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The Health Councils in Brazil: How Much Have We Advanced in the Agreement of Interests?

Vera Schattan P. Coelho

The 1988 Brazilian Constitution, which established the formal transition to democracy, sanctioned the decentralization of policymaking and established mechanisms for citizens to participate in the formulation, management, and monitoring of social policies. This legal foundation promoted the development of an extensive institutional framework for participation by citizens, including management councils, public hearings, conferences, participatory budgeting, and deliberative mechanisms within regulatory agencies. Since the 90’s, over 28,000 management councils have been established for health policy, education, the environment, and other matters. These councils are organised at all levels of government, from local to federal, and they provide forums in which citizens join service providers and the government in defining public policies and overseeing their implementation. Management councils enable citizens to have a voice in policymaking and provide a mechanism with a greater downward accountability. 

This article examines the experience of municipal and district health councils in the city of São Paulo in the light of the literature on citizen participation in Brazil. Previous research has raised questions about how effective these councils are at promoting effective citizen participation. In this view, the democratic promise of these councils has been compromised by the authoritarian tradition within the Brazilian State and, more generally, a lingering authoritarian political culture, fragile associational life, and resistance from both society and State actors.

In sum, this literature has attributed the success or failure of participatory mechanisms either to the degree of civil society involvement or to the level of commitment to such mechanisms on the part of the political authorities. This begs the question of what happens where both factors are present but the participatory mechanisms nevertheless remain relatively ineffectual as institutions for promoting the interests of the excluded. Drawing on research into participation in São Paulo’s health councils, the paper argues that the success of this type of participatory mechanism depends not only on the involvement and commitment of civil society and State actors, but also on their willingness and ability to promote institutional innovations that guarantee clear rules of political representation, and processes of discussion and decision-making that lead to effective participation by representatives who command less technical knowledge and fewer communicative resources.

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