Pergamon

World Developmenr, Vol. 23, No. 10, pp. 1699-1712, 1995 Elsevier Science Ltd Printed in Great Britain

Social Movements and the State: The Politics of Health Reform in Brazil
KURT WEYLAND* Vanderbilt University, Nashville, Tennessee, U.S.A.
Summary. - This paper shows how institutional factors shape the strategy and condition the success of a social movement. In Brazils new democracy, a movement of health professionals tried to reform the medical system, which failed to provide adequate health care to the poor. Pervasive clientelism, however, prevented the movement from gaining firm mass support in society. Movement leaders therefore sought top positions inside the state to launch equity-enhancing reform. Yet this state-centered strategy exposed them to severe institutional obstacles, especially bureaucratic politics with its divisive impact, and stubborn opposition from clientelist networks. As a result, the movement achieved few improvements.

1.

INTRODUCTION

How much impact on public policy making do social movements in Latin Americas new democracies have? What are their strategies and channels of influence? In order to address these questions, the following case study analyzes the movement for health reform in post-authoritarian Brazil. This movement made an ambitious effort to revamp the countrys system of medical service provision in order to satisfy the unfulfilled health needs of vast numbers of poor citizens. Why did this effort achieve rather little success? The wide variety of theories on social movements in the First World (Cohen, 1985; Tarrow, 1989; Wasmuht, 1989) offers little guidance because it focuses more on the factors explaining the emergence of social movements than on the conditions for their success. Rarely . . . have movement scholars sought to assess how effective movements are in achieving their ends (McAdam, McCarthy and Zald, 1988, p. 727; also Tarrow, 1989, p. 71). This is particularly true of identity-oriented approaches (Cohen, 1985, pp. 691-705; see Alvarez and Escobar, 1992, pp. 318-319). Even the approaches most interested in the policy impact of social movements, all of which are variants of resource mobilization theory (Cohen, 1985, pp. 674-690; Tilly, 1978, chapters 3-4), emphasize societal factors and pay scant attention to the state. Scholarship informed by this theory assumes, for example, that social movements seek allies among political parties and other movements in society, not inside the state. They depict social movements as parts of society that confront or pressure the state

from outside (Gamson, 1990; Piven and Cloward, 1979; Cohen, 1985, p. 665; Tarrow, 1989, chapter 5). Given the centrality of the state in Latin America, theories on social movements in the region necessarily focus more on the state. Since these movements must rely on the state to improve public services and satisfy the needs of the poor, they have to establish contacts to public agencies to advance their proposals. In order to expand their own turf, some state agencies even become allies of social movements (Cardoso, 1988, pp. 370-374; Jacobi, 1989, pp. 100-111; Boschi, 1987, chapters 2, 7). Reflecting these practices, the literature on social movements in Latin America has paid considerable attention to the state. With some exceptions,* however, theorists still see the state and social movements as separate. In their view, the impetus for positive change emerges in society, not inside the state. The state is the object of movements pressure, not the protagonist of reform (Eckstein, 1989; Kowarick and Bonduki, 1988; Krischke, 1987; Slater, 1985; 1994).

2.

THE MAIN ARGUMENT

I argue that such a society-centered approach does not provide an adequate understanding of the efforts

* 1 would reviewers Science Research financial accepted:

like to thank Wendy Hunter and two anonymous for many helpful suggestions, and the Social Research Council as well as the University Council of Vanderbilt University for generous support for my field research. Final revision May 7, 1995.

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of Brazils health reform movement to affect public policy. Members of this social movement penetrated the state itself in order to launch reform projects. State officials recruited from social movements thus became major protagonists of attempts to satisfy the unfulfilled needs of popular sectors. In this way, movement leaders tried to compensate for the difficulty of gaining firm, wide-ranging support in society that could serve as a base for attaining their goals. Yet this state-centered strategy also had limitations and risks, such as involving the movement into bureaucratic politics and clientelist machinations. As a result of these problems, the movement in fact failed to shape public policy and to achieve most of its goals. In order to account for this choice of a state-centered strategy and for its rather limited success, this article advances an institutional constraint argument. Applying insights of sociological institutionalism (March and Olsen, 1989), it points to formal and informal institutional patterns that have restricted the health reform movements chances for resource mobilization and skewed its political opportunity structure in unfavorable ways. Organizational obstacles have limited the influence the movement could gain in Brazilian society and inside the state. Specifically, pervasive clientelism has enveloped many of the poor and disadvantaged. This has reinforced the inherent difficulty of mobilizing them for collective action and prevented them from providing powerful support for health reform. Unable to gain a mass base in society, leaders of the health reform movement occupied positions inside the public bureaucracy from which they could launch their progressive efforts. But this shift from a society-centered to a state-centered strategy exposed the movement to new institutional obstacles. First, members of the movement gained posts in different public agencies. They soon absorbed these agencies organizational interests and were drawn into the rampant bureaucratic politics that ravages the Brazilian state. The resulting conflicts weakened the movement and limited its success. Second, the efforts of movement members to enact programmatic reforms jeopardized clientelist politicians use of the established health care system for purposes of pohtical patronage. If the poor had their needs fulfilled through equity-enhancing reform, they would be less dependent on favors granted by patrons in exchange for political support. Reform that provided benefits as a matter of universal right thus posed a deep threat to the electoral sustenance of many powerful politicians. Therefore, clientelist politicians in the government and in Congress soon offered strong resistance to equity-enhancing change and pressed for the dismissal of members of the health reform movement from the public bureaucracy. By undermining the movements state-centered strategy in this way, clien-

