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PERMISSION
to DREAM
TO
DREAM:
Healthcare from
Brazil to Britain
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The socio-political backdrop
to the creation of the Brazilian
health system is fascinating....
Story by Gavin deAlmeida
A
ndrea Cornwall attributes her
fairly liberal attitudes on citizen
empowerment to her upbringing
in the ‘60s: “My parents would consult
me and my siblings about domestic
decisions, from what color the bathroom
should be to whether we were going to
move to a different part of the country.”
With her drive to question the status quo
instilled in her at an early age, the transition to consumer advocacy in health policy
seems a fairly logical one. So, there’s little
wonder she developed a fascination with
the ultra-democratic health system in Brazil, the Sistema Único de Saúde. It arose,
says Cornwall, as a result of an “intense
struggle by visionary health reformers for
a system that could embody the principles
of equity that were so vital a part of the
struggle for democracy. It is highly decentralized, integrated, free at the point of
use, publicly funded, and rights-based.”
Andrea Cornwall
During her time spent as a researcher in
Brazil, Cornwall found the country had
profound ideological differences in their
healthcare system compared to her home
in England. “There have been a series of
weak and ineffectual initiatives for ‘patient and public involvement’ in health in
the UK, which have rarely amounted to
more than the State selecting individuals to give them a view from the street.”
She contrasts this with Brazil where she
notes citizens are seen as “makers and
shapers” of health policy, and notes the
model of healthcare encourages and
develops social engagement processes
to allow members of the public to understand and participate in policy creation.
Under the Sistema Único de Saúde,
thousands of health councils meet
monthly, half of whom are representatives
of “organized civil society at each tier
of government” with the rest made up
of health workers and health service
managers. Cornwall says training is
provided to council members as part
of the broader objective of holding
the government to account. She
says at the recent National Health
Conference in Brasilia, around 3,000
representatives met to discuss health
policies affecting 300,000 Brazilians
from across the country. She notes
even the poorest states had some
form of representation. She says
when she attended one such event
a few years back she was “incredibly
moved” by a huge banner, which stated,
“Here you are permitted to dream.”
The socio-political backdrop to the
creation of the Brazilian health system
is fascinating, not only in the way it mirrors the country’s other broader cultural
changes, but in the way it differentiated
with the global direction of public health
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at that point in time. Cornwall notes in the
late ‘80s and early ‘90s, while the rest of
the western world was looking at neoliberal
health reforms, the “radical public health
doctors” and the social movement pushing for democracy in Brazil were looking
for a more democratic, representative
system in line with their ideals of “controle
social,” translated as: the right of the public
to hold the government to account and
the requirement of the government to be
accountable to the citizens. These two
groups felt that the state had a duty to
guarantee health services for the populace and achieve health equity. So, in part
thanks to the very progressive Citizens’
Constitution of 1988, which had created
the overall framework for wider cultural reforms in Brazil, this gave rise to the creation
of the Sistema Único de Saúde in 1990.
She observes that in Brazil the inequalities between the classes are often oddly
disproportionate, citing on one hand,
“for-profit private health providers offering
everything from complex heart surgery to
intimate procedures to enhance sexual
pleasure,” while on the other, people unnecessarily dying from easily preventable
diseases. She says, “Persistent inequalities have fired political imaginations, and
throughout Brazil you can find left wing
and left-of-center political parties in power
at municipal, state, and of course national
levels. This backdrop contributed to the
development of the Brazilian health system.” Cornwall says the main concern of
the Sistema Único de Saúde is equity in
health for all Brazilians, regardless of their
racial background or sexual preference.
Cornwall is adamant that ordinary Brazilians have been able to affect healthcare policy. She says national health
conferences have been able to change
healthcare policies and do allow citizens
representing their communities to have an
actual say. She says the ordinary people
she has met at conferences are enthusiastic about using their democratic powers
to affect healthcare, and she is inspired
by their stories. To exemplify, she points
out that in the area she was based, infant
mortality dropped from approximately
50 to 10 out of 1,000, an all time low,
in less than a decade. She attributes a
large part of this to a national primary care
program made up of community health
agents working with auxiliary nurses.
With all the talk about the revolutionary underpinnings of the Brazilian health system,
you could be forgiven for thinking the scenario was one which presented a perfect
paradigm of democratic idealism. Unfortunately, Cornwall admits the reality is not
as ideal as it may appear from the outside.
In her paper “Deliberating Democracy:
Scenes from a Brazilian Municipal Health
Council,” she states that despite appearances, the public health reform movement,
or the “movimento pela reforma sanitaria,”
was hindered by political complications
within Brazil. She says these obstacles
to true representation are large and
ever-present, noting “the health sector
is a site for powerful interest groups, not
least the medical profession itself.” She
says it is hard for the average person to
access the information they need to be
able to participate in a meaningful way.
