Confer en CIA Fleury - Welfare State in Brazil

8/6/2019 Confer en CIA Fleury - Welfare State in Brazil

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BUILDING DEMOCRACY IN AN INEQUITY

SOCIETY- THE CHALENGE OF THE WELFARESTATE IN BRAZIL

Sonia Fleury1

Abstract

Recently, Latin American countries had to face the challenges of achieving socialinclusion and economic redistribution as well as consolidating democratic institutions.The author analyzes the process of building up a new pattern of welfare state in Brazil,starting from an elitist social insurance model to the challenges of designing a universal

institutional social security model in 1988. New governance prototypical arrangementswere built in order to respond to the emergent demands of decentralization and socialparticipation.The financial constraints reduce the scope of the national government to implementinclusive policies. In this scenario, the stronger players -- be they national and undernational government, corporative professionals or international companies -- areresponsible for a reshape of the welfare design that is far from the one establishedlegally by the Constitution, the poverty reduction is widely recognized as a result of

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The outstanding features are the combination of a highly decentralized andhierarchically organized network of services with a decision-making process that

incorporate the federative or participatory arenas. The existence of political spheres fornegotiation and instruments for consensus-building were important innovations in theintergovernmental relationships, and in the relationships between the state and socialactors.

Most of the studies on WS took their conclusions from comparing the Europeanand North American experiences. This literature has pointed out some conditionsassociated with the emergence and consolidation of the WS. A few studies havedemonstrated the characteristics of the social protection models which were prevalent inLatin American countries during the last century. Others have shown how these modelswere reformed in the last quarter of that century, engendering new designs of socialpolicies. The continuity between the old and the new models is the persistence, to acertain degree, of the main features of the social protection policies in the region,namely stratified inclusion of former workers through centralized social systems withthe exclusion of the most part of the population. Poverty and inequality are the results of a social system that is far from being a mechanism of distribution and actually ends up

as an instrument of unfairness.The importance of studying the Brazilian experience of building up an

egalitarian WS is not only to observe the path dependence impact of the formerinstitutional social protection model, but also to consider the absence of the most important requirements pointed out by the WS studies as part of the successfulexperiences. This article reviews the literature on the WS and compares it to theBrazilian experience in order to stress precisely this discrepancy. It shows that thestatecraft of the institutional framework of social policies occurred during the 90’s and

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dynamics and less redistributive, the second one is restrictive and conditioned by theworker location in the market place, whereas the last one is organized as a public system

with universal coverage. In this last case one can find the more institutionalized,inclusive and redistributive situation. This typology is based on the extension of socialrights and on the double movement of expanding state structures and policies on the onehand, and redistributing resources according necessities on the other hand.

Marshall (1967) emphasizes the core role of citizenship in the welfare butfollows the same pattern in his classical article on social classes and citizenship,identifying three kinds of rights as components of citizenship – civil, political and social

– each with its own path and institutional structure. Instead, Esping-Andersen (1990)shed new light on social rights, which were reconceptualized in terms of their capacityfor “de-commodification”, meaning the capacity to take social reproduction far awayfrom the merchandise circulation. He understands the role of WS regarding socialstratification as a two-fold process. On one hand, WS is identified with the policies of social-amelioration and wealth redistribution which corrects inequalities, but, on theother hand, social stratification is also an outcome of the WS, because socialstratification is shaped by the nexus of state and market in the distribution system. He

also underlines the importance of institutionalization when he analyses theconsequences of the WS crisis in the three different regimes: the liberal welfare regime;the corporatist-state regime, and the social democratic regime. He concludes that thepolitical and institutional mechanisms of interest representation and consensus building,especially in the social-democratic arrangement, have a strong impact on theemployment and preservation of social rights (Esping-Andersen, 1995:77).

