BUILDING DEMOCRACY IN AN INEQUITY SOCIETY- THE CHALENGE OF THE WELFARE STATE IN BRAZIL

Sonia Fleury1

Abstract Recently, Latin American countries had to face the challenges of achieving social inclusion 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 arrangements were built in order to respond to the emergent demands of decentralization and social participation. The financial constraints reduce the scope of the national government to implement inclusive policies. In this scenario, the stronger players -- be they national and under national government, corporative professionals or international companies -- are responsible for a reshape of the welfare design that is far from the one established legally by the Constitution, the poverty reduction is widely recognized as a result of public policies but the inequity resists to decline. It is necessary to revisit the European theory of the Welfare State in order to dialogue with the experiences in other adverse context that are now approaching both regions.

Introduction During the last two decades, Brazil has been building a welfare system (WS) based on the principle of extending social rights to all citizen through universal social policies -- a principle that is enshrined in the Social Security concept of the Federal Constitution of 1988. This represented a rupture with the previous existent social protection structure, which was based on stratified social insurance for formal workers and charity or some kind of benefits for the poor, who were excluded from the other system. The struggle for a new comprehensive social protection model had an original component of social mobilization in favor of expanding social rights as part of the transition to democracy. The singularity of having a social policy project designed by social movements and its strong association with the transformation of the state and society in a democracy has added some important characteristics to the Brazilian WS.

Professor at the Brazilian School of Public Administration and Business EBAPE/Getulio Vargas Foundation. Sonia.fleury@fgv.br

The outstanding features are the combination of a highly decentralized and hierarchically organized network of services with a decision-making process that incorporate the federative or participatory arenas. The existence of political spheres for negotiation and instruments for consensus-building were important innovations in the intergovernmental relationships, and in the relationships between the state and social actors. Most of the studies on WS took their conclusions from comparing the European and North American experiences. This literature has pointed out some conditions associated with the emergence and consolidation of the WS. A few studies have demonstrated the characteristics of the social protection models which were prevalent in Latin American countries during the last century. Others have shown how these models were reformed in the last quarter of that century, engendering new designs of social policies. The continuity between the old and the new models is the persistence, to a certain degree, of the main features of the social protection policies in the region, namely stratified inclusion of former workers through centralized social systems with the 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 former institutional social protection model, but also to consider the absence of the most important requirements pointed out by the WS studies as part of the successful experiences. This article reviews the literature on the WS and compares it to the Brazilian experience in order to stress precisely this discrepancy. It shows that the statecraft of the institutional framework of social policies occurred during the 90s and had to cope with dreadfully restrictive economic constraints. The resistance of social actors to dismantle of the WS project was not strong enough to avoid important changes, although keeping the constitutional prescriptions. Moreover, important interest groups and social actors gathered around specific social policies, in a way that impeded their planned integration were responsible for the disaggregation of the components of the Social Security unity. As the analysis of the way the economic constraints have affected the construction of WS as well as the study of the institutional process demonstrate how the absence of important requirements for the successful construction of a WS in the Brazilian context have led to the occurrence of a hidden welfare state. Although there have been important outcomes of the social policies, as the poverty reduction, the low governmental priority given to the universal systems of health and education, would augment the stress and contradictions among new demands from these groups and the capacity to provide access and services with good quality. Moreover, the disparity in the distribution of power and resources among the Brazilian population is menacing the public interest since powerful vested private interests are now disputing the resources assigned for social protection policies. Welfare Systems Theory and the Latin American Experience Starting with Titmuss (1958) classical Welfare System (WS) typology we can find a confluence of criteria encompassing both the market and public sector relationships and the degree of redistribution through social policies. Combining these two dimensions he could differentiate between three well-know models of social policies: the residual model, the industrial achievement performance model, and the institutional-redistributive model. While the first one is determined by the market

