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By Andrea Cornwall Brazil's innovative institutions offer inspiring lessons for engaging citizens in improving health for all
"Isn't this great!" exclaimed Area. "We should have this kind of conference every year, not wait for two -- or is it now four? -- years to get us health workers together with service users and health managers to talk about policies, about the changes we want to see. It's so good to do this." A health services union activist in her 40s, Area was a seasoned participant in these kinds of debates. She'd taken her turn as a health worker representative, attending the monthly meetings of the municipal health council of Cabo, a municipality of some 150,000 people in the impoverished northeastern Brazilian state of Pernambuco. These days, she's taking a break, making space for others to take up the seats on the council allocated to health professionals. But she didn't want to miss the conference, as that's where the policies and plans for the next few years get debated -- and she wanted a chance to have her say. Perched around a small plastic table in an improvised restaurant that had been set up to feed the 200 delegates, we mulled over the morning's debates and over where the sticking points would come when it came for delegates to vote. The densely packed room was unusually quiet; the debates had raged into the lunch break and people were starving. The last time I'd seen Area was in her workplace, the town's mortuary. We'd spent the afternoon chewing over the challenge of what Brazilians call 'Controle Social' -- society guiding the state towards better policy choices and holding government to account for delivering on them. In the post-Dictatorship era, Brazil has established a publicly-funded, rights-based health system that is based on the conviction that 'health is a right of all and the duty of the state to provide'. The 1988 Brazilian Constitution, which marked the beginning of a new democratic era in Brazil, was dubbed 'the Citizens' Constitution' for establishing, among other things, citizens' rights to participate in deliberations over health policy. Spurred by the public health reform movement, which came to be known as the movimento sanitarista, the Constitution made provision for a mandatory system of participatory health policy councils in each of Brazil's 5,530 municipalities and 26 states, and at the federal level. Citizen representatives hold half of the seats in these councils. Health council approval of health plans, budgets and accounts is needed for transfers of centrally held resources to pay for health services. The remaining half is allocated equally to health managers and health workers: a system of parity that gives clout to citizen voice. Together, their task is to monitor the functioning of the national health service, and develop policies that can make it better serve the needs of Brazil's 180 million citizens. Tens of thousands of Brazilian citizens representing a spectrum of civic associations -- churches, the women's, black, disabled and LGBT movements, unions, non-governmental organisations, neighbourhood associations and more -- meet every month with those who run their health services and provide healthcare. They come together with a broader body of citizen, health manager and health worker delegates every two or four years in municipal health conferences, from which delegates are put forward for health conferences at the state and national level. To give some sense of the sheer numbers involved, an estimated 300,000 people took part in shaping the proposals that were debated amongst the 5,000 participants at the most recent National Health Conference in December 2003. As one National Health Conference delegate, a young black woman from the northeastern state of Cear, declared as we waited together in the lunch queue: "All of Brazil is here. We are all here. We are Brazil." And indeed, Brazil it is: this is not "consultation" where there is little scope for gathering new ideas or reframing policies. Brazilians have developed sophisticated technologies to collate and include objections and amendments to specific policies in such a way that the best thinking that emerges can be directed into government policy. While it is not perfect, it has a lot going for it. Preparation for Cabo's 6th Municipal Health Conference had begun some months before, with a committee of health workers and users thinking through how best to engage people from the very different communities that make up the municipality -- from rural hinterlands where seized settlements of landless people exist alongside the deprivation of agricultural labourers, to the ring of favelas that circle its industrialised centre, to the beaches that are packed at the weekends with locals and their families, along with the occasional foreign tourist. Their efforts were successful: around 700 people came to pre-conferences held in each of Cabo's four regions, generating 176 specific proposals. The conference began with a series of presentations -- on the Brazilian National Health Service and how it worked, on the challenges for health improvements in Brazil and how they were being addressed, on the specific health situation of the municipality. For some of the delegates, especially those newly nominated as representatives of their communities, this was information that would otherwise be