The WS is, then, considered a peculiar articulation of distributive conflicts,particularly the conflict between the market logic and the principles of politicalll ti t d th i tit ti l t f i l li i i h i t



The European bias in the WS literature lead to an unintentional conclusion thatthis experience would not be possible to be replicated in other contexts, where the

previous signaled conditions were absents. Although the economic recent capitalistgrowth could be stronger in other continents, as America or Asia and the association of this phenomenon with distributive policies could have happen in certain circumstances,like the New Deal in USA, it was not sufficient to generate a universal public protectionsystem outside of the European countries, based in the State guarantee of social citizens’

rights.In my previous work (Fleury, 1994) I considered the existence of a cluster of

variables -- from the ideological, political and institutional to the managerial andfinancial ones -- that could characterize three different patterns of social protection,namely social assistance, social insurance and social security. These patterns are quitesimilar to other typologies, although I call the attention to two important issues. Firstly,I stress the need to consider the constellation of variables gathered in each pattern in avery broad way, in order to go from the traditional ideological and political clusters tothe identification of actuarial and managerial variables occurring close together. I founda strong relation between the political variable and the administrative and financial

structure that are encompassed in the same pattern. Secondly, I established a connectionbetween the social protection patterns and the citizenship status that results from it. Thiscontribution adds a new element to how we think about the relationship betweendemocracy and WS, far from the mere institutionalization of the social rights andcompetitive political parties. The point here is understand the consequences of eachpattern of social protection in shaping different modalities of citizenship -- all of themcompatible with democratic regimes, but dissimilar in terms of their capacity to create amore equalitarian public sphere.

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To summarize, the development of the WS has been associated with an array of elements related to the progress of the capitalist economy, as well as with the

transformation of societies as a consequence of urbanization and industrializationprocesses that imposed a new division-of-labor and led to more complex socialrelationships. The WS is also part of the state-building process, and this expansion is acomponent of the democratization of power and wealth in a mass society, with theemergence of new collective actors and political organizations. The WS is considered anew arrangement for consensus building and to convey conflicts to the redistributivearena, where they can have a negotiated solution. Different patterns of social protectionwere identified according to whether the main aim of inclusion was centered on the poorand other vulnerable groups, the labor fractions of the work force, or the citizens. Theinclusion of social rights as part of the status of citizenship represented the mostparadoxical solution for the distributive conflict in a class economy, since it hadgenerated a public sphere not primarily subordinated to the process of accumulation, ananti-value mechanism (Oliveira, 1988). Nonetheless, it contributed to the creation of amore cohesive society, based on social principles of solidarity, in which social inclusionwas widespread. However, during the crisis of the capitalist economy since the 70’s, the

institutional mechanisms of social protection were accused of impeding the renovationof the productive relationships in order to increase competition and productivity. Lately,the loss of affiliation links was pointed out as the being responsible for the crisis of sociability, the rise of insecurity, the sprout of negative individualism, the replacementof policies of inclusion by policies of insertion (Castel, 1995). All this symptoms arerelated to the growing earning and income inequalities in OECD countries (OECD,2011) and threaten the continuity of the social-democratic model that gave rise to theWS. In this new context that is each day far apart the signed prerequisites for the

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Filgueira and Filgueira (2002) study, combining the amount of public socialexpenditure and the social indices in some countries, reaffirms Mesa-Lagos’s

conclusion on the Latin-American pattern of social benefits stratification, even in thealmost universalistic systems in the region. What they stress is the variable combinationof this stratification characteristic with the social exclusion degree of each group of countries, not basically dependent on the date of its emergence. They found, until the70´s, three different groups: a group of Stratified Universalism; a group of Dual Systemand a group of Excluding System.

These results were important to highlight the limits of the path dependenceanalysis of the social protection models, even considering the importance of thematuration of them. Then, it is possible to lay stress on the political forces and thegovernment orientation to counteract the structural determinants of their course.Nonetheless, the comparative studies of social protection in Latin American tend toreduce the importance of the political options, minimizing the important social indicesachieved in countries like Uruguay, Costa Rica and Cuba, during the last century. Theequalitarian results of public policies are considered either under suspicious or asimpossible to be expanded to the big countries in the region.