telist politicians posed the most important obstacle to health reform. Thus, social movements in Latin Amenca may end up between a rock and a hard place. While pervasive clientelism reduces the promise of a society-centered strategy, a state-centered strategy also faces enormous difficulties, stemming from bureaucratic politics and clientelist machinations. As a result, social movements may have limited impact on public policy.3 The institutional constraints 1 emphasize create strong obstacles, but not absolute impediments to social movements efforts to influence policy. Clientelism, for instance, makes reform unlikely, but does not block it invariably. Committed political leaders who concentrate a high level of authority can control clientelism (Tendler and Freedheim, 1994) or even use it to effect change (Grit-idle, 1977). But such a concentration of power is rare in Latin America; it prevails only in institutionalized authoritarian systems such as Mexico (Grindle, 1977), or on a limited, regional scale, as in the Brazilian state of Ceara (Tendler and Freedheim, 1994). On a national scale, and under democracy, which provides the most propitious setting for social movements efforts to influence public policy, political authority is dispersed in Latin America, and a multitude of clientelist networks compete for power. Under these conditions, reform projects are drawn into the rivalries among clientelist networks. Since none of these networks manages to prevail, innovative projects are commonly obstructed. Thus, while my institutional constraint argument is probabilistic, not deterministic, exceptions are rare. With this institutionahst argument, I complement explanations pointing to resistance from the socioeconomic forces that would bear the cost of equityenhancing change (Teixeira, 1988). The private medical sector, in particular, defended the established health system, but it did not succeed in blocking reform on its own. Opposition from private hospitals and doctors was not decisive, especially when the conflict broadened in scope (Schattschneider, 1975, chapter 1) and electoral politicians came to see equity-enhancing change as a threat to their political survival. These politicians strongly resisted health reform in order to defend their control over patronage. Clientelist networks -crucial informal institutions in Brazilian politics - thus posed more formidable obstacles to change than class forces. While socioeconomic factors certainly matter, institutional structures are indispensable for explaining the dearth of equityenhancing reform in Brazils new democracy. This article substantiates the institutional constraint argument through an in-depth examination of the Brazilian case. It analyzes the emergence of the countrys health reform movement (section 3), its unsuccessful efforts to mobilize mass support in society - obstructed especially by clientelism - (section

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4) and its consequent shift to a state-centered strategy (section 5). Section 6 shows how members of the health reform movement occupied top state posts under the new democracy and launched some reforms, but also became ensnared in bureaucratic politics. Section 7 analyzes how the movement sought allies, especially inside the state. Section 8 explains why its major reform initiative ran into widespread opposition, particularly from clientelist politicians. As section 9 demonstrates, the movement succeeded in including progressive principles in Brazils new constitution, but it failed to have many of these mandates translated into specific legal norms (section 10). Based on the meager results of these reform efforts, the conclusion emphasizes the strength of the institutional obstacles which social movements in Brazils democracy face.

3.

THE EMERGENCE OF BRAZILS HEALTH REFORM MOVEMENT

Brazils health reform movement arose in the mid197Os, reacting to the highly unequal health care system which the military regime (1964-85) had installed. This inequality rested on the uneven nature of the countrys socioeconomic development. Conservative modernization, reinforced by the authoritarian governments, concentrated the benefits of rapid growth disproportionately in the middle and upper class of urban centers in Brazils Southeast. While poorer people gained in absolute terms, they fell behind in relative terms. Sharpening income concentration was reflected in a health system that provided fairly good, sophisticated services to the middle class, but neglected basic care for the disadvantaged. The structure of Brazils health care model exacerbated this inequality. It provided mainly curative services for the sick and neglected preventive measures designed to keep people from falling ill in the first place. The military regime stimulated the rapid growth of the private health sector, which specialized in curative medicine. Considering public agencies inefficient, the government contracted more and more medical services from the private sector (Braga and Paula, 1986; Oliveira and Teixeria, 1986, part II). This privatization reinforced inequality. Following demand (rather than need), the private sector maintained facilities disportionally in middle-class neighborhoods of urban centers. This concentration limited effective access to health care for the urban poor and most of the rural population (MPAS, 1975; Rodrigues, 1987). Contracts with the private sector also led to much fraud and waste of public resources. They gave private hospitals and practitioners irresistible incentives to perform unnecessary treatments - or even to charge for treatments never performed (Mello, 1977, pp. 121-209).

Narrow rules of entitlement further aggravated inequality by excluding large portions of the population from adequate health care. Most medical services were provided by the social security system, which covered mainly workers and employees in the formal sector of the economy. Since the mass of the urban poor and the rural population did not pay direct social security taxes, they qualified only for minimal services. Due to these legal restrictions, many pressing health needs of the poor went unmet. Yet the middle and organized working class received rather sophisticated and costly medical attention. Health professionals and experts from academia and research institutes critized this unequal and wasteful model of health care ever more vocally. In the mid-1970s. they formed a sanitary movement demanding profound reform, which created as its organizational headquarter the Brazilian Center of Health Studies (CEBES) and as its mouthpiece the journal Debate on Health (S&de em Debate). This social movement attributed the problems of the established system to its heavy reliance on the private sector.4 It therefore called for strengthening the public sector in order to guarantee all citizens equal rights and effective access to health care and to shift the emphasis from curative treatments to preventive measures, such as vaccination and sanitation. The health policy the sanitary movement proposed would help especially the poor and satisfy their basic needs. It would also limit the explosion of health spending by diminishing the need for the expensive treatment of people falling ill with diseases that were easy to prevent.5

4.

THE EFFORT TO FIND MASS SUPPORT

The medical experts and professionals who initiated the health reform movement sought support for their far-reaching goals. They tried to gain a massive following in society, especially among the poor, whose needs they claimed to represent.6 This strategy of mobilization was not, however, very successful. Poverty made many of the poor concentrate on the needs of their families or neighborhoods. Clientelism strongly reinforced their focus on small-scale demands, exacerbated divisions among them, and restricted support for a national-level movement. From the mid-1970s on, movement members worked with local communities, especially in the poor peripheries of large cities. They tried to convince the less well-off that a comprehensive health reform was necessary to guarantee their well-being (Jacobi, 1989, pp. 73, 112-113, 128-137; Sader, 1988). Limited measures, such as the building of a health post in their neighborhood, which the clientelism pervading Brazils political system might provide sooner or later, would not be sufficient.

