User participation and reform of the Brazilian health system : the case of Porto Alegre
Municipal health commissions have been key elements in the reform of the Brazilian health system over the past thirteen years. The reform made publicly financed health care, in principle, universally accessible, while the system became better integrated as well as decentralised. Municipal health commissions have become a widespread institutional feature of the health system. They have gradually increased their planning and supervisory roles over health services located within their territorial jurisdiction. The participatory schemes of municipal health commissions can achieve better results in areas where they have the support of strong social and trade union movements. This is the case in the southern region of Brazil and, in particular, in Porto Alegre. This study analyses the ways in which users were involved in the municipal health commission of Porto Alegre, between 1985 and 1991, verifying which institutional-political factors have most influenced their involvement. The study develops a "methodology" for the assessment of user participation in statutory fora. The attendance lists and minutes of meetings, interviews with regular participants in the forum, and other sources of information, were used to build up indicators of user involvement and of the factors that could influence the participatory process. Two main sets of variables are identified. The first set of indicators is concerned with the ways in which users participated in the commission. Two indicator-variables were created to assess this participation: the attendance of users at weekly plenary meetings of the commission (the decision-making division of the forum) and the types of involvement of user representatives in the decision-making process. The second set of indicator-variables refers to institutional- political factors that could have most influenced the participation of users. Among these are; (a) major policy changes in the institutional framework of the Brazilian health system, (b) changes in the organisation of urban social movements in Porto Alegre (since trade unions had not regularly participated in the work of the commission), (c) changes in the relationship between public health professionals and leaders of urban social movements, (d) the types of interest which municipal, state and federal health authorities had in promoting the participation of user representatives in the decision-making process, and, finally, (e) the types of issues discussed in the majority of plenary meetings. Relationships were then established between both sets of variables to verify which factors most influence this involvement. The study concludes that, between 1985 and 1991, variations in the attendance of users at plenary meetings, as well as variations in the type of involvement user representatives had in the decision-making process of the forum, were strongly associated with important changes: (1) in the institutional framework of the Brazilian health system, (2) in the organisation of urban social movements in Porto Alegre and (3) in the relationship between public health professionals and leaders of urban social movements. The position of municipal health authorities on user participation has also influenced user involvement in the commission. The other factors, however, had apparently determined only short term changes in user involvement. The study also highlights the role of Brazilian health system reformers as promoters or stimulators of these changes. This policy community had a central role in attracting urban social movement activists to become involved in these formalised fora. They can be regarded as policy formulators as well as an active part of an alliance established between them and urban social movement activists. In the case of Porto Alegre, it is possible to affirm that social organisations, particularly those representing shantytown populations, sustained consistent involvement of their representatives in the overt political spaces of the local and municipal health commissions. These commissions had limited power over health services in the city, mostly due to delays in placing these services under municipality control. However, the case examined indicates the gradual formation of an alternative type of political relationship in the health sector in Porto Alegre, in which the interests of the urban shantytown residents are represented formally and publicly. In this sense, the consolidation of participatory fora can assist in the democratisation of Brazilian institutions, giving voice to social sectors traditionally excluded from the political system. Through their involvement in the commission, these representatives were also increasing the responsiveness of publicly financed health services to the needs of users who, individually, lacked the political power to sustain their demands.