More recently, other authors have produced new analyses of social protectionmodels in Latin America, considering the impact of the process of globalization andmarket-oriented reforms upon their earlier social protection system. Katzman´s work (2002), reviewed by Filgueira and Luna (2009) try to answer the question about whetherthe countries’ historical legacy in terms of social structures and welfare regimes mark sdifferent paths and differential capacities to resist and adapt to this new context. Thegeneral conclusion, affirm Filgueira and Luna (2009:475) “is that the welfare matrixes

and their level of development were unable to counteract these deteriorating labork t th h b i t ti i t t d h it l d di t ib ti ”



both private and public resources thus shaping a pluralistic model based on managerialcompetition regulated by the public authority. This model place the regulated

competitive insurance market in the core of the health system, since a package of benefits is guaranteed either by the individual’s own contribution or through the

collective contribution to a solidarity fund. In the last case, the package of benefits islower than in the first, and the inclusion of the poor depends on the amount of resourcesyearly available. This complex network of public and private interests with differentlogics was unable to overcome the constraints of this design, based on the limited salarycontribution and on a saving-oriented logic, proper to the insurance companies. Thethird model was based in the Brazilian experience of creating a public universal systemof integral social protection directing the demands towards a more democratic,equitable, decentralized and participatory system of social policies.

The three different social policy designs can be named as dual, plural oruniversal, according to their proposals, contents, instruments, public-private relationsand supportive coalitions. A crucial variable to explain these differences is the timingof the reform with respect to two main macro processes: 1) the economic crisis with theensuing macro-structural adjustment and 2) the transition to democracy and the outburst

of a new political fabric and social demands. It explains the prevalent ideology as wellas the material possibilities of each paradigmatic reform.

Latin American societies are assuming a new profile, with a more pluralistic andcomprehensive system of social protection. Instead of an outright denial of membershipto some groups, there is a movement for stratifying the population in accordance withthe purchasing power of each group. Nonetheless, the possibility of designing auniversal system, as it was done in Brazil, goes in the opposite direction of this generaltrend. This singularity can only be explained based on the close relationship established

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worker’s segments, indicates the place that each occupies in a certain correlation of forces.

In the period of populist democracy (1946-1963), the expansion of the socialsecurity system was part of a political game of exchange of benefits at the discretion of governors, benefiting in different ways the groups of workers that have the greatest

bargaining power. This phenomenon became known as the “mass privileges” drive andis appointed to be one of the causes of the financial and administrative crisis in thesocial security system.

The change in the social protection systems, policies and mechanisms after thebureaucratic-authoritarian regime that was installed in 1964 follows takes four masterlines: 1) the centralization and concentration of power in the hands of the technocracy,with workers removed from the political game and the administration of social policies;2) the increase of coverage, incorporating precariously some previously excludedgroups such as domestic, rural and autonomous workers; 3) the creation of socialcontributions as a mechanism to fund social programs; 4) the privatization of socialservices (university, secondary education and hospital care became profitable business).

In the mid-1970s the struggle for the democratization of policies takes on new

characteristics and strategies. Whereas before it was confined to universities,clandestine parties and social movements, from then on it begins to be located at thecenter of the state itself, with a strong push towards reforms. At first, based oninnovative experiences developed by the governments elected in 1974 by theopposition; secondly, by occupying strategic positions in central organs in order to takeadvantage of their financial crisis and to introduce transformative elements in the socialpolicies model, and; in third by strengthening the technical capacities of political partiesand parliaments in social matters.

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risks inherent to this reformist strategy, what represented an appealing threat of beingeither co-opted by the political elites or legitimating an unsuccessful transformation.

The fragile political party system did not impede that the social movementsassumed the assignment of projecting new policies and public structures, under the flagof the universal citizens’ rights. In a society that is marked by its ancestral and profoundinequality the defense of equalitarian policies represented a counter-hegemonic bannerfor the democratic project.

The previous experience of expressive economic growth without redistributioncontributed to the learning that the mere presence of the State or even its leadership inconducting the development was insufficient to assure the prevalence of the publicinterests. The building up of a democratic and inclusive nation was assumed by the civilsociety organizations as their commitment in the public policies transformation. All thisdemocratic effervescence was channeled to the National Constituent Assembly whoseworks began in 1987. The construction of a democratic institutional order supposed arearrangement of social policies in response to society’s demands for greater social

inclusion and equality. Projected for the social policies system as a whole, this demandfor inclusion and inequalities reduction led to the affirmation of social rights as part of

citizenship.The Federal Constitution of 1988 represented a profound transformation in the

Brazilian social protection model, legally consolidating the social rights in response tothe pressures that had already been felt over a decade. A new period was inaugurated,where the model of social security started to structure the organization and format of Brazilian WS towards a universal citizenship.