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Yet these mobilizational efforts faced an uphill battle. Poor Brazilians have certainly formed many social movements to demand relief from their health problems. Most of the poor, however, have focused their attention on improvements for their families or local communities. The hardships of their lives have forced them to devote almost all energy to their own survival (Durham, 1984; Mainwaring, 1987, pp. 141-142). The pervasive clientelism that envelops many of the poor has reinforced this tendency to focus on interests of restricted scope, not on national-level goals. Poor people often consider petitioning with higher-status patrons for small-scale benefits as the only realistic way to obtain gains. In this way, they compete (rather than cooperate) with other poor people requesting similar favors for themselves (Cardoso, 1988, pp. 377-378). In contrast, efforts to exert powerful pressure through collective organization, especially on a supra-local level, would challenge the patron (such as local politicians or their agents) and therefore risk repression. Clientelism has thus helped to keep the poor divided and made mass mobilization difficult. Poverty and clientelism, which reinforce each other, have impeded the health reform movement from ever gaining a mass base. Support for the movement has remained limited to Brazils major urban centers, especially .%o Paulo and Rio de Janeiro, where clientelisms hold is weaker than in Brazils vast rural areas and smaller towns. Yet even in these more mobilized settings, the health reform movement has not been able to count on massive, solid support. While claiming to speak for the impoverished, it has not managed to establish a firm organization integrating its intended beneficiaries. The movement has remained an initiative mainly of health professionals and experts from the urban middle class. 5. THE SHIFT TO A STATE-CENTERED STRATEGY

deficiencies of the established health care model threatened important state interests. Above all, the explosion in health care costs exacerbated the fiscal crisis of the state, which became ever more pressing with the recession and debt problems erupting in the early 1980s. These financial difficulties also endangered the autonomy and power of the agencies administering health care, especially the Ministry of Social Security and Welfare (MPAS) and the National Institute for Health Care of the Social Security Systems (INAMPS), a parastate agency under MPAS supervision. The Ministries of Finance (MF) and Planning (SEPLAN) used the fiscal crisis to claim control over the health care budget, which the MPAS had administered on its own. In addition, the predominance of the private sector limited the power of public health agencies. Strengthening the state, as the sanitary movement demanded, would augment the resources of these agencies and enhance their officials career chances. Important state and agency interests thus coincided with some goals of the health reform movement. Therefore, movement members gained some highlevel positions inside the public bureaucracy already in the last phase of authoritarian rule (Rodriguez, 1988, p. 27). This was surprising, given the ideological distance between a conservative military regime and a left-leaning reform movement. Yet the effect of this incipient penetration on public policy was exceedingly limited. For instance, a major overhaul of the health care system was blocked in 1980 by opposition from the private medical sector, state officials and clientelist politicians.8 Thus, the sanitarisfus state-centered strategy achieved only minimal success under the military regime. 6. EARLY SUCCESSES AND PROBLEMS UNDER CIVILIAN RULE

The failure to mobilize strong support in society led the health care movement to pursue a more statecentered strategy (Campos, 1988, pp. 181-194; Cohn, 1989, pp. 131-140). The weakness of the sanituristus mass base turned the state into the only possible launching ground for change. Members of the sanitary movement therefore tried to occupy leading positions inside the public bureaucracy. Sympathetic observers have even claimed that this state-centered strategy has detracted from efforts at mass mobilization and thus perpetuated the movements weak support in society (Campos, 1988, pp. 181-194); Cohn, 1989, pp. 133140). This effort to penetrate the state already had some success under the last authoritarian government (led by General Jogo Figueiredo, 1979-85), because the

Brazils return to civilian rule created a more auspicious setting for the state-centered strategy of the health reform movement. In fact, a number of movement members gained important positions in the public bureaucracy. They thus obtained the opportunity to launch their progressive initiatives. In the beginning, they indeed seemed to be on the path to success. But difficulties stemming from bureaucratic rivalries soon emerged. The demise of authoritarian rule in Brazil seemed to open the door for significant health reform. As part of a broad alliance of forces, the Purfido do Movimento Democratico Brasileiro (PMDB), the main center-left force that had opposed the authoritarian regime, assumed power in March 1985. For years, it had demanded equity-enhancing change in many areas, including health care. Certainly, the new governing alliance included the conservative Partido da

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Frente Liberal (PI%), whose members - including the new President, Jose Samey -had stopped only in 1984 to support the military government. The democratic transition nevertheless seemed to give centerleft and even leftist forces considerable opportunities to advance their reform goals. The health reform movement used all available avenues for advancing its goals. Most importantly, it pressed hard to have its members appointed to top state positions. This effort at invading the upper echelons of the public bureaucracy was quite successful; it focused on the main agencies in the charge of health care, namely the Ministry of Social Security and Welfare (MPAS), its executive agency, the National Institute for Health Care of the Social Security System (INAMPS), and the Health Ministry (MS). As leading members of the movement, Eleuterio Rodriguez Neto became Secretary-General of the MS, Jose Saraiva Felipe Secretary of Medical Services in the MPAS, and HCsio Cordeiro President of INAMPS. While party politicians were appointed ministers, reform-minded experts had a strong voice in the second echelon. This institutional penetration seemed to open the door to the profound health reform which the movement had long advocated. Yet it also involved the sanitary movement in the vicissitudes of bureaucratic politics, which rages inside the Brazilian state. Thus, the state-centered strategy was a double-edged sword.9 Members of the movement gained positions in different states agencies, which were often locked in long-standing bureaucratic rivalries over influence and resources. Trying to demonstrate good job performance and thus further their career prospects, the new state officials soon absorbed the organizational interests of their agencies. In this way, they were drawn into bureaucratic politics. This wrangling created tensions inside the sanitary movement and led to competing reform efforts. The worst conflict centered on whether the Social Security Ministry (MPAS) or the Health Ministry (MS) should supervise INAMPS. Due to the traditional linkage of health care to social security in Brazil, MPAS controlled INAMPS, which was in charge of administering curative services. Funded generously through social security taxes, INAMPS expanded the public provision of curative treatments, while the MS, in charge of preventive programs, had to operate with meager budget allocations. For many years, the MS had hoped to get control over INAMPS and its enormous resources. Before 1985, the sanitary movement had always advocated such a transfer of INAMPS from the purview of MPAS to the MS. In this way, the provision of curative treatments by INAMPS could be integrated into a comprehensive health system that would privilege preventive measures. Yet after demanding the transfer as late as early 1985 (Escritorio Tecnico, 1985, pp. 27-28). the movement members appointed