dynamics and less redistributive, the second one is restrictive and conditioned by the worker 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 social rights and on the double movement of expanding state structures and policies on the one hand, and redistributing resources according necessities on the other hand. Marshall (1967) emphasizes the core role of citizenship in the welfare but follows 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 capacity for de-commodification, meaning the capacity to take social reproduction far away from the merchandise circulation. He understands the role of WS regarding social stratification 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 the other hand, social stratification is also an outcome of the WS, because social stratification is shaped by the nexus of state and market in the distribution system. He also underlines the importance of institutionalization when he analyses the consequences 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 the political and institutional mechanisms of interest representation and consensus building, especially in the social-democratic arrangement, have a strong impact on the employment 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 political allocation, centered on the institutional arrangements of social policies in each society. The starting point is considered to be the industrialization process (Rimlinger, 1971) and the emergence of the insecurity issue. The break of the traditional communitarian bonds of solidarity and their replacement with class organization and identities, as well as the development of civil service and state administrative structures, are considered as lying at the roots of the WS development. Wilenskys (1975:27) conclusion is that the WS is the most persistent structural tendency in the development of societies, in spite of ideological and political regimes, associated with the economic development and the social modernization process. Differently from this non-historical perspective, other authors have highlighted the determinants of the universal systems of social protection since the same demand for social protection has received different responses according to the previous institutional, political and economic environment. Flora and Alber (1981) identify the emergence of the universal model of social protection as dependent on the strength of a homogeneous working class in the fighting for social rights, as well as on the capacity of each society to institutionalize this conflict through democratic procedures. The WS and the competitive political party system are seen by Offe (1984) as the main features to promote the coexistence of capitalism and democracy in its virtuous cycle, since they transform the political competition in merchandise and the private economy in a political matter. However, in the end of this cycle both were regarded as inflexible obstacles for renewing the capitalist economy. In this sense, the WS was responsible for forging new bonds in complex societies and also for creating a new institutional pattern of redistributive conflict resolution, launching the basis for social cohesion and integration. The issue of social integration through WS protection is also the focus of Castels (1995) study on the fundamental bonds in a labor-based society.

The European bias in the WS literature lead to an unintentional conclusion that this experience would not be possible to be replicated in other contexts, where the previous signaled conditions were absents. Although the economic recent capitalist growth 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 protection system 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 and financial ones -- that could characterize three different patterns of social protection, namely social assistance, social insurance and social security. These patterns are quite similar 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 a very broad way, in order to go from the traditional ideological and political clusters to the identification of actuarial and managerial variables occurring close together. I found a strong relation between the political variable and the administrative and financial structure that are encompassed in the same pattern. Secondly, I established a connection between the social protection patterns and the citizenship status that results from it. This contribution adds a new element to how we think about the relationship between democracy and WS, far from the mere institutionalization of the social rights and competitive political parties. The point here is understand the consequences of each pattern of social protection in shaping different modalities of citizenship -- all of them compatible with democratic regimes, but dissimilar in terms of their capacity to create a more equalitarian public sphere. The different social protection models can be summarized as follows1: In the assistance model, emergency actions are directed to the most vulnerable groups of the poor, inspired by a charitable and re-educational perspective. They are organized based on association between voluntary work and public policies and are structured in a pulverized and discontinuous manner, thus generating organizations and programs that are often overlapped. Although they permit access to certain goods and services, they do not assure social rights, as they are compensatory measures that have a stigmatizing effect. For this reason, I call this type of relationship inverted citizenship, where the individual has to prove that he/she failed in the market in order to be object of social protection. In the social insurance model, the social protection of the occupational groups establishes a contractual rights relationship, where the benefits are dependent on past contributions and on the individuals affiliation to those occupational categories that are authorized to operate insurance. The highly fragmented organization of the insurance model expresses the conception of the benefits as different privileges for each category, as the result of their capacity to pressure the government. Since social rights are dependent on the insertion of individuals in the productive structure, Santos (1979) called the relationship, regulated by working conditions, a regulated citizenship. In the social security model there is an attempt to break with the notions of coverage restricted to sectors inserted in the formal market and to loosen the connection between contributions and benefits, thus generating more comprehensive and redistributive mechanisms. The benefits start being granted according to needs, based on the principle of social justice, which requires coverage to be extended universally and to be integrated in governmental structures. In this last case social protection generates social rights included in the status of a universal citizenship.

