Engaging citizens: Lessons from building Brazil's national health system

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    restrict access to expertise through professionalisation

    and services through bureaucratic means; and between

    medicine.This article addresses a further dimension of these

    changes: that of the involvement of citizens in deliber-ation over health policy, in mechanisms for ensuring

    * Corresponding author. Institute of Development Studies, Univer-

    sity of Sussex, Falmer, Brighton BN1 9RE, United Kingdom.

    E-mail addresses: a.cornwall@ids.ac.uk (A. Cornwall),a.shankland@ids.ac.uk (A. Shankland).


    Social Science & Medicine 66 (20277-9536/$ - see front matter 2008 Elsevier Ltd. All rights reservsal, publicly-funded, rights-based health system.Designed and put into place during an era in whichneo-liberal health reforms elsewhere in the world eand especially in Latin America e have driven themarketization of health, Brazils SUS holds a numberof important lessons for the development of futurehealth systems. Health systems, Bloom and Standing(2008) argue to this Special Issue are based on twokinds of compact: between states and professions, to

    states and the market, through the use of market mech-anisms to manage risk by limiting access. They arguethat these means of socialising health systems have,in recent decades, come to confront a number of chal-lenges. Health expertise is increasingly pluralised, rede-fining what it means to be an expert and redrawing theboundaries of what counts as knowledge. Otherboundaries come to be reconfigured in the process: be-tween the public and the private, between the roles ofthe state and the market, and between systems ofBrazils Sistema Unico de Saude (SUS) is a univer-

    in return for the power to regulate access to goodsIntroductionBrazils Sistema Unico de Saude (SUS), a universal, publicly-funded, rights-based health system, designed and put in place in anera where neo-liberal reforms elsewhere in the world have driven the marketization of health services, offers important lessons forfuture health systems. In this article, we focus on the innovative institutional mechanisms for popular involvement and accountabil-ity that are part of the architecture for governance of the SUS. We argue that these mechanisms of public involvement hold thepotential to sustain a compact between state and citizens and ensure the political momentum required to broaden access to basichealth services, while at the same time providing a framework for the emergence of regulatory partnerships capable of managingthe complex reality of pluralistic provision and multiplying sources of health expertise in a way which ensures that the needs andrights of poor and marginalised citizens are not relegated to the periphery of a segmented health system. 2008 Elsevier Ltd. All rights reserved.

    Keywords: Participation; Brazil; Health systems; Accountability; Rights; Public sectorEngaging citizens: LBrazils nation

    Andrea Cornwal

    Institute of Development Studies, Univ

    Available onli

    Abstractdoi:10.1016/j.socscimed.2008.01.038sons from buildinghealth system

    Alex Shankland

    of Sussex, Brighton, United Kingdom

    March 2008

    008) 2173e2184www.elsevier.com/locate/socscimed

  • Amongst the challenges faced by current and futurehealth systems, two are key to the analysis pursued inthis article. The first is that of democratizing prioritysetting, which in the context of scarce resources and

    2174 A. Cornwall, A. Shankland / Social Science & Medicine 66 (2008) 2173e2184accountability and in decision-making over prioritiesfor health service delivery. Users of health serviceshave traditionally been viewed by the medical estab-lishment as passive recipients of health care and healthinformation. Recent years have seen shifts driven bycultural and political changes. Those who were onceviewed simply as patients have come to be seen asusers and choosers (Cornwall & Gaventa, 2001),with the capacity to exercise preferences and seek bet-ter quality services, whether through exit or voice(Hirschmann, 1970). The users as choosers logic hasgained a quasi-hegemonic hold on health systems inthe north as well as the south, integral to reforms drivenby a logic of marketization and the rhetoric of choice.

    Where the Brazilian SUS departs significantly fromthis logic is in treating those who seek access to healthservices as rights-holding citizens rather than empow-ered clients. The Brazilian Citizens Constitutionof 1988 established health as the right of all, definedits provision as the duty of the state and guaranteedthe right to participate in the governance of health, set-ting the ground for the establishment of institutional-ised mechanisms for citizen engagement atmunicipal, state and national level. The impetus thatled to the creation of the Brazilian SUS grew out ofa conjunction of elements: the democratisation of po-litical and societal institutions in the post-dictatorshipperiod; successful mobilisation by the Movimentopela Reforma Sanitaria (movement for health reform)that gathered momentum and influence over the courseof the 1980s; innovative institutional experiments thatprovided the inspiration for mechanisms for popularinvolvement and accountability within the SUS archi-tecture; and a political commitment to the provisionof publicly-funded services to all Brazilians.