The Constitution of 1988 advanced in comparison to the previous legalformulations by guaranteeing a set of social rights, expressed in innovative Social Order

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a single political command and a unique fund in each sphere of government,regionalized in a hierarchal arrangement. Moreover, it also created deliberative

instances which equal participation of organized society and government representativesin each sphere of administration.

From Rhetoric to Reality

During the 90s Brazil has experienced a hard period of economic crisis withhyperinflation and a great amount of debt accumulation, having to launch manydifferent policies and instrument to cope with this stressing situation, but that onlystarted to succeed after the middle of the decade. At the same time, the government hadto deal with the social pressure to implement the important transformations requested inthe new Constitutional frame. In other words, there were two concurrent movementsgoing in opposite directions: one expressed by the macro economic adjustmentmeasures and the other by demands for assuring social rights and institutionalizing thenew WS design.

As many of the constitutional prescriptions required a new infra-constitutionallegal frame, the government postponed at the most its approval, up to the point where itcould not ignore social pressures anymore. As the political supporters of social rightsgreatly varied in each sector – social insurance, health care and social welfare – according to their coalition political power and capacities, each of the social securityparts had a different institutional path. Nonetheless, they had to face the same contextand restrictions, thus enabling an analysis of the general trends as well as requiring theidentification of their specificities.

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observe efforts to join forces and construct political actors, either before or as aconsequence of the policy institutionalization. The union of retired workers was

decisive in defending the comprehensive benefits plan and also to avoid the intents toprivatize social insurance. Lately, the political presence of social insurance fiscalattorneys gathered in their important association – ANFIP - became the key factor in thediffusion of alternative information about the financial situation of the SS system. In thecase of social assistance, the formation of a critical mass of powerful civil service in thecentral government is the more recent product of this policy institutionalization.

The fragmentation of this process into three different trajectories confirms thelack, from the beginning, of a unified movement in defense of the general SocialSecurity construction. This important concept was developed during the works of theNational Constituent Assembly, but was short of roots in social movements. It had atechnical support, but this was not enough to gather important social actors around it.On the contrary, the most mobilized group, the health sector, felt suspicious about thisproposal and identified in it the intent to create a mega ministry encompassing pensions,health and social assistance. The recent articulation in favor of the SS is therefore aproduct of its own institutional process and has gained some projection after two

decades of its constitutionalization.The mandatory precept expresses in the Constitution is that Social Security is an

integrated set of initiatives concerning the assurance of social rights related to health,social insurance and social assistance. To guarantee this arrangement the Constitutionstates the creation of the SS Budget managed by the SS Council. These two mechanismsof planning and integrating policies did not work properly, from the beginning. Thebudget became only a formal accounting instrument instead of a common integratedplan of resource allocation. Moreover, the government introduced some mechanisms to

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which lead it to take loans for covering regular expenses (Santos, 2008). The demandfor a new source to fund the health system gained visibility and the congress approved a

tax on financial transactions (CPMF) for this purpose. Not being an earmarked tax, theresources were allocated by the national government to other expenses, and only 1/3was assigned to the Health Ministry, until this tax was extinct in 2009. Since the year2000 a new Constitutional Amendment (EC. 29) defines the responsibilities of eachlevel of government to fund the health care system, but the national duties are stillvague. The result is that the relative participation of national government in funding thehealth sector is decreasing, while the state level ignores their mandatory contributionand the burden is directed to the local authorities. In 1980 the participation of eachgovernment level in the public social expenditure was 65% for the national, 23.6% forthe estates and 10.6% for the municipalities, while in 2005 the national level decreasedits participation to 61.9%, the states to 21.8% and the municipalities’ participation roseto 16.3% (IPEA, 2009).