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 industrialization processes that imposed a new division-of-labor and led to more complex social relationships. The WS is also part of the state-building process, and this expansion is a component of the democratization of power and wealth in a mass society, with the emergence of new collective actors and political organizations. The WS is considered a new arrangement for consensus building and to convey conflicts to the redistributive arena, where they can have a negotiated solution. Different patterns of social protection were identified according to whether the main aim of inclusion was centered on the poor and other vulnerable groups, the labor fractions of the work force, or the citizens. The inclusion of social rights as part of the status of citizenship represented the most paradoxical solution for the distributive conflict in a class economy, since it had generated a public sphere not primarily subordinated to the process of accumulation, an anti-value mechanism (Oliveira, 1988). Nonetheless, it contributed to the creation of a more cohesive society, based on social principles of solidarity, in which social inclusion was widespread. However, during the crisis of the capitalist economy since the 70s, the institutional mechanisms of social protection were accused of impeding the renovation of 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 replacement of policies of inclusion by policies of insertion (Castel, 1995). All this symptoms are related 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 the WS. In this new context that is each day far apart the signed prerequisites for the success of the distributive policies of the WS, the point is whether it is sustainable or must be transmigrated to a new and more compatible arrangement in a less equalitarian and collectivist context. The possibility to analyze the intents to build up social protection in a region as Latin America can be useful, considering the secular prevalence of the highest levels of inequality, in spite of the influence of the European social ideals in these countries intelligentsias. The recent wave of democracy in Latin America put the social protection matter and the poverty reduction in public agenda, notwithstanding the legacy of authoritarian regimes and the overweight of the elite vested interests in the public arena. In a economic restrictive circumstance the dispute for scarce public resources adds more pressure to the challenge of developing social policies, either in Latin America and elsewhere. Comparative studies on social protection development in Latin America grouped the countries according to different criteria. Mesa-Lago (1978), studying the retirement and pension systems, adopts the timing of social policies emergence as the main explicative factor that permits grouping the countries in the region. According to the emergence of the social protection system, he categorizes them as the pioneers, the intermediate and the delayed countries. This timing line was responsible for differences in policy institutionalization and benefit plans as well as in the population coverage. Although he could find different timings in the process of social protection institutionalization, he outlines the common feature of stratification as the mark of the Latin-American social protection model. As a consequence, even the more inclusive old systems keep different conditions and benefits, according to the bargain power of each group covered.

Filgueira and Filgueira (2002) study, combining the amount of public social expenditure and the social indices in some countries, reaffirms Mesa-Lagoss conclusion on the Latin-American pattern of social benefits stratification, even in the almost universalistic systems in the region. What they stress is the variable combination of 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 the 70s, three different groups: a group of Stratified Universalism; a group of Dual System and a group of Excluding System. These results were important to highlight the limits of the path dependence analysis of the social protection models, even considering the importance of the maturation of them. Then, it is possible to lay stress on the political forces and the government orientation to counteract the structural determinants of their course. Nonetheless, the comparative studies of social protection in Latin American tend to reduce the importance of the political options, minimizing the important social indices achieved in countries like Uruguay, Costa Rica and Cuba, during the last century. The equalitarian results of public policies are considered either under suspicious or as impossible to be expanded to the big countries in the region. More recently, other authors have produced new analyses of social protection models in Latin America, considering the impact of the process of globalization and market-oriented reforms upon their earlier social protection system. Katzmans work (2002), reviewed by Filgueira and Luna (2009) try to answer the question about whether the countries historical legacy in terms of social structures and welfare regimes marks different paths and differential capacities to resist and adapt to this new context. The general conclusion, affirm Filgueira and Luna (2009:475) is that the welfare matrixes and their level of development were unable to counteract these deteriorating labor market through basic protection, investment and human capital, and redistribution, although the path dependency analysis seems to explain other points in their recent trajectories. Analyzing the proliferation of health care reforms in the region after the 70s, I observed that the fragile institutionalization of social rights and the explosion of massive urban demands are responsible for transforming the region in a social laboratory, where many different projects were designed and implemented (Fleury, 2001). These reform efforts in health care and in social security systems -- have been part of the changing context brought about by the democratization of the regions political systems, the updating of its economic productive models, and the redesigning of the states role. All of these have served as means to address the fiscal crisis and create the necessary conditions for positioning the regional economies more advantageously in the integrated and competitive global market. In this context, there has been a change in the political structure around social protection policies with traditional powerful actors like bureaucracy and trade unions losing control over the social security system. A new political arena was formed as a consequence of the introduction of market mechanisms in social policies, generating a complex web of relations among financiers and providers, public and private agencies. As a result of this changing process, I could find some reform models in the region, drawing special attention to the political coalition that supported the reform project. The first type is the market-oriented reform, based in the Chilean experience. Its design generated a dual model of health care and pensions systems, with the segregation of the poor in the public sector and the compulsory affiliation of those who can afford it in an insurance market company. The second type is the Colombian reform that tried to avoid the inequalities of the Chilean market-oriented model, through the combination of

