laws, which include the way individuals agree, or not, to be part of the same norms [1,26-28]. In another aspect, we have in the IA, that the concept of institution, is inherent in Hegel's dialectical perspective, constituted by three distinct moments: instituted (thesis), instituting (antithesis) and institutionalization (synthesis) [26,27,29,30]. The traditional Greek dialectic, the Platonic dialectic, was constituted of two moments, a duality with the character of exclusion (two opposites).

The addition of the third moment proposed in the Hegelian dialectic, aimed at the character of overcoming and conservation in the search for synthesis between opposites, where the thesis accommodates or not the antithesis in infinite movements of negation and accommodation, which constitutes the Hegelian system [31]. In Hegelian logic, "dialectics compels us not to be content with the dualistic opposition between particular interests and general interest. The universality of the institution through the mediation of each particular case is embodied in the singular and differentiated forms" [27]. It is understood here the various meanings of the concept of institution and from the various ways and uses in the studies analyzed, sometimes taken in its immaterial dimension, sometimes in its dimension of rules, norms and laws, other times being two moments, refer to many possibilities for analysis. In this way, it is understood that the game between instituted vs. instituting may or may not result in accommodation and conservation, and may be refuted or accepted in the institutionalization process, which does not invalidate studies that demonstrate only one or another moment of the concept, as long as the operation process appears.

Thus, IA is considered a dynamic and instituting theoretical contribution, with concepts that can be directed to operate social practices, transforming it, while generating transformations in realities [32]. In counterpoint, some authors point out on the plurivorous character of the concept that to leave aside the instituted is to stop at the transcendent positivist conception of institution for real social relations. By isolating the institution as economism and subjectivism (group psychology) tend to do, one plunges into a phenomenological and psychologistic vision. Just as Sociology does, to solar institutionalization, and, in general, organizationalist ideology, is to autonomize the rationality and positivity of social forms, to the detriment of history, contradictions and class struggle [25]. That is, to capture the institutionalization process of every institution, it becomes "impossible to isolate any one of the three moments" [2]. In this perspective, of the parts involved in institutionalization, also composing an institution, it has that the instituted are firmed, being linked to what is placed and what is formed of this game of forces and social forms. The established, therefore, refers to the practices and discourses that prevail and are established - in this game of forces and social forms produced and historical - to the detriment of others.

Some investigations denote the enterprising way in which Brazil approaches the strands of IA - Socioanalysis and Schizoanalysis-and operates the concepts [24]. The Brazilian IA is historically marked by the hybridism between the French Socioanalysis current and the Latin American production on groups - especially, Grupo Operativo-that integrates the institutionalist movement, constituting what is called a "heterogeneous marriage" [32]. In this sense, the second dimension of this clash emerges, which are the instituting forces: the sparks that make one form strange and make way for others, in contradiction and displacing the instituted, making possible, in this dynamic, the movement and transforming institutions.

AI's constituent lines

The results reveal the existence of variability in the contexts and objects of study that chose IA, as shown in Table 1; however, it is noticeable that some research objects in the health field were little explored, such as the hospital area, which only three studies proposed to question [33-35]. When it comes to the context of PHC it is evidenced the predominance of studies that contemplated this scope of action, believing in the perspective of a new look for the use of IA in this conjuncture [36-40]. It becomes imperative to also highlight the growth of the use of the IA referential in studies related to Collective Health [41-45] and Health Management [46-49], which denotes the importance of this theme in this scenario.

Among the institutions that permeated the study objects in an explicit way were education (university, research, school) [50,51], the group, health, technical and social division of labor, justice [42] and parenting [52]. In other investigations, institutions appeared implicitly, such as: health professions, beliefs/religions, family, machismo and/or patriarchal society, death, and the biomedical model of health care. In dealing with the various objects of study analyzed, the institution of research, as a model was the analysis, questioning the methodological procedure - techniques and/or tools, the crystallized places of the researcher, the neutrality and the idea of non-interference of the interviewer in data production, the lack of experience and skill of researchers, and the time limit and research schedule, often imposed by agencies and research foundations in the country. These are questions that express the instituted form of this institution and that cross through the research objects analyzed. In this sense, the IA interrogates the instituted and hegemonic modes of knowledge production, bringing into play the possibility of creative and more flexible arrangements, being itself an institution of research.