to INAMPS and MPAS suddenly came to oppose this reorganization, incurring the wrath of movement members appointed to the MS (Rodriguez, 1988, pp. 46-47; Felipe, 1988, p. 67; interview Cordeiro, 1988). Thereafter, these two groups often went separate ways. This conflict created lasting resentments and weakened the reform movement internally. Despite these problems, members of the sanitary movement used their new top positions inside the state to promote health reform. Those appointed to posts in INAMPS started in 1985 to remove the rules and regulations that excluded large parts of Brazils population from full health care coverage. Announcing that every citizen had the same right to health care, they universalized legal entitlements and eliminated discriminatory rules which restricted the actual provision of medical services in Brazils vast rural regions. These rule changes, which gained support from trade unions and even the private health sector, did not arouse any open opposition (0 Globo, 1986; interview Cordeiro, 1990; INAMPS, 1988, pp. 10-l 1; Cordeiro, 1988, p. 229; Felipe, 1988, p. 69). They completed the gradual extension of health care coverage that had been underway for decades and that even the military regime had promoted (Malloy, 1979, pp. 83-l 32). The reformist experts knew full well, however, that legal changes as such would have very limited impact unless the poor gained better effective access to medical facilities. This goal, however, was much more difficult to achieve; it required a profound revamping of the established health care system. The members of the sanitary movement in INAMPS and MPAS undertook such a reform effort, but had only very limited success. As a result, many long-standing problems have persisted, undermining the effective impact of the initial rule changes. As INAMPS president Cordeiro himself admitted at the end of his tenure, the regional discrepancies in the provision of [medical] services and the extent of unsatisfied need for care in the poorest regions were maintained (INAMPS, 1988, p. 10). 7. THE DIFFICULTIES OF HEALTH REFORM

AND THE SEARCH FOR ALLIES

In order to advance the needs of poor Brazilians, the members of the sanitary movement in INAMPS and MPAS tried to reorient health care away from an emphasis on curative treatments and toward an emphasis on preventive medicine. They attempted to establish stricter public control over medical business, which preferred the existing system with all its distortions. But medical business had considerable bargaining power and successfully resisted the first reform effort. This induced the health reform movement to seek allies, which it found especially inside the state, among municipal and state governments.

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In the sanitary movements view, the state should guide health care provision to favor the needs of the less well-off. Since the private medical sector satisfied only those needs that were backed by ability to pay, it provided many of its services to better-off people in urban centers while neglecting the poor. For this reason, members of the sanitary movement who gained top posts in INAMPS proposed subordinating medical business to planning and supervision by the state. In this way, the private health sector would become an agent of state goals. This plan aroused strong opposition from health business, which profited handsomely from the established system. Trying to defend its latitude and bargaining power, the private medical establishment insisted on defining its relationship to the INAMPS as a contract among equals. The health reformers, in contrast, demanded superiority for INAMPS so that it could direct the activities of medical business (Cordeiro, 1988, pp. 169-176). The new, reform-minded INAMPS leadership tried to advance these goals in long negotiations with associations of private hospitals. Yet the profit-seeking hospitals persisted throughout 1986 in their opposition. In December of that year, MPAS Minister Raphael de Almeida Magalhaes finally tried to decree unilaterally new rules for contracts with the private sector, which stipulated the states superiority. Medical business flatly refused to accept this imposition, however, especially the governments right to intervene in private facilities under ill-defined conditions of public need. The private sector simply refused to sign the new contracts. Since the state depended on private providers for the maintenance of health care, it could not enforced its will (Cordeiro, 1988, pp. 165-189; MPAS, 1986, p. 19174; interviews Magalhles, 1988, and Ferreira, 1989; Es&o de S&o Paul0 1986 and 1987). The reform-minded health experts sought political allies because bilateral negotiations did not allow them to subordinate the private sector to their plans. Interestingly, they gained their most powerful support not from society, but from inside the public bureaucracy itself, namely from municipal and state govemments. Their state-centered strategy and their proposal to decentralize the health system was appealing to subnational governments. Indeed, as on the federal level, members of the sanitary movement had responded to the lack of a mass base by seeking leading positions in state and city governments, from which they backed national reform efforts. Thus, in line with my main argument, the weakness of societal pressure for health reform helped to turn subnational state agencies into the major supporters of progressive change. The sanitary movements restricted following in society could provide moral backing for reform efforts, but did not have sufficient influence on policy

making. Particularly, the Eighth National Health Conference (March 1986), convoked by movement members inside the MS, espoused the goals of health reform to the public. But the rather drastic proposals adopted by the conference, including the gradual takeover of health care by the state, only reinforced the fierce resistance of the private sector, which decried all reform efforts as steps toward the socialization of medicine (Folha de Srio Paula, 1986; Federacao Brasileira de Hospitais, 1989; interview Ferreira, 1989). These plans also found only limited resonance among movement members inside the public bureaucracy, who had scaled back their original goals. Their experiences in top state posts had convinced them that attempts at radical change were unrealistic; they would be foiled by active opposition from medical business and clientelist politicians and by passive resistance from the health care bureaucracy itself, which would defend its established routines and organizational interests. Compromises with opponents and lukewarm supporters were unavoidable. Working within the public bureaucracy thus had a deradicalizing effect.O Because of this cleavage between movement members inside and outside the state, temporary pressure for reform from society had only a limited impact on public policy making. Since the reformist experts in state positions could not face down private sector opposition on their own and since the societal wing of the sanitary movement could not provide much help, they turned to allies among municipal and state governments. The subnational governments had for years demanded a decentralization of Brazils health system, which, as a legacy of authoritarian rule, was controlled by the national government. States and municipalities wanted to take away from INAMPS the responsibility for administering medical services (Conselho National, 1985). In this way, they tried to gain more funds and increase their autonomy. Since its inception, the sanitary movement also advocated a decentralization of health care (Rodriguez, 1988, pp. 28-29, 3945). In its effort to promote preventive measures, it wanted to shrink INAMPS, which had always preferred expensive curative medicine, and to break the stranglehold which the private health sector had imposed on INAMPS. Under the military regime, there were many links of favoritism between medical business and INAMPS officials. Decentralizing attributions would cut these links and break the power both of INAMPS and of the private health sector. This would make possible a profound revamping of the health system. Members of the sanitary movement in leading public posts therefore saw state and municipal govemments as important allies for their reform efforts. In the eyes of the progressive experts, the subnational

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governments would pay more attention to the basic health needs of the poor because the citizenry could better control them than the distant federal govemment. Popular movements, which have mostly a local scale, would exert more influence on municipal and state governments than on the national government. By decentralizing the administration of the state, the sanitary movement hoped to augment the influence of its fledgling societal wing (Cordeiro, 1988, pp. 31-36, 95-97, 104-108). Thus, the demands of the health reformers in the national government overlapped with the organizational interest of state and municipal governments.