both private and public resources thus shaping a pluralistic model based on managerial competition 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 individuals own contribution or through the collective contribution to a solidarity fund. In the last case, the package of benefits is lower than in the first, and the inclusion of the poor depends on the amount of resources yearly available. This complex network of public and private interests with different logics was unable to overcome the constraints of this design, based on the limited salary contribution and on a saving-oriented logic, proper to the insurance companies. The third model was based in the Brazilian experience of creating a public universal system of 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 or universal, according to their proposals, contents, instruments, public-private relations and supportive coalitions. A crucial variable to explain these differences is the timing of the reform with respect to two main macro processes: 1) the economic crisis with the ensuing 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 well as the material possibilities of each paradigmatic reform. Latin American societies are assuming a new profile, with a more pluralistic and comprehensive system of social protection. Instead of an outright denial of membership to some groups, there is a movement for stratifying the population in accordance with the purchasing power of each group. Nonetheless, the possibility of designing a universal system, as it was done in Brazil, goes in the opposite direction of this general trend. This singularity can only be explained based on the close relationship established between the political movements in favor of the countrys democratization on the one hand, and the strong demand for a new design of the social protection institutional framework on the other hand. All of this has occurred in a context of high social mobilization and lower perception of the economic constraints. However, they would immediately start to impose restrictive measures of economic adjustment to cope with high inflation rates and the public fiscal debt growth. It is worthwhile to observe the difficulties involved in the implementation of the Brazilian comprehensive WS model in such an adverse context. Brazilian Trajectory of Social Protection Brazilian social policies were developed over an 80-year period, creating a type of social protection model that was only changed with the Federal Constitution of 1988. Up to 1988, the Brazilian social protection system combined a model of social insurance, including pensions and health care for formal workers, with a precarious assistance model for the majority of the population, without formal labor ties. Both systems were organized and consolidated between the 1930s and 1940s, as part of the more general process of construction of the modern, interventionist and centralizing state, after the revolution of 1930. The construction of the nation state is a never-ending process, in which power relationships in the institutionalization of the administrative apparatus are constantly being drawn, whether it is direct to the implementation of the economic project, or to the reproduction of the workforce through the incorporation of the political demands of subordinate groups. The choice of a stratified social policy format, crystallized in the combination of distinct benefit packages for different

workers 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 social security 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 and is appointed to be one of the causes of the financial and administrative crisis in the social security system. The change in the social protection systems, policies and mechanisms after the bureaucratic-authoritarian regime that was installed in 1964 follows takes four master lines: 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 excluded groups such as domestic, rural and autonomous workers; 3) the creation of social contributions as a mechanism to fund social programs; 4) the privatization of social services (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 the center of the state itself, with a strong push towards reforms. At first, based on innovative experiences developed by the governments elected in 1974 by the opposition; secondly, by occupying strategic positions in central organs in order to take advantage of their financial crisis and to introduce transformative elements in the social policies model, and; in third by strengthening the technical capacities of political parties and parliaments in social matters. Rescuing the social debt became the central theme of the democracy agenda, gathering social movements of diverse natures. This process was intensified in the 1980s with the rise of a rich social fabric based on the union of the new syndicalism and the social urban movements, the construction of a new opposition party front, and the organization of several reformist movements. One of the most distinguished was the Sanitary Movement, a coalition of political actors that was capable of formulating a consistent project for the new health care system. There were some important political reasons in the roots of this democratic and statecraft strategies adopted by the leftists social movements in Brazil. The predominance of the Communist Party influence among the intelligentsia up to the 1970s was a fact. Its option for a democratic strategy to struggle the dictatorship regime was an important element to build cohesion around the democratic social mobilization. The introduction of the Gramsci concept of hegemony and the importance of its conquest in a more complex civil society has refreshed the Marxist conception of class struggle, leading the leftist groups to give priority to achieving strategic positions, in a piecemeal reforming process. The importance of the State in the Brazilian history was well known and highlighted by the most important sociological studies. However, the Poulantzas lessons on the state apparatus as the material translation of the political correlation of forces called the attention to understand the State further than the dominant pact. It became clear that the since the political struggle was not exterior to the state apparatus, it was necessary to understand its modus operand in order to occupy strategic positions in it and to conduct, both from outside and from within, a process of democratic state reform. Differently from other left wing parties and groups in Latin America, it must be recognized that the Brazilian opposition ones opted for taking the