This perspective affirms the specificity of the institutional analyst's practice, no longer through a constituted empirical object - the institution - but through a constitutive epistemological approach. That is, when the institutional analyst inserts himself in the field, he not only observes, but also participates with his interlocutors in the various social situations which circumscribe the social universe he is researching. Thus, it can be said that the theoretical object of IA is no longer linked to a particular cultural or historical space, but is characterized as a way of looking at the other and at oneself. According to the studies in line with Table 1, it is evident that the most analyzed moment of the concept of institution was the instituted moment. It was noticed that norms and laws were repeated in institution and in the instituted moment, demonstrating that the authors chose to use one among several dimensions of the concepts. Thus, "the 'instituted' is considered to include installed social forms, socially recognized and validated; the 'instituted' includes not only the established order, the values, the modes of representation and organization considered normal, but also the usual procedures of forecasting (economic, social and political)" [26,27]. The way of analyzing institutions brought some objections to the IA, especially in the identification of the instituted with the "good" and the instituted with the "bad" [2].

Basically, the dialectic entanglement between instituting, instituted and institutionalization makes it an unfinished reality, a project under construction. The instituting should not be reflected as a force that results in the instituted, but as a permanent relation of forces, which includes both power and singularities of resistance and production of new strands. In the contour of the instituted space, the instituting space is argued to be unpredictable and ambiguous. Thus, the institution cannot be understood only as something conservative, without contrary movement, in the face of the instituted. The instituted survives hidden inside every institution by means of its transforming genesis, desire, an iceberg of which we can see the sharp tip, whose submerged part is an impetuous supremacy.

The results of this study reveal that the substitution of instituted social practices by other instituting practices, among them health practices, requires that the health needs of people and collectivities be centralized; thus, the operation of IA concepts is channeled to question which objectives such practices want to institute, which projects of society are being implemented and to whom they are of interest. Thus, depending on the prism that the analysis is observed and the object in question, the instituted may represent something better than the instituting and vice-versa. Another perspective of conceptualizing institution, the instituting is constituted by marginal social forces that may or may not be recognized by the installed social forms, which is not necessarily good or bad in relation to the instituted. "By 'instituting' is meant at the same time contestation, the capacity for innovation, and, in general, political practice as a 'signifier' of social practice" [26]. In dealing with the analyzed objects of study, the instituting processes that inquired the instituted are highlighted. That said, the operation of the moment could contribute to maintain the established health practices and/or modify those that were not consistent with the conjectures of the institutions under investigation.

Institutionalization constituted the last analyzed moment of the concept of institution, which was the least highlighted by the studies. This moment incorporates the existence of two other moments within institutionalization: founding institutionalization, understood as the initial moment of creation and shaping of the institution, and permanent institutionalization, which consists of reactualizing and resuming its purpose of operation over time, towards or away from its purpose of creation [53]. This is the process by which the institution becomes legitimate and is maintained, or not, over time, consisting of the successive transformation processes that make its existence lasting or ephemeral. The analysis of successive processes of institutionalization is fundamental because they reveal the capacity for adjustments, refinements, and to integrate its contradictions [54].

Such a perspective affirms that institutions are instances of knowledge that make it possible at all times to recompose social relations, organize spaces, and cut out boundaries. Despite their virtual, imaginary, and symbolic form, they are not detached from social practice. Each society, according to the infra-structural model it follows, creates a type of institution that will be maintained and sustained at all levels, from the State to the family, church, school, labor relations, and the legal system [55] among others. When there is a prevalence of the instituted, the institutions and their establishments capture the singular processes of subjectivation imposing on them their own model through the centrality of power, knowledge, money, prestige, and the dissemination of guilt. On the other hand, when the instituting forces emerge, there is the possibility of the production of new agencies, new compositions and arrangements of free and desiring subjectivities.