8.

THE REORGANIZATION HEALTH SYSTEM

OF THE

MPAS Minister Magalhaes drew on support from the subnational governments to attempt a major reorganization of the health care system in mid-1987. Conservative forces, however, offered fierce resistance. Above all, clientelist politicians saw health reform as a threat to their political sustenance and successfully tried to evict members and supporters of the reform movement from leading state positions. As a result, the reorganization made only halting progress and did not serve as the first step in the planned overhaul of the Brazilian health system. For Minister Magalhaes, an alliance with state and municipal governments was highly attractive. An ambitious politician, Magalhles was a leader of the more progressive wing of the main government party, PMDB. This center-left party had taken power in 1985 in coalition with the conservative PFL, which President Jose Sarney had helped to found. In 1987, the PMDB current to which Magalhaes belonged entered into conflict with Samey, who was moving more and more to the right. Particularly, Sameys agenda for the Constituent Assembly, which convened in early 1987, differed in important ways from that of the PMDBs center-left wing. In order to win support from state governors, who had considerable influence over the constitutional delegates from their states, the president used his command over patronage as a carrot and stick (Jornal do Brusil, 1987a, 1987b, 1987~; 0 Globe, 1987). Sameys efforts posed a threat to several state governments, which the PMDBs center-left wing controlled. Minister Magalhaes apparently was concerned about protecting his fellow party members from presidential blackmail. The decentralization of health care could further this goal by transferring large amounts of resources to the state governments. This could compensate for any politically motivated cut-off of other federal funds by the president. While definite proof is impossible to attain, the importance of patronage in Brazilian politics (Geddes, 1994,

chapters 2-3) makes it highly likely that this political goal was one of MagalhBess main motives in suddenly decentralizing health care in mid-1987. By then, the MPAS also had an organizational interest in decentralization: It hoped to preempt the transfer of INAMPS to the Health Ministry (section 6). While decentralization would reduce the MPAS power, it would preserve the ministrys control over resource allocation, one of the main sources of bureaucratic and political influence. Therefore, the decentralization was preferable to a complete loss of INAMPS. The Health Ministry was indeed pressing for a transfer of INAMPS to its own purview. Advancing the sanitary movements initial agenda, members who held positions in the MS supported this goal. More importantly, President Samey seemed to regard this transfer as a way to boost his own political fortunes. Since the conservative Health Ministers were his loyal friends while the center-left heads of MPAS supported his critics, a transfer of INAMPS to the MS could have given him more control over patronage, thus bolstering his political prospects. The desire to preempt this transfer and protect center-left state governors from presidential wrath probably triggered Minister Magalhaes abrupt decision to initiate the decentralization of health care in mid1987. By transferring many INAMPS attributions and facilities to state and municipal governments, he created the Unified and Decentralized Health System (SUDS) (MPAS, 1989). The surprising enactment of this reform did not allow the opposition to coalesce. Yet the private medical sector saw the decentralization as a threat to its privileged position and soon tried to undermine the farther-reaching goals of health reform. INAMPS bureaucrats also offered fierce resistance in order to defend the survival of the administrative structure they controlled. More importantly, President Samey came to view the reorganization as a trick to limit his own political clout. Many other conservative politicians, who rely heavily on clientelism, especially members of the PFL, also felt threatened. Clientelist politicians guarantee their electoral support by handing out small benefits, especially to the poor. In order to obtain patronage resources, they count on placing their followers into the health care administration, who in turn hand out benefits to their patrons political supporters and withhold them from their adversaries. In this way, these intermediaries have induced many poor people to vote for their patrons, building a solid base for clientelist politicians.i2 Until MagalhPes formed SUDS, the patronage sustaining these networks had been controlled ultimately by President Samey. This had given Sameys conservative friends privileged access. Yet the decentralization of health care threatened to disrupt these patronage networks. Most state and many municipal governments were in the hands of center-left forces since the PMDBs landslide vic-

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tory in the elections of 1986. The decentralization of health care therefore jeopardized the access of conservative politicians, especially members of the PFL, to health care patronage (F&a de Srio PC&O, 1987; Jomal do Brasil, 1987d). Health reform as such posed a danger to clientelist politicians. They feared that any substantial improvement in health care would reduce the dependency of the poor on patrons. This would weaken their own domination over large numbers of voters and undermine their electoral sustenance. Many conservative politicians therefore joined President Samey in his opposition to the decentralization, and to comprehensive health reform in general. These clientelist forces relentlessly attacked the initiators of the reorganization, including members of the sanitary movement. Leaning on President Samey, they gradually succeeded in removing many reformers from top posts in the public bureaucracy. Facing heavy pressure,13 Minister Magalhaes resigned in October 1987. In March 1988, Samey dismissed INAMPS president Cordeiro, a leader of the sanitary movement; he put a conservative crony in office, who started immediately to sabotage the decentralization. With this and other dismissals, the health reform movement lost much of its institutional basis inside the public bureaucracy and was put more and more on the defensive. Its state-centered strategy had drawn it into bureaucratic fights and battles over patronage which posed severe obstacles to its reform efforts. Its tactic to broaden the scope of the conflict over health reform by allying with center-left state governors had backfired by arousing suspicions from conservative clientelist politicians, who feared for their control over patronage - the base of their political survival. As a limited policy issue turned into a battle over the distribution of power between major political forces, the sanitary movement lost the initiative and its progressive efforts encountered fierce resistance. Sharp competition over patronage obstructed equityenhancing reform. Facing all these obstacles, the decentralization made much more halting progress than planned. The new conservative INAMPS leadership created innumerable bureaucratic hurdles. More importantly, the administrative reform may have broken the rigid structures of the established health care system, but did not put in its place a new model that served the poor better, as leading members of the health reform movement admitted.14 A number of state and municipal governments showed little concern for improving health care. They siphoned off part of the additional resources they received and reduced their own health spending (TCU, 1989). The sanitary movements hope that the decentralization would pave the way for a profound reorientation of Brazils health system did not come true. In many states, medical business rapidly gained strong