risks inherent to this reformist strategy, what represented an appealing threat of being either co-opted by the political elites or legitimating an unsuccessful transformation. The fragile political party system did not impede that the social movements assumed the assignment of projecting new policies and public structures, under the flag of the universal citizens rights. In a society that is marked by its ancestral and profound inequality the defense of equalitarian policies represented a counter-hegemonic banner for the democratic project. The previous experience of expressive economic growth without redistribution contributed to the learning that the mere presence of the State or even its leadership in conducting the development was insufficient to assure the prevalence of the public interests. The building up of a democratic and inclusive nation was assumed by the civil society organizations as their commitment in the public policies transformation. All this democratic effervescence was channeled to the National Constituent Assembly whose works began in 1987. The construction of a democratic institutional order supposed a rearrangement of social policies in response to societys demands for greater social inclusion and equality. Projected for the social policies system as a whole, this demand for 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 to the 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 legal formulations by guaranteeing a set of social rights, expressed in innovative Social Order Chapter, which includes education, environment, culture, sports, minorities, communication, Science and technology, and the Social Security structure. This Social Security arrangement was recognized as the Brazilian WS inner core. It was defined as an integrated set of initiatives by the Public Powers and society, destined to ensure rights related to health, social security and social assistance (Title VIII, Chapter II, Section I, art. 194). Therefore, the inclusion of social insurance, health care and social assistance as parts of Social Security introduces the notion of universal social rights as part of the condition of citizenship. This new arrangement innovated in separating, for the first time, the social order from the economic one, which gives to the former the same status and priorities usually given to the economic principles. The primacy given to social rights became evident with this autonomy and with the prescription of exclusive contributions for funding social policies. They should be joined in a unique social security budget, created apart from the fiscal national budget. These resources would be managed by the Social Security Council, integrated by the three ministries and representatives of the users. The new constitutional social policy model is characterized by the universality of coverage, the recognition of social rights, and the affirmation of the duty of the state, the subordination of private practices to regulation based on the public relevance of actions and services in these areas, with a new public arrangement of a decentralized public network cooperatively managed by participatory mechanisms. The originality of Brazilian Social Security lies in its strong State reform component, in redrawing the relationships between the three levels of federal entities consensus building. The reshaped federalism addresses the main responsibility in the delivery of social policies to the local authority. The organization of the social protection systems should adopt the format of a decentralized, integrated network, with

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 representatives in each sphere of administration.

From Rhetoric to Reality During the 90s Brazil has experienced a hard period of economic crisis with hyperinflation and a great amount of debt accumulation, having to launch many different policies and instrument to cope with this stressing situation, but that only started to succeed after the middle of the decade. At the same time, the government had to deal with the social pressure to implement the important transformations requested in the new Constitutional frame. In other words, there were two concurrent movements going in opposite directions: one expressed by the macro economic adjustment measures and the other by demands for assuring social rights and institutionalizing the new WS design. As many of the constitutional prescriptions required a new infra-constitutional legal frame, the government postponed at the most its approval, up to the point where it could not ignore social pressures anymore. As the political supporters of social rights greatly varied in each sector social insurance, health care and social welfare according to their coalition political power and capacities, each of the social security parts had a different institutional path. Nonetheless, they had to face the same context and restrictions, thus enabling an analysis of the general trends as well as requiring the identification of their specificities. Considering the reviewed literature regarding the WS development in Europe, one can affirm that the creation of the Brazilian WS at the end of the 20th century does not fulfill the critical conditions pointed out as required for it. This challenge stresses the importance of studying this experience, pointing out its limitations but also its innovations. This analysis will focus on two themes related to WS accomplishment: the economic constraints and the institutional statecraft process. The strength of supporters of the universal social protection system, crystallized in the Social Security paradigm, was based in the fact that, differently from all other countries in the region, this reform proposal was designed by social movements. Although clustered around specific social policies they were articulated in the general mobilization for transition to democracy. Based on the Sanitary Reform, I pointed out the three components of this process as part of building up the democratic state. The construction and materialization of the reform project takes place through three processes which, although simultaneous, have distinct rhythms -- differences that generate new tensions and some complementarities. The processes are: subjectivation, constitutionalization and institutionalization. Subjectivation relates to the construction of political subjects, constitutionalization deals with guaranteeing social rights, and institutionalization is responsible for building the institutional apparatus including the knowledge and practices that implement health policy (Fleury, 2009). The coalition formed to support the Sanitary Reform has changed throughout its institutionalization varying from the original academic and professional hegemony to the local managers and union workers predominance. The component of permanently refreshing the political subject has been crucial to keep the strength of this project, based on the same original principles. Concerning the other social policies one can also

