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A Participatory Health Care System: What Can We Learn from Brazil?

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Carol Marina Tojeiro
May 4, 2018

Public participation is easier said than done. Mobilizing a large group of people who share different values, ideas and backgrounds can be challenging and polarizing. This is particularly true for countries that have not fully reached political and economic stability. Despite being a young democracy, however, Brazil has been able to effectively engage its citizens on a variety of issues and in a variety of public institutions. Public participation in public health systems is one area in which Brazil has been particularly successful.

In 1988, the right to health was enshrined in Brazil’s Constitution. Moreover, the Constitution mandated, “the participation of the community: in health actions and public services.” To meet this constitutional mandate and increase the quality of and access to health services in the country, the state pursued a strategy of decentralization and municipal control. Various laws led to the establishment of health councils at the municipal, state and national levels. Today, local health councils exist in over 5,000 municipalities. These local councils, along with their state and national counterparts, engage tens of thousands of citizens across Brazil in health-related decision and policy making.

Local health councils are very diverse, with citizen representatives, health professionals, civil society members and other actors from public and private entities. They are empowered by law to act as watchdogs over the health system. Council participants can inspect public health accounts, demand accountability in budgeting and service-delivery, and exert influence on how resources are spent. Health conferences, organized by the Government of Brazil, bring together delegates from different municipalities to share their experiences at the state and national levels and influence policy.

Through these participatory efforts, health policy and service delivery have become more responsive to the needs of Brazil’s diverse population. In part, this is because the health councils serve as an open space and forum for those who are concerned about public health or whose health concerns have been overlooked. Through this system of local health councils, marginalized groups, such as women, indigenous peoples, ethnic minorities and the LGTBQ population have increased their presence, voice and involvement in decisionmaking about health issues. Although diversity and participation rates vary across localities, Brazil’s participatory management strategy has not only strengthened the social contract between citizens and the state, but also has increased the transparency of public health expenditures and accountability in the public health system.


Such participatory arrangements are especially important in light of the United Nations’ Sustainable Development Goal #3, which seeks to “Ensure healthy lives and promote well-being for all at


all ages.” Although the United Nations recognizes that significant progress has been made in several areas, “many more efforts are needed to fully eradicate a wide range of diseases and address many different persistent and emerging health issues.” While there are many differences between Brazil and other countries, Brazil’s approach to public participation in healthcare systems could nevertheless serve as model for other nations seeking to improve their health-related systems, service delivery and outcomes.

The information provided in this article was retrieved from Participedia, a free online database of public participation in different countries. For more information about Brazil’s Municipal Health Councils, click here. To learn more about how other governments are using public participation in health and other arenas, check out other cases on participedia.net.

Author: Carol Marina Tojeiro is pursuing a dual master’s degree in Economics and International Relations at the Maxwell School of Citizenship and Public Affairs – Syracuse University. She is passionate about gender issues, economics, data, and policy. Prior to her graduate studies, she worked at the United Nations. Twitter handle: @caroltojeiro

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