influence on public authorities while social movements continued to have limited clout. The weakness of popular movements became obvious in a govemmental program to enlist the support of local communities to control the implementation of health care. The MPAS hoped that councils with citizen participation would guarantee the quality of medical services and prevent clientelist favoritism and discrimination. Yet despite promotion by enthusiastic government experts, only 118 such community councils formed in Brazils more than 4,000 municipalities by the end of 1989. In rural areas, where clientelism is most deeply entrenched, only two councils were operative (MPAS, SAS, 1989, p. 6). Even on the local level, the popular base of the health reform movement thus did not make a strong contribution to national health reform. For these reasons, the halting decentralization of Brazils health care system did not bring about a comprehensive reform that improved the quality of medical services and eliminated social and regional inequities. With its state-centered strategy, the movement gained temporary access to power, but also was thrown into the vagaries of bureaucratic politics and into fierce conflicts over political patronage. Clientelist politicians offered the most powerful opposition to health reform. 9. HEALTH REFORM IN THE NEW CONSTITUTION

The sanitary movement inside and outside the state also tried to advance its goals through the parliamentary arena. The elaboration of a new constitution, which began in early 1987, provided an ideal opportunity. Left-leaning members of Congress who were close to the movement managed to include progressive principles in initial constitutional drafts. Yet opposition from conservative politicians and the private medical establishment, which the health reform movement could not neutralize through countermobilization, weakened the constitutional reform mandate. Brazils Constituent Assembly determined not only the basic institutional framework of the new democracy, but also set guidelines for economic and social policies, including health care. The sanitary movement hoped to have its progressive principles enshrined in the new constitution (Satie em Debate, 1985). This would define a mandate that policy makers would have to execute sooner or later. With this goal in mind, movement members inside and outside the state advised center-left and leftist constitutional delegates who were sympathetic to their goals. Selfselection for committee assignments gave these parliamentarians, who were a clear minority in the Constituent Assembly, a strong voice in the committees elaborating the new rules for health care. These

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committees therefore proposed norms which embodied the major principles of a progressive health reform (Rodriguez, 1988, chapter 3). Rejecting the old view of medical services as benefits reserved for affiliates of the social security system, they declared health a universal citizen right which the state had to guarantee through medical care and welfare-oriented social and economic policies. They mandated that the state integrate curative and preventive measures and create a decentralized unitary health system (SUS), which would give priority to public facilities and contract private medical providers only as a last resort. The movements success instilled fear in the private medical sector, which started a powerful countermobilization (Rosas, 1988). As a result, the initial drafts were watered down during the constitutional debates. In response, the sanitary movement elaborated a peoples amendment on health reform in order to preserve its gains and press for further advances. Through this innovative mechanism, citizens could call for amendments which the Constituent Assembly was required to consider. To increase the weight of such proposals, their authors tried to gather as many signatures as possible. The peoples amendment on health reform, however, acquired only 54,133 signatures - a minuscule number, given the enormous mass of poor people with unsatisfied health needs. This result revealed the low level of popular support for health reform, as prominent movement members admitted (Arouca, 1988, pp. 42-43). The movements failure to mobilize a broad organized following in society again limited its accomplishments. The reformist effort of the sanitary movement was also hindered by intensifying rifts in its midst. To a considerable extent, these tensions resulted from bureaucratic politics. The fight over which ministry should control INAMPS and the huge allotment of funds devoted to health care was especially fierce. Having festered for years (sections 6 and 7), this conflict became most acute and consequential during the constitutional debates. Particularly, movement members in MPAS and INAMPS supported their agencies goal of creating an integrated social security budget which would finance all of social security, health care, and welfare, and which the MPAS as the collector of social security taxes would control. Movement members in MS, in contrast, advocated a separate fund for health care administered by the MS, as this ministry as well as the sanitary movement had long demanded. They feared that in administering an integrated fund, MPAS would assign priority to fulfilling the quasi-contractual rights of social security recipients and neglect the needs of health care, which were not clearly stipulated. This had regularly happened during economic crises, when MPAS had always slashed health spending much more drastically than social security expenditures. Yet MPAS mobilized the influence which its

command over an enormous mass of patronage provided and prevailed in the constitutional debates (interview Scalco, 1989; Rodriguez, 1988, pp. 91-93). This conflict deepened the tensions inside the movement and weakened the cause of progressive health reform. These internal rifts and the lack of firm mass support, as well as the continuing pressure from the private medical sector to tone down the new constitutional principles, caused the reform movement to suffer further setbacks. From inside and outside the state, however, the movement persisted in lobbying constitutional delegates. Therefore, the new constitution of late 1988 contained many general principles which the health reform movement had proclaimed for a long time (articles 196-200). Health was declared a universal citizen right, which the state should guarantee through the decentralized provision of curative services and preventive measures. The private medical sector was assigned a supplementary role (article 199, paragraph I), but also assured of considerable latitude. While not reaching all of its goals, the health reform movement was quite content with the new constitution.

10.