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observe efforts to join forces and construct political actors, either before or as a consequence of the policy institutionalization. The union of retired workers was decisive in defending the comprehensive benefits plan and also to avoid the intents to privatize social insurance. Lately, the political presence of social insurance fiscal attorneys gathered in their important association ANFIP - became the key factor in the diffusion of alternative information about the financial situation of the SS system. In the case of social assistance, the formation of a critical mass of powerful civil service in the central government is the more recent product of this policy institutionalization. The fragmentation of this process into three different trajectories confirms the lack, from the beginning, of a unified movement in defense of the general Social Security construction. This important concept was developed during the works of the National Constituent Assembly, but was short of roots in social movements. It had a technical 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 this proposal 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 a product 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 Constitution states the creation of the SS Budget managed by the SS Council. These two mechanisms of planning and integrating policies did not work properly, from the beginning. The budget became only a formal accounting instrument instead of a common integrated plan of resource allocation. Moreover, the government introduced some mechanisms to retain 20% of this budget to assure the payment of the public debt interests. The National SS Council was called off in 1999, after some years of ineffective coordination and integration of the three sectors. Each of them had a different institutional trajectory, clearly path dependent on their previous history and formal legacy. Sposati (2009: 176) highlights the diversity among the three sectors according to different variables, such as: the criteria of inclusion; the nature of the rights labor, social and human -; the relation with the market and philanthropy; the management experience and its degree of institutionalization in all governmental levels. One can also add the important difference of the social coalition formed around each politic arena with a clearly discretion to veto or to introduce new policies. The institutional fragmentation inside SS had many consequences. The abandonment of the integration principle compromises the other constitutional principles of integrality and universalism. Recent results from a survey with the beneficiaries of non-contributive pensions demonstrated that they use the increase in family revenue to buy more food and also medicine (Lobato, 2007). Its a clear example of the disintegration of social policies, with the government targeting the poor and continuously transferring cash benefits to people who use them to acquire goods and services that should be part of their social rights. The existence of distributive conflicts among the SS sectors and the incapacity of the established mechanisms to coordinate a consensus building process had a strong impact on the statecraft of the Unified Health System (SUS). In 1993 the health care services of the social insurance were transferred to Health Ministry in order to create the SUS, but the resources to fund them did not come along. Although 30% of the SS Budget should be assigned to Health Ministry during the first five years after the CF 88, this legal prescription was ignored. As a consequence, the Health Ministry bankrupted

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which lead it to take loans for covering regular expenses (Santos, 2008). The demand for 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, the resources were allocated by the national government to other expenses, and only 1/3 was assigned to the Health Ministry, until this tax was extinct in 2009. Since the year 2000 a new Constitutional Amendment (EC. 29) defines the responsibilities of each level of government to fund the health care system, but the national duties are still vague. The result is that the relative participation of national government in funding the health sector is decreasing, while the state level ignores their mandatory contribution and the burden is directed to the local authorities. In 1980 the participation of each government level in the public social expenditure was 65% for the national, 23.6% for the estates and 10.6% for the municipalities, while in 2005 the national level decreased its participation to 61.9%, the states to 21.8% and the municipalities participation rose to 16.3% (IPEA, 2009). Since the municipalities are responsible for health care delivery, the strain is on their shoulders. Pressure is put on local governments either by the participatory mechanisms, denunciations of the mass media or, more recently, through judicial decisions that guarantee the right to the consumption of some expensive health services and merchandises. One can analyze that the sanitary movement was strong enough to keep the original design of the SUS as a public universal and integral system, but could not avoid the growth of a powerful market inside the health care field. From the beginning the interactions of both public and private services existed, but it was organized in two different types: those private facilities that sell services to the SUS, called complementary, and the others that only sell services in the marked, named supplementary. Differently from the complementary sector that encloses private services linked to the SUS as providers of public goods, the business of health insurance and health services was considered as substitute for the SUS. With the financial crisis of the public health sector there was a deterioration of the public facilities, followed by the contention of wages and investments. The inclusion of the whole population as beneficiary of the public health sector was accomplished, despite its extremely difficult financial situation. This contradiction led the middle class to escape from the public system by contracting private insurances either voluntarily or mostly trough corporations. Although the coverage of the business insurance does not go beyond 30% of the population, all the pressure groups, like trade unions, push towards this market solution, and more popular plans were launched recently to attend the lower middle class demand. The national government itself gives a private insurance affiliation to the civil servants and considers the expenses of consumers with pensions and health insurances as tax deductible. All this policies strengthen the health care market and contribute to debilitating the public sector. During the last two decades, the position of the business health sector changed from a total opposition to a closer and profitable relation to the SUS. As a powerful pressure group, the private insurance sector resists strict regulation and tries to control the managers board of the regulatory agency. They are also benefited by the possibilities of sending the privately insured people to get public treatment in the SUS, and use legal instruments to escape the duty of reimbursing their expenses. Their allegation to do so is that the public health attention is a citizens right. Many other flows of patients, financial resources, professionals, and technologies were developed in the last two decades linking in different ways public and private services.