    In this article, we argue that it is the latter two fac-tors which provide particularly strong pointers to theways in which future health systems can learn fromthe Brazilian experience as they face the challenge ofreconstituting institutional arrangements to takeaccount of social change (Bloom & Standing, 2008).In particular, we highlight their potential to sustain acompact between state and citizens which can ensurethe political momentum required to broaden access tobasic health services, while at the same time providinga framework for the emergence of regulatory partner-ships (Bloom & Standing, 2008) capable of managingthe complex reality of pluralistic provision and multi-plying sources of health expertise in a way whichensures that the needs and rights of poor and marginal-ised citizens are not relegated to the periphery of a

    segmented health system.growing contestation over the values and knowledgesthat should inform their allocation is a matter of polit-ical expediency as well as of pragmatic efficiencygains. The second is that of creating new compacts be-tween citizens and the state that reconfigure relation-ships at the multiple interfaces between those whouse health services and those who provide them. Theanalysis that follows picks up on these two challengesand explores the dynamics of engaging citizens in theconstruction of the Brazilian health service. We beginby tracing the origins and development of the SistemaUnico de Saude (SUS) and its framework for citizenparticipation. We then go on to examine citizen partic-ipation through snapshots from three moments ofinstitutionalised engagement: the National Health Con-ference, which took place in Braslia in December2003, the National Conference on Indigenous Healthheld in Caldas Novas in central Brazil in March 2006and the Municipal Health Conference held in Cabode Santo Agostinho in North-eastern Brazil, in April2006. Our analysis seeks to draw lessons from the Bra-zilian experience to address a broader set of questionsabout the possibilities e and limits e of citizen en-gagement in the shaping and management of healthservices, and the prospects these lessons offer for fu-ture health systems.

    The Brazilian Sistema Unico de Saude

    That the Brazilian SUS is making substantial in-roads in improving Brazils health indicators is beyondquestion. Between 1992 and 2004, national under-fivemortality figures fell from 65 to 27 per thousand,1 andthe proportion of poor households accessing health ser-vices rose by almost half, with the PNAD householdsurvey recording an increase in the number declaringthat they had used these services in the preceding 2weeks from 9.73% in 1986 to 14.18% in 2003(IBGE, 2005; Silva, 2003). In some places, improve-ments have been dramatic. In Cabo de Santo Agos-tinho, the site of one of our case studies, the infantmortality rate fell from 49/1000 in 1994 to 10.5/1000in 2006,2 due in no small part to the reorganization

    1 Figures from Ministry of Health IDB-2006 database (http://tab-

    net.datasus.gov.br/cgi/idb2006/matriz.htm, accessed 15 June, 2007).2 Cabo de Santo Agostinho Municipal Health Secretariat epidemi-ological report, 2006.

  • positions in the federal and state-level health bureau-cracy (Costa, 2007; Melo, 1993; Weyland, 1995).

    It was the group of sanitaristas led by CommunistParty activist Sergio Arouca (a researcher from theRio-based National School of Public Health who hadbecome an advisor to the Ministry of Health duringthe transition) that convened the historic 8th NationalHealth Conference of 1986. Previous Health Confer-

    2175A. Cornwall, A. Shankland / Social Science & Medicine 66 (2008) 2173e2184of the delivery of primary care services and the intro-duction of a hugely successful national primary careprogramme, the Programa Saude da Famlia (PSF).

    There is still much to be done to improve health eq-uity. Significant inequalities have persisted despite im-proved access, with marked differentials in healthindicators becoming evident when the data are disag-gregated by gender, race, income and region (Oliveira,2002). Middle-class consumption of private health in-surance has grown hugely since the introduction ofthe SUS, with private spending rising faster than publicspending. The expansion of the SUS has been punctu-ated by funding and management crises, reflected infrequent media stories of service collapse and abuse.Yet, the SUS has remained hegemonic, combining re-distributive action through the rollout of primary careprogrammes such as the PSF with increasingly asser-tive attempts to impose regulatory control over the bur-geoning private sector. Successive resource squeezeshave been overcome by political mobilisation to enactnew hypothecated taxes and protect the health sectorsshare of public spending from austerity-minded Trea-sury teams, culminating in 2000 with the passing ofa Constitutional Amendment guaranteeing the alloca-tion of a rising share of government revenues to theSUS. As we argue elsewhere (Shankland & Cornwall,2007), the SUS derives much of its legitimacy froma powerful epistemic community (Haas, 1992) com-mitted to its rights-based principles, which emergedfrom the struggle to create it. This has since beenable to reproduce itself through the Brazilian healthsystems unique array of participatory institutions.