Since the municipalities are responsible for health care delivery, the strain is ontheir shoulders. Pressure is put on local governments either by the participatorymechanisms, denunciations of the mass media or, more recently, through judicial

decisions that guarantee the right to the consumption of some expensive health servicesand merchandises.

One can analyze that the sanitary movement was strong enough to keep theoriginal design of the SUS as a public universal and integral system, but could not avoidthe growth of a powerful market inside the health care field. From the beginning theinteractions of both public and private services existed, but it was organized in twodifferent types: those private facilities that sell services to the SUS, calledcomplementary, and the others that only sell services in the marked, named

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Powerful interests groups are now involved in a complex arena that encompassesthe Legislative, the Executive and the Judiciary. Several demands for improvement of

the SUS – for more financial resources for the SUS, for an increase of its procedurerates, for broadening tax exemptions, for reserving part of public facilities for privatepatients, and for more credit and amnesty for private establishments and providers -- arechannelized to these arenas, reshaping the SUS’s original design.

The proposal of a public national health system was the most radicaldecommodification project in the Brazilian social policies design in the democracy.Nonetheless, the previous dependence on private health care facilities, established sincethe military government, concurred to invalidate this proposal. The public sector,despite being underfunded, is nevertheless responsible for the preventive care andsurveillance for all and delivers services for more than 70% of the population (achieving90% in the poorest regions). All the pools in the last years indicated that the users of thepublic service have a better evaluation of the SUS than the users of the private sector.However, problems of access and low quality, magnified by a constant mediaexposition, are responsible for an unambiguous popular preference for the privateinsurance and service sectors. This preference for the private sector is explained by the

desire to avoid long waiting periods for treatments, which are characteristic of the SUS,but also by the fact that acquiring private insurance is generally associated withprosperity as a sign of ascendant social mobility.

There is no doubt that the most impressive impact of the social policies designafter the Constitution of 1988 was in the reshaping of the state apparatus and itsrelations with society. The creation of the SUS was followed by a similar system forsocial assistance policies - SUAS, based on the same principles of assuring social rightsthrough a public national network with different and articulated levels of government.

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resource to insert the councilor in important power networks and also an arena tochallenge the control by organized groups, like the political parties and unions members

(Côrtes, 2009).In spite of all the limitations there is no doubt about the democratic component

of the participatory mechanisms and the enlargement they are promoting in the publicsphere, so far restrict to the traditional elite. The construction of some dialogicmechanisms imposes the recognition of popular actors and demands, and might permit arenovation of the political elites. The development of the WS was ever related to thechanges from a liberal capitalism to a neo-corporatist form of relations among collectiveactors under the state regulation. The singularity of late developing societies like Brazilis the composition of the civil society, where the few trade unions have to share theparticipatory space with social movements and other civil organizations. Besides theheterogeneous composition of civil society, another peculiarity is related to theintroduction of mechanisms of participatory democracy. While in a traditional politicalconception participation is limited to the electoral process and redistributive policies, inthe Brazilian case a great emphasis is given to the construction of co-managementinstances, where state and society contribute to the policy-making process and the

monitoring of policy implementation. Far from a deliberative democracy where thedecisions are mandatory, even though there is an empowering process in progress aspart of this statecraft blueprint.

The institutionalization of the social assistance policies starting from theConstitution of 1988 represented a turning point in this field, since it was the first timethat this kind of protection and services were considered as part of the social rights. Theconstruction of a new and compatible institution was not a straightforward process.Initially, there was a clear governmental refusal to materialize this constitutional

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In spite of the convergence in social assistance policies, some differences stillpersist, for example, concerning to the means-test criteria in both programs: while for

the BPC the criterion of inclusion is over restrictive, with the per capita family revenueunder ¼ of the minimum wage, for the Family Grant it is under ½ minimum wages percapita. Other important difference between the two lines of social assistance programs isthe fact that some benefits are automatically conceded as part of the citizenshipconditions while others are submitted to conditional requirements. Whereas the formerare institutionalized as citizens’ rights, the latter are associated to government’s

priorities, giving space for populist links between political leaders and the masses.Nevertheless, Brazil presents a high coverage level for elderly people (81.7%),