THE NEW LAW ON THE HEALTH SYSTEM

The constitutional principles left, however, much room for divergent interpretations. A law was required to transform them into specific legal norms. Only this law would resolve the many conflicts on substantive issues which the Constituent Assembly had left undecided by passing generalities. The elaboration of a new law gave the anti-reform forces the opportunity to roll back the sanitary movements advances. Lacking firm mass support and losing ever more of its top positions inside the public bureaucracy, the health reform movement was unable to exert strong influence in this process. Medical business, which lobbied very actively in Congress, proved more successful. Clientelist politicians forced further limits on progressive health reform. Therefore, the reformist constitutional provisions gained a much more conservative legal interpretation. Seeking to shape the new law, members of the sanitary movement inside and outside the state joined other experts and state officials in drafting a bill. This proposal stressed the role of the state in health care and wanted to subject the private medical sector to strict public control (NESP, 1989). Yet health business protested vehemently and insisted on wide latitude for its activities. Similarly, INAMPS bureaucrats drafted their own bill in order to reverse the decentralization of health care (interviews Figuelra, 1989; Jefferson, 1989). The Health Ministry, which was in charge of drafting the bill on behalf of the government, struck a compromise between these diametri-

1708

WORLD DEVELOPMENT responsible for the profound crisis that has afflicted Brazils medical system in the early 1990s. The law maintained the dependence of health care on revenues from social security taxes, which the Social Security Ministry (MPS) administrated. Given severe financial problems, the MPS has fulfilled first its own resource needs and given the Health Ministry only the meager leftovers (MPS, SPS, 1993, p. 2; 1994, p. 10). Starved for funds, medical care has suffered greatly (interviews Dellape, 1992; Jatene, 1992). Thus, bureaucratic politics has not only helped impede equity-enhancing reform in health care, but even worsened the already deficient status quo.

tally opposed positions (MS, 1989). Despite opposition from medical business and INAMPS, the govemment submitted this bill to Congress in mid-1989. The private health sector and INAMPS developed a powerful lobby in Congress to defend their interests. Since the conservative parliamentarians supporting this lobby could not muster a majority, they engaged in obstruction. Evicted from most leading positions inside the public bureaucracy and exhausted from the mobilization efforts during the Constituent Assembly, the health reform movement did not build up strong counterpressure. Its loose organization and lack of a solid mass base rendered it incapable of exerting sustained influence (interview Lefcovitz, 1990). In order to have any law passed at all, the parliamentarians supporting progressive health reform had to enter into a compromise with the conservative obstructors. As a result, the possibility of profound health reform was restricted further. The draft bill preserved the private sectors significant role in the medical system, provided it with new economic safeguards, and gave nonstate providers of medical services direct participation in health policy making. In addition, while it mandated the decentralization of medical service provision, it preserved INAMPS as a planning and supervisory agency. This Congressional bill made a drastic reorientation of Brazils health care system impossible. Conservative forces celebrated their victory, while the health reform movement lamented its defeat (F&a de S&o Paula, 1989; Cdmara dos Deputados, 1989; FENAESS, 1989). President Collor and his first Health Minister, Alceni Guerra, however, saw this bill as a threat to their control over funds that could serve as patronage. They disliked the Congressional decision to mandate automatic financial transfers to state and municipal governments, which limited the federal governments ability to extract political favors. Collor therefore vetoed parts of the project and forced changes that enhanced presidential discretion over resource allocation (MS, 1991, pp. 23-35; interview Arouca, 1992). These modifications kept the door open for clientelist manipulation and outright fraud. As in the case of SUDS, interference by clientelist politicians combined with bureaucratic politics and opposition from sectoral associations to water down reform. With these compromises, the new legal framework for health care, finally enacted in late 1990, fell behind the hopes which the 1988 constitution had created in the sanitary movement. The constitutional principles received a legal interpretation that made only modest change possible. Medical business, established bureaucrats, and clientelist politicians had blocked the effort at profound health reform. These conservative forces had survived the attack from the sanitary movement and succeeded in preserving many parameters of the existing system. In fact, the new legal framework was partly

11.

CONCLUSION

As this study shows, Brazils sanitary movement has achieved only limited success in promoting equity-enhancing health reform. It never managed to mobilize wide-ranging, firm support in society, and its shift toward a state-centered strategy produced only modest achievements. Leading members of the movement used their high-level public posts to enact some rule changes, but they also faced powerful institutional obstacles which blocked the effective implementation of these modifications. As a result, the movement has not brought about much equityenhancing reform. While achieving a few successes, it has clearly failed to reach its original goals. Pervasive clientelism has greatly exacerbated the difficulties of the sanitary movement in mobilizing support from society. Particularistic links to patrons of higher status have induced most poor people to focus on small-scale goals and prevented them from joining in national-level efforts. Although they have suffered from the severe deficiencies of Brazils health care system, few of them have therefore supported the sanitary movements call for a profound overhaul. The lack of a solid mass base in society has led reform-minded experts and professionals to concentrate on penetrating the upper echelon of the public bureaucracy. This state-centered strategy has diverged from the conventional expectation that social movements - as part of society -pressure the state from outside. Brazils sanitary movement has instead tried to occupy leading positions inside the state, regarded the public bureaucracy as the decisive instrument for achieving its goals, and sought allies among state actors. Interestingly, some social movements in the First World have pursued similar statecentered strategies (Gale, 1986). Yet while this state-centered strategy provided opportunities for effecting some equity-enhancing change, it also exposed the reform efforts of the sanitary movement to a series of powerful institutional obstacles. It pulled the movement into the trenches of