    The principles of the SUS e universality, compre-hensive care, equity, decentralisation and controlesocial (social oversight) e are the outcome of an in-tense process of renegotiating the nations health ser-vice design in the post-dictatorship period. Until themid-1980s, state-provided curative services were con-centrated in the cities and their hospitals, open onlyto the minority of workers who were employed in theformal sector (Costa, 2007). Systematic exclusion gen-erated popular discontent which was mobilised bypeoples health movements in several locationsacross Brazil (notably in the East Zone of Brazils larg-est city, S~ao Paulo). Catalysed by progressive publichealth practitioners who had been developing alterna-tive community health approaches with the supportof universities and the Catholic Church, these localmobilisations coalesced into a national Movimentopela Reforma Sanitaria (movement for health reform).In the transition from dictatorship after 1985, leading

    reformers (known as sanitaristas) took up keyences had been closed gatherings of technocrats andpower-brokers, but for the 1986 Conferencia Nacionalthe Ministry of Health brought together thousands ofcommunity health activists from all corners of the na-tion, in a convincing demonstration of the mobilisationpower of what had now become known as the movi-mento sanitarista. The Conference declared health tobe the duty of the state and the right of the citizen,affirmed the principles of universality, equity, decen-tralisation and participation and generated sufficientpolitical momentum to ensure that these principleswere written into the new Constitution in 1988, andsubsequently into the legal framework for makingthem operational, the Lei Organica da Saude or BasicHealth Law of 1990 (Carvalho & Santos, 1995).

    Establishing the SUS required bargains to be struckwith two key sets of players: municipal governmentsand the private sector.3 Winning over the former wasessential to achieve the SUS vision of decentralisationto the municipal level, and took a combination of polit-ical pressure, fiscal incentives and the creation of trans-parent criteria and mechanisms for resource allocation(Arretche, 2003).4 Accommodation with the privatesector, by contrast, was not the result of deliberatestrategising e the movimento sanitarista was viscerallyopposed to marketisation e but emerged out of politi-cal defeat for the movement: in the teeth of sanitaristaopposition, conservative political parties succeeded ininserting provisions into the Constitution that affirmedthe legitimacy of private-sector involvement in healthcare provision. This, in turn, underpinned the institu-tionalisation of substantial purchasing of services fromprivate hospitals and clinics by the SUS, giving privateproviders a stake in the system (Melo, 1993). Italso gave Constitutional legitimacy to the then-nascent

    3 As Melo (1993) has shown, the lobbying efforts of bodies repre-

    senting health professionals were relatively ineffective during the pe-

    riod between the 8th National Conference and the establishment of

    the SUS, precluding any possibility that the new system would be

    based on a compact between state and professionals of the type

    which gave rise to Britains National Health Service.4 By 2002, 99.6% of municipalities had taken on decentralised re-

    sponsibility for primary care, following a steep rise from 23.4% to88.7% in the period 1994e1998 (Arretche, 2003; Costa, 2002).

  • and service providers, with the former occupying50% of the seats while 25% were reserved for healthworkers and the remaining 25% assigned to represen-

    2176 A. Cornwall, A. Shankland / Social Science & Medicine 66 (2008) 2173e2184private insurance sector, enabling it to expand signifi-cantly over the 1990s before coming under SUS regula-tion by the end of the decade.

    Writing in 2003, Marta Arretche described the es-tablishment and consolidation of the SUS as a para-digm shift through which the country replaceda centralised health care model based on contributoryprinciples with one in which the legal right of free ac-cess to health actions and services at every level ofcomplexity is universal and in which service provisionis organised through a decentralised hierarchy (2003:332 e our translation, emphasis in the original).Arretches (2003) conclusion was that while therewould be an ongoing process of adjustments to the sys-tems management arrangements, the ri...