thanks to the efforts to include them in non-contributive benefits. Nonetheless, theexistence of a significant parcel of workers not covered by social insurance (34.1%according to Schwarzer, 2009:73) represents an important challenge to the proposal of auniversal WS. The last point to consider is related to the financing of the social policies.One can observe an increase in the federal social expenditure from R$ 179.8 billion in1995 to R$ 312 billion in 2005, a rise of 74% in 11 years. However the socialexpenditure performance varies in an ambivalent way among the social policies. In this

period, while the social insurance expenditure grew from 44% to 51% and socialassistance had an augmentation of 1% to 6%, the health participation diminished from16% to 11% and education was reduced from 8% to 6% (Castro, 2009:111). This datareveals that the universal policies, health care and education have not been the mainconcern of governments in the last years. Poverty reduction and social insurance werethe priorities.

The impact of social protection on poverty reduction is one of the most

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Classe DE

92.936.688

Classe C

62.702.248

Classe AB

26.421.172

Classe AB

42.195.056

Classe C

101.651.003

Classe DE

47.945.964

Fonte: Folha de São Paulo, 24/03/2011. “Brasil é o novo País da classe C”

2005 2010

This result on income distribution trough the synergic combination of

distributive policies and economic growth is stupendous, and the consolidation of theprevalence of a middle class is not only a product of the democracy, but a centralrequirement for its sustainability. Even though this kind of distribution only considersincome, ignoring the profound disparities in other basic assets among the Brazilian

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manufacture of the political actors and political coalitions; the process of constitutionalization, through which the social rights gained their legal framework; the

process of institutionalization of social policies through the making up of thecorrespondent structures and mechanisms. In this paper special attention is given to thelatter process and its associations and oppositions to the other two.

The stresses and contradictions occurred in the institutionalization of the WSwere visible in the inobservance of many constitutional prescriptions concerning theSocial Security framework and also in the transformations of its fund arrangement andbudget management. Besides, the legacy of a corporative social protection model wascapable of keeping the social insurance as the dominant policy, reserving the bulk of thefunds for the less egalitarian policy. The different legacies of the three social securitybranches in terms of knowledge and capacities, degree of institutionalization, politicalsupporters, governmental priorities, and relations with private sector were determinantsof the path followed by each one.

The advances in the institutionalization of the constitutional model could beobserved in several aspects of the three policies, as the introduction of non-contributivepensions for rural workers, the cash transferring programs to fight poverty, the

expansion of health system in the small municipalities. The most expressivetransformations were in the state structure, with the introduction of new instruments of the federalist organization and other mechanisms of social control and participation.

The restrictions placed on the full institutionalization of the constitutionalguidelines open up space for the progressive introduction of other interests andstructures in the original design, reshaping in practical terms the WS proposal. Theresult is a hybrid design with hidden mechanisms that progressively introduced newflows and articulation between public and private sectors in the social policies field.

I d f i h h i i l SS d i b i i l



scenario, but the political restriction worsened with the clustering of many powerfulvested interests grouped around the social policy arena. Last, but not least, it is

necessary to change the prevalent elitist culture, since the slavery legacy that tends toinjustices and discriminations as banal forms of treatment of minorities and poor people,thus reproducing differential access and quality of public goods consumption.

The worsening of inequalities in the European countries and the strict economicrestrictions to face fiscal debt is now a menace to the sustainability of their traditionalsocial protection policies. It is time to develop a theory of the WS less Eurocentric andmore capable to cope with the new challenges. A decolonized analysis of the LatinAmerican experiences can be valuable to identify the identity of some constraints aswell as the disparities in the degree of social rights institutionalization and also in thecivil society mobilization. These identities and differentials could permit designdistinguished political scenarios for the reshaping the WS.

Bibliography

Castel, Robert (1995). Les Métamorphses de la Question Sociale. Paris: Gallimard.Castro, Jorge (2009). “Política Social: Alguns Aspectos Relevantes para Discussão”, in

Brasil, MDSCF (Ministério do Desenvolvimento Social e Combate à Fome),Concepção e Gestão da Proteção não Contributiva no Brasil. Brasília: UNESCO,pp. 87-132.