The theorization about the implementation of the IA has it that institution becomes more lasting to the extent that the greater the transformations of accommodation of the instituted by the instituted. Institutionalization is the third moment of the Hegelian dialectic, "it is up to the moment of singularity - the moment of integration - in singular forms of organization, management, administration, functioning - to ensure the institutional implication of each individual that constitutes society. In this sense, the negative unity of social forms, always in unstable equilibrium, makes singularity the moment of regulation". An example of a long process of institutionalization is the Catholic Church, which, with more than two thousand years of existence, was one of the objects of study of the IA [30].

When dealing with the concepts of IA, it is asseverated that they coadunate the foundation for the area of Nursing, as well as Psychology, the two areas that most published works using this theoretical-methodological referential in the health field. Several analyzed study objects constitute priority themes for the health and nursing areas, which could be questioned in order to know which perspectives meet, or are consistent or not, with the principles and guidelines of the health system. In this format, the IA corroborated to analyze the instituted social forms, their modes of functioning, the instituting movements, the most present institutions that have crossed the field of health and Nursing and in the same perspective, in the same way as their institutionalization processes.

Finally, it is important to point out that, although the institutionalist movement covers a broad theoretical and practical field, its main mark is the interstitial knowledge, that is, proposals that are not fixed, are not bound to dogmas, but constitute permanent propositions, relying on unprecedented, fluid and disjointed devices, aiming, operationally, at the self-management of organizations. In this article, the understanding of IA is seen as a collective procedure, which aims at the analysis of the members of an organization, its relations, structures, attitudes, conventions and usual practices. The role of the coordinator, institutional analyst, is to propose the emergence of the "unsaid". To do this, it is necessary to create historical, spontaneous and natural "analyzing devices". The analysts organize the "subversion" (another version) of the institution with the help of the word, the analyzing devices, and the participation of the members. This refers to the political dimensions implicit in institutional relations, as for political action within the institution.

Conclusion

This scoping review identified that throughout the IA process there are challenges and they are present from the production of new knowledge to its implementation in clinical health care practices. One of the main challenges is to minimize the asymmetry between the research universe and health care practices. Another challenge for IA is the lack of research funding that promotes not only the production of knowledge (primary investigations), but also its implementation. From the moment the evaluation in health in Brazil gained greater repercussion, through the purposes and results of the studies applied by the body of researchers in the evaluation area, involved with Collective Health and PHC, knowledge started to be socialized through scientific publications, in order to build the support for the research methodologies and strategies used, as well as for decision-making in the management of health systems. This study of scientific production analysis also made it possible to expand the knowledge about the methodological and conceptual approaches of research in IA in the context of collective health, reinforcing its strategic positioning in PHC. The bibliographical examination also reveals the existence of a scientific production diversified in concepts and methods. At this point, the existence of quantitative, qualitative and mixed character studies, in addition to diverse conceptual frameworks, such as approaches linked to the models proposed by Starfield, and Rene Lourau reveal this scenario of methodological pluralism. Such methodological approaches and conceptual frameworks used in analytical studies respect the various visions of public health policies, as well as the look at the operationalization of health systems, and converge to the potential that IA has, as a strengthener and organizer of primary care.

The findings of this study point to the need to incorporate IA for the monitoring of programs and policies created by the Ministry of Health. In this sense, the institutionalization of evaluation in the health sector in Brazil should not lose sight of its conceptual and methodological plurality, in order to ensure a broad and change-provoking evaluation process. It is reiterated that the accumulation of knowledge produced by the evaluated studies indicates the need to continue advancing in the area of IA and to broaden the scope of institutions and researchers with technical skills and abilities to develop studies of this nature throughout the country. At the same time, we emphasize the expressive number of publications in the last five years, which increased the curiosity to know other ways to put IA into action, which were not researches. It is suggested the production of new reviews to know the panorama of theses and dissertations, interventions, among others, to expand the knowledge of the experiences with the theme in Brazil.

In conclusion, overcoming the current challenges of IA goes beyond a movement with a single direction, since it is necessary to mobilize the sectors responsible for producing and implementing health actions in PHC. In this sense, it is necessary to strengthen networks, with consistent nodes, among researchers, health professionals (who know the demands of users and services) and policy makers. Likewise, this network cannot neglect the space and power that civil society has in it, since popular movements mobilize policies and politicians, in a perspective of instituted and instituting.

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