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1709

bureaucratic politics and weakened its internal unity and force. It induced movement members in top state positions, who noticed the inertia of the bureaucracy, to moderate their plans and goals, creating cleavages with the societal wing of the movement. Most important, the state-centered strategy drew movement leaders into conflicts among powerful political forces over the command of electoral patronage. As clientelist politicians launched a counterattack, the sanitary movement quickly lost most of its leading positions in the public bureaucracy, revealing its precarious base. Thus, institutional obstacles severely impeded the sanitary movements reform efforts. As other authors have emphasized, the socioeconomic sectors that would bear the direct cost of reform, especially medical business, also offered resistance. But this socioealone was not decisive, conomic opposition especially as the scope of the conflict widened to include a wide range of political forces, such as state and municipal governments and, above all, clientelist politicians. When these politicians came to see health reform as a threat to their control over patronage and, thus, as a danger to their political survival, they combatted it in order to defend their established clientelist networks. Analyses of the fate of social reforms therefore need to give serious consideration to institutional factors, such as clientelism. Institutionalist arguments emphasize continuity over change, obstacles over possibilities for reform. Does this approach leave any room for progress? Can the institutional impediments analyzed in this article ever be overcome, or is Brazil condemned to sociopolitical stagnation? The sobering findings of this case study suggest a tentative answer: given pervasive institutional obstacles, isolated reform attempts by social movements may have little impact, especially on the national level. Instead, a broad-based, longterm effort at comprehensive, yet gradual institutional transformation is required. Certainly, on a local or regional level, committed political leaders can concentrate sufficient authority to effect reform. In Ceara, for instance, a state in Brazils poor Northeast, a movement of medical professionals convinced an incoming governor from the center-left Partido ah Social Democracia Brasileira (PSDB) to implant a highly successful preventive health program (Tendler and Freedheim, 1994). Strict controls by the state government and the skillful encouragement of community participation limited the corrosive impact of clientelism in this case. Thus, on a limited scale, strong political leadership can override the institutional obstacles emphasized in this paper. Such success is very difficult to extend to the national level, however. Given the dispersion of power in Brazils democracy and the coexistence of rivalling clientelist networks, the federal government finds it extremely difficult to concentrate sufficient

authority for enacting reform against resistance. At present, President Fernando Henrique Cardoso, a PSDB leader who took office in January of 1995, faces enormous obstacles to his reform efforts, which include improvements in health care for the poorest sectors. Many of Cardosos conservative and centrist allies in Congress depend for their political survival on patronage. Reforms that threaten their control over distributable benefits are therefore virtually infeasible. Despite his strong electoral mandate, based on a stunning first-round victory in the presidential election of October 1994, Cardoso has encountered widespread resistance. Thus, the institutional obstacles to social reform on the national level are exceedingly difficult to override. Equity-enhancing success therefore hinges on a long-term effort at comprehensive, yet gradual institutional transformation, supported by a solid, wideranging organization in society. Social movements need to join forces, broaden their concerns, design a comprehensive program, and participate in the electoral arena. They need to form an encompassing, nonsectarian, reformist party that seeks mass support (Hellman, 1992; Castatieda, 1993, pp. 200-202, 363-364). Such a party could over time erode the sustenance of clientelist politicians by competing for the allegiance of the poor. If it wins government power, its organizational discipline and programmatic orientation can mitigate the divisive pull of bureaucratic politics. A party with these characteristics may reduce institutional obstacles and thus gain the capacity to mobilize sufficient countervailing power to overcome elite opposition to reform. Yet such a party can only emerge through long-standing organizational efforts. In Brazil, the core of such a broad-ranging reform party may already exist: the leftist Workers Party (PT), which has for years endeavored to include social movements of the urban poor, unions of industrial workers and rural laborers, and associations of middle sectors into a fairly disciplined, programmatic party organization (Keck, 1992; Castaheda, 1993, pp. 149-155). Appealing to an ever wider range of social sectors, the PT has demanded comprehensive equityenhancing reform. To avoid antagonizing established elites, the leadership has renounced its initial radicalism. The PT has pursued profound, yet gradual sociopolitical change, in some ways similar to early social-democracy in Europe. The PTs defeat in the presidential election of October 1994 shows that its organizational network is still limited. Yet the large increase in its congressional delegation - from 35 to 60 deputies - suggests that the party is making important advances. It took the social-democratic parties of Europe decades to win government power. If the PI can maintain its organizational momentum, it may eventually repeat this success and obtain the opportunity to enact lasting equity-enhancing reform in Brazil.

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WORLD DEVELOPMENT

NOTES
1. This article focuses only on the policy impact of social movements, not their effect on the consciousness of their members (Cardoso, 1983, pp. 234-239; Mainwaring, 1987, pp. 147-149). 2. Cardoso (1983); Mainwaring 190-195; Alvarez (1990). chapter (1994). pp. 87-89. (1989), pp. 177-182, 10; review in Assies 8. Oliveira and Teixeira (1986). pp. 270-275. A special program for basic health care and sanitation in the rural Northeast (PIASS), which reformist experts helped administer, brought some improvements for disadvantaged sectors. This success was possible because the authoritarian govemment could override clientelist resistance and because the private medical sector, which had little interest in destitute rural regions, did not offer opposition. See Weyland (forthcoming), chapter 4. 9. For a similar argument on the paradoxical effect of governmental responsiveness to social movements, see Mainwaring (1987) p. 152. 10. Interview Felipe (1989). Compare, e.g., Cordeiro (1979) with Cordeiro (1988). 11. Rodriguez (1988). pp. 7679; Felipe (1988); confidential interviews with decision makers, Brasilia (1989). 12. Jo~M~ do Brusil(1987b); Veju (1987); E&do de Scio Puulo (1988); confidential author interview with the MPAS official administrating this patronage, Brasflia (1990). 13. A leading PFL politician told this author in a confidential interview (Brasilia, September 1989) that conflicts over patronage had caused the sharp conflict between Magalhaes and this clientelist party. 14. Confidential author interviews, Brasilia (June-September 1989); Jornal do Brusil(1989); articles by Chonny and Noronha, Felipe, and Dantas et al., in Governo do Es&o de Srio Paulo (1988).

3. For a mote in-depth assessment of the achievements of Brazils health reform movement, see Weyland (forthcoming), chapters 4.7. 4. In recent years, the sanitary movement has adopted a more nuanced, less negative view of the private sector (interview Arouca, 1992). 5. Mello (1977). pp. 197-212; Landmann (1977); CEBES (1985). This paper uses the sanitary movements own goals as the measuring rod for assessing its success. 6. A number of movement members, who belonged to Brazils small orthodox Communist Party (PCB), saw this mobilizational effort as part of a broader strategy to win support among the poor for a move toward socialism. This sector. which regarded Italys Riforma Sanitaria as its main model (e.g., Berlinguer, 1988). saw its hopes dashed when mass mobilization failed. 7. Gay (1988). chapters 3-4; Mainwaring (1989). pp. 188-189, 195; also Hellman (1994), pp. 128-139. Even in the highly mobilized setting of Limas shantytowns, patterns of conservatism and clientelism persisted.. . (Stokes, 1991, p. 77).

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