Côrtez, Soraya (2009). “Conselhos e Conferências de Saúde: Papel Institucional e

Mudança nas Relações entre Estado e Sociedade”, in Sonia Fleury, Lenaura Lobato (eds.), Participação, Democracia e Saúde. Rio de Janeiro: Cebes, pp.102-28.

C Nil R (2009) “S i l P i i B il U i li d T i i



Fleury, Sonia (2009). “Brazilian Sanitary Reform: Dilemmas between the Instituing andthe Institutionalized”, Ciência & Saúde Coletiva, 14(3): 743-52.

Flora, Peter and Alber, Jens. (1981). “Modernization, Democratization, and theDevelopment of Welfare States in Western Europe”, in Flora, Peter &Heidenheimer, Arnold. The Development of the Welfare States in Europe and

America. New Brunswick: Transaction Press, pp.37-65.Foweraker, Joe and Todd Landman (1997). Citizenship Rights and Social Movements – a comparative statistical analysis. Oxford University Press.IPEA (Instituto de Pesquisa Econômica Aplicada) (2005). Radar Social. Brasília: IPEA.IPEA (2009). Receita Pública: Quem paga e como se gasta no Brasil, Comunicado da

Presidência. Brasil: 30 Junho.Katzman, Rubén and Wormald, Guillermo (eds) (2002). Trabajo y Ciudadanía: Los

Cambiantes Rostros de la Integración y Exclusión Social en Cuatro Áreas Metropolitanas de América Latina. Montevideo: Ford Foundation y UniversidadCatólica de Uruguay.

Lobato, Lenaura et all (2007). “Avaliação do Benefício de Prestação Continuada”, in

Jeni Vaitsman e Romulo Paes e Souza (orgs), Avaliação de Políticas e Programas

do MDS – Resultados, Volume 2. Brasília: MDS/SAGI, pp. 257-84.Lobato, Lenaura (2009). “Dilemmas of the Institutionalization of Social Policies in

Twenty Years of the Brazilian Constitution of 1988”, Ciência & Saúde Coletiva, 14(3): 721-30.

Marshall, Thomas H. (1967). Cidadania, Classe Social e Status. Rio de Janeiro: ZaharEditores.

Mesa-Lago, Carmelo (1978). Social Security in Latin America: Pressure Groups,Stratification and Inequality. Pittsburg: University of Pittsburg.

i l Cô ( d ) (2010)



Sposati, Aldaíza (2009). “Seguridade Social e Inclusão: Bases Institucionais e

Financeiras da Assistência Social no Brasil” in Lenaura Lobato e Sonia Fleury

(orgs.), Seguridade Social, Cidadania e Saúde. Rio de Janeiro: Cebes, pp173-188.Titmuss, Richard (1958). Essays on the Welfare State. London: George Allen and

Unwin.Wilensky, Harold (1975). The Welfare State and Equality- Structural and Ideological

Roots of Public Expenditures. Berkeley: University of California Press.



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Figura 1: SUS – Brazilian Policy Formation Process and Decision-Making Structure

Levels of

Government

Consensus Building

and Managerial

Instruments

Health

Authority

Functions Decentralization

Process

Social

Control

Mechanism

Counselors

50%

Government50% Society

Policy Formation

Mechanism

Federal

(elected)Ministry

- Central Fund

- National

Policies and

Programs

- Target

Programs

National

Health

Conference

States

(elected)

26 + 1 DF

State

Secretary

- State Fund- Regional

System

Coordination

- ReferenceServices

Human

resources

Health carecenters and

HospitalsFinancialresources State

Health

Council

StateHealth

Conference

Municipalities

(elected)

5.507

C o n s o r t i u m

B i - p a r t i s a n

C o m m i s s i o n

T r i - p a r t i s a n C o m m i s s i o n

MunicipalSecretary

- Municipal

Funds

- Municipal

SystemCoordination

Management of

DeliveryNetwork

Levels of

Autonomy

A – Management

of the LocalHealth Care System

B – Management of

the Primary HealthCare Program

MunicipalHealth

Council

Municipal

Health

Conference

National

Health

Council

Documents

Confer en CIA Fleury - Welfare State in Brazil