Democratizing Health Care in Brazil The experience of health forums

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Democratizing Health Care in BrazilThe
experience of health forums
Dais Gonçalves ROCHA, PhD Simone Tetu MOYSÉS, PhD
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Overview

• National Health System in Brazil (SUS)
• Strategies for social control and participatory
  management
• Local experience
• Attributes of Health Councils
• Challenges to effective participation in Health
  Councils

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Building the National Health System (SUS)
The Sanitary Reform Movement
Democratization during the 1970s and 80s
National Constitution (1988) Health is a right
of all people and duty of the State
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Social participation as a diretriz of SUS present
in the National Constitution
Social control is a strategy to build a new
relationship between the state and society,
meaning an open formal space for participatory
decision making.
social control has been used as a synonymous of
social participation.
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Strategies for social control and participatory
management

• Formal mechanisms of social control
• Spaces for agreement among managers
• Strategies to listen the communities demands and
  perspectives
• Popular education and constant dialogue with
  social movements and other groups
• Intersectoral actions.

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Strategies for social control and participatory
management

• 1. Formal mechanisms of social control
  Health Councils Health Conferences

National Law 8142/1990
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Health Councils
50 health users 25 health professionals 25
managers and health care providers (private
sector, non-profit services)
National Law 333 /2003
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Strategies for social control and participatory
management
2. Spaces for agreement among managers
Tripartite Intermanagerial Commissions (CIT)
Bipartite Intermanagerial Commissions (CIB)
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Institutional and decision making structure of SUS
Management
Intermanagerial Commissions
Social Control
Comissão
Conselho
Tripartite Commission
Ministério da
Ministry of Health
National Health Council
Nacional
Nacional
Tripartite
Nacional
Saúde
n1
Conselho
State Healthcare System
State Health Council
Secretarias
Estadual
State
Estadual
Estaduais
n27
Bipartite Commission
Conselho
Secretarias
Municipal Healthcare System
Municipal Health Council
Municipal
Municipal
Municipal
Municipais
n5558
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The virtuous circuit of global health governance
(Burris, Hancock, Lin, Herzog 2007)
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Strategies for social control and participatory
management

• 3. Strategies to listen the communities demands
  and perspectives
• Ombudsman
• Users satisfaction surveys
• Public hearings

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Strategies for social control and participatory
management

• 4. Popular education and constant dialogue with
  social movements and other groups

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The right to health and sexual diversity
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The right to health and the black population
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The right to health and indigenous people
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Strategies for social control and participatory
management

• 5. Intersectoral actions involving different
  sectors of government and civil society sharing
  decisions to produce health
• Pró-Saúde (Ministry of Health and Education)
• National Food and Nutrition Policy
• Fome Zero
• Quadro Convention
• Health in School

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Municipal Health Council
Local experienceCuritiba
CONSELHO MUNICIPAL DE SAÚDE
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Curitiba

• 1,800,000 inhabitants
• 125 health units
• 5,900 health professionals
• 1,130 community health agents

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Municipal Health Council

• Created by municipal law in 1991
• 36 members
• 50 health services users
• 25 health professionals
• 25 managers and health care providers

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Municipal Health Council

• Main functions
• Follow and control actions, functioning, and
  resources of the municipal SUS
• Discuss and approve the municipal health budget
• Create and approve the Municipal Master Plan

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Mechanisms for Planning
Citizenship streets
Public hearings
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Municipal Health Council

• 104 local health councils
• Local Conference
• health issues are discussed
• search for a consensus of what has to be
  prioritized

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Municipal Health Council

• Participation steps

Bottom-up planning
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Municipal Health Council

• Publicize information
• Site
• Online/printed newspaper
• Meeting schedule

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Attributes of Health Councils1

• Legitimacy the way the council was created, as
  well as rules and other documents
• 2. Representativeness the institutional and
  social makeup of the council, the process of
  selecting members and leadership
• 3. Organization dynamics and working conditions,
  attendance at meetings and capacity- building
  events

(Shimizu 2008)
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Attributes of Health Councils2
4. Autonomy structure and available tools for
democratic management, deliberative and
consultative power, the capacity to develop
problem-solving strategies 5. Intersectoral
action building different coordination channels
among sectors and 6. Community-based
participation how the councils act and their
credibility in society, the capacity of
organizations and communities to mobilize in
order to effectively address issues and concerns.
(Shimizu 2008)
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Attributes of Health Councils3
Evaluation of health councils attributes,
RIDE-DF, 2008, Brasília-DF.
Attributes Legitimacy Representativeness Organiza
tion Autonomy Community based participation
Intersectoral Action
85 79 67 49 36 14
Legal Adequacy High Medium Does not apply
Low Incipient Does not apply
(Shimizu et al 2008)
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Challenges to effective participation
representativeness, legitimacy, intersectoral
actions, health council member capacity-building,
active participation as a powerful practice to
consolidate democracy, getting council and
conferences deliberations executed by public
officials (administration), communication
strategy to disseminate achievements.
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