This applies not only to actual medical
knowledge, but also to the health system
and the effective auditing of accounts.
Cornwall states that Brazil’s private sector
and associated lobby groups wield great
power, and she laments the “inherent contradiction between a rights-based
approach to health and the interest
of for-profit private providers.”
The flow on from this is the inability of the citizens to question substantial monetary
transactions between the
private health system and
government coffers, through
contracts she says “the state
is obliged to have with private
providers.” Separate to this, she
also observed there were historical disadvantages caused by the inherent racism,
sexism, homophobia in Brazil, although
thankfully, there have been moves by the
government to overcome these issues.
For now Cornwall has a few things in the
pipeline. Using her long-standing links to
UK health authorities, from her time at the
British National Health Service a decade
ago, she now wants to explore ways by
which the various Brazilian democratic
approaches to healthcare can be implemented in the UK. She’s been invited
to address the Occupy London Stock
Exchange rally where she will discuss the
Brazilian principles of “controle social”
“Persistent
inequalities
have fired
political
imaginations,
and
throughout
Brazil you
can find
left wing
She says parallels can be drawn with the
British term VFM (Value For Money), although she feels the Brazilian ideologies
go further: “They’re much better, much
clearer, much more direct as principles
than talk about citizen ‘participation,’ ‘empowerment,’ ‘involvement,’ or ‘engagement’
that can so easily be watered down, and
turned into tokenistic gestures.” Many of
her views on this are encapsulated in her
2000 book Democratising Citizen Engagement: What the UK Can Learn from
International Experience, published by innovative social research institute Demos.
She’s also organizing a participatory accounting session for her
students at the University of Sussex where they will look at ways
to audit the UK’s Department for
International Development. She
says, with the help of an accountant, they will publish their findings
on the “fiscalização of government
spending on aid” to help teach others
about state accountability on expenditure.
and
left-ofcenter
political
parties in
power at
municipal,
state, and
of course
national
levels.”
The liberal direction Cornwall’s work has
taken her has enhanced her open and
inclusive view of the role of the citizen in
society: “I think my work has taught me
more than anything else that everyone
has a contribution to make to the way their
institutions, their societies, their government, work.” She says good ideas can
be generated from unexpected sources,
but this is dependent upon getting more
people involved in the decision-making
process. She adds in her time in leadership roles she has relied upon “the principles of radical democracy” to identify
deficient and undemocratic practices,
where a lack of greater social engagement stifled productivity. Not everyone
shared her collaborative standpoint:
“I was once reprimanded by the director of a place where I worked, who told
me in no uncertain terms: ‘This is not a
democratic institution.’ I realized I’d taken
for granted the right that I thought we all
had to contribute ideas, to have opinions,
to disagree.” She says this marked a profound change in her outlook. “I used to
Cornwall acknowledges this current
stance will mean she won’t always see
eye to eye with others. Yet, fundamentally,
her approach to take an open and more
inclusive mindset is more than just a way
to open up the creative process – it’s
a mirror of the democratic spirit that
she saw all those years ago in Brazil.
Cornwall is also continuing her longrunning work on gender and sexuality, currently through the Pathways of
Women’s Empowerment program, where
she examines the socio-political challenges that are still present in this area.
“My interest in women’s empowerment
arose from grappling with a paradox. On
the one hand, I’d come to feel that the
term ‘empowerment’ had become such an
all-encompassing feel-good word that it
had lost its political bite.” She muses she
had set up a Google alert for “women’s
empowerment” and found the term had
an unusually broad scope--the latest
was a piece promoting empowerment
through G-spot enlargement surgery.
Yet she refuses to abandon the term entirely, stating “I wanted to get involved in
figuring out how it could be reappropriated and put to work again for transformative, structural change. That’s what took
me down that particular road.” For her, empowerment is more than a tokenistic term
used to loosely convey power. Its fundamental meaning is about having a voice,
the chance to be heard, and ultimately
to be democratically given the ability to
have power over one’s life. She points out
her interests in health policy were always
about true empowerment: “the fundamental importance of the right to participate
in decisions that affect our lives – at every
level, from the most intimate to questions
of national policy - and through this to
gain greater control over our own destinies, and to be able to expand horizons
as well as the boundaries of possibility.”
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hate the idea of disagreement. I wanted
everyone to agree (usually with me), and
I thought it was possible to win people
over with a good argument – even if they
believed something completely different.”
From being an admitted fan of routine
consensus in the workforce, she came to
realize that it could stifle idea generation
and worse, was often a process used by
those in power to “suppress dissent.”
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and “fiscalização” - loosely translated as
inspecting the accounts, facilities, and the
contracts invested in by the state, as part of
the wider objective of holding it to account.