pretty much out of their reach. Four thematic sessions followed. Then the discussions began. Delegates and those who had been invited as guests were put into eight working groups: two for each theme. As a guest, I'd been assigned to a working group on 'Controle Social' -- citizen oversight. I was told that I did not have the right to vote, but if I had any good ideas to chip in that might improve the proposals, they would be welcome. We began at 10.30, armed with a daunting list of 54 proposals. How were we going to manage to debate each of them in turn, rephrase them if necessary, and then vote on whether they should be carried to plenary in one day without staying there deep into the night? I soon found out how. Running down the list of proposals, people registered objections to any that they thought should be discussed further. These were then taken in turn, with the person who had raised the objection speaking first to suggest a course of action -- striking the proposal or amending it, and supplying a potential amendment. Any other proposals to the contrary were then sought. People were given up to three minutes to speak; lengthy speeches were cut short by an exemplary chairperson. Then the delegates voted for or against rejecting or amending the proposal. And we moved on. By 4.30, we'd worked our way through the list, come up with a number of useful amendments, rejected a couple of proposals that simply restated existing policy -- with which a number of participants, citizens included, were familiar -- and passed the rest. On the third and last day of the conference, delegates gathered before a huge screen onto which was projected the collated, revised proposals from each working group. Each was read out in turn. Delegate cards were raised in the air to mark proposals for further debate. These were noted, then returned to one by one. As amendments were made, they appeared on the screen; for each, delegates voted by raising their cards. Lively debate arose on unexpected issues, as was the case when two male health user representatives took the microphone to debate the technicalities of service provision for the prevention of cervical cancer. At one point, the municipal health secretary rose from his seat and gave a long, impassioned defence of his commitment to health for all, by way of an explanation as to why, with a budget of less than 3 million, the municipality simply could not afford to have one of the proposals voted through. Health managers came forward to defend their proposals, presenting arguments for why certain forms of service delivery needed to be introduced or sustained -- arguments which citizens often don't get to hear, and which persuaded the majority of delegates to vote against amendment or rejection. The conference ended with a rousing reassertion of its democratic principles: with a motion to denounce the provision of a separate eating space for the health managers and their guests, on the grounds that in a democracy all should be treated equally. As the motion was voted through, there was a whoop of exhilaration. People spilled out of the building, exuberant and exhausted. "The first time I went to a conference," Joo, a seasoned community activist and former health user representative on the health council told me, "I came out of it full of all the proposals. And then reality hit. I had to wake up to the fact that we arrive at this marvellous list of things, and then nothing happens. Then I came to see it differently. It's good to be here, to be heard, to name our desires, to be with each other here as civil society making our demands on the government. It gives us strength, the strength to be what civil society should be: we need to be the ones that hold them to account for doing these things, these things that are our desires." And, he added: "Now it's the work of the council to make sure that they're done." Brazil's system of health councils and conferences shows the value of the knowledge that ordinary citizens and the health workers who serve them have about the health problems of their communities and how they might be addressed. Good ideas find a place and take form in policy proposals that are debated, contested, refined and reformulated as they move up from the municipal to the national level. Brazil's health user representatives are elected to speak for their communities of place or of interest: as society-at-large, not as isolated individuals. The process of deliberation makes these good ideas everyone's, neither that of 'experts' nor of 'communities'. Brazilian experience shows that participation need not mean spending hours and hours going round in circles and not arriving at any conclusions. The techniques Brazilians have developed make the business of deliberating and deciding efficient and inclusive. These experiences show the value of popular participation in sustaining political commitment and popular support -- and as the very real improvements in health outcomes over the last decade demonstrate, they show that a viable, publicly-funded, rights-based and democratic alternative to the neo-liberal logic of the marketization of health systems is possible. (Andrea Cornwall is a researcher based at the Institute of Development Studies, Brighton, where she works on feminisms, democratic engagement and rights) InfoChange News & Features, December 2006
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