12

Powerful interests groups are now involved in a complex arena that encompasses the 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 procedure rates, for broadening tax exemptions, for reserving part of public facilities for private patients, and for more credit and amnesty for private establishments and providers -- are channelized to these arenas, reshaping the SUSs original design. The proposal of a public national health system was the most radical decommodification project in the Brazilian social policies design in the democracy. Nonetheless, the previous dependence on private health care facilities, established since the military government, concurred to invalidate this proposal. The public sector, despite being underfunded, is nevertheless responsible for the preventive care and surveillance for all and delivers services for more than 70% of the population (achieving 90% in the poorest regions). All the pools in the last years indicated that the users of the public 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 media exposition, are responsible for an unambiguous popular preference for the private insurance 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 with prosperity as a sign of ascendant social mobility. There is no doubt that the most impressive impact of the social policies design after the Constitution of 1988 was in the reshaping of the state apparatus and its relations with society. The creation of the SUS was followed by a similar system for social assistance policies - SUAS, based on the same principles of assuring social rights through a public national network with different and articulated levels of government. Although the stimulus for decentralizing was top-down, it provided a guideline in the direction of strengthening local governance by increasing local administrative skills. Furthermore, the design of the decentralization process included original elements, namely the existence of participatory mechanism in each administrative level. In this sense it requires a twofold movement, from the central administrative level to the local levels and from the state to the society. The intersection of these two lines gives place to a new model of local governance, with the existence of important mechanisms of consensus building, social control and policy formation (see diagram in annex I). The main mechanism for decision making and consensus building among the three levels of government with concurrent competences concerning social policies is the Tri-Partite or Bi-Partite Commissions, encompassing, respectively the three or two governmental levels. This innovation is being considered a major advance in the federalism design in the country, since there was not an effective channel to deal with the inherent conflicts concerning concurrent competences in many subjects. The existence of this arena permits negotiating the policies and pacting the establishment of norms and parameters for resources allocation. The participatory mechanisms that include both health authorities and population are two: the Councils and the Conferences. The Councils exist in each level of the system and are mechanisms of social control and budget approval, evaluating executive proposals and performance. The Conferences, on the other hand, are called periodically to discuss a set of subjects in order to convey different interests to a common platform and form the polity. Many experts discuss whether the Councils effectively have capacity to control the government, and the conclusion is less clear-cut than one might desire, due to the great diversity inside the country and the unequal distribution of resources among the participants. Studies proved that participation in the Councils is a

13

resource to insert the councilor in important power networks and also an arena to challenge the control by organized groups, like the political parties and unions members (Crtes, 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 public sphere, so far restrict to the traditional elite. The construction of some dialogic mechanisms imposes the recognition of popular actors and demands, and might permit a renovation of the political elites. The development of the WS was ever related to the changes from a liberal capitalism to a neo-corporatist form of relations among collective actors under the state regulation. The singularity of late developing societies like Brazil is the composition of the civil society, where the few trade unions have to share the participatory space with social movements and other civil organizations. Besides the heterogeneous composition of civil society, another peculiarity is related to the introduction of mechanisms of participatory democracy. While in a traditional political conception participation is limited to the electoral process and redistributive policies, in the Brazilian case a great emphasis is given to the construction of co-management instances, where state and society contribute to the policy-making process and the monitoring of policy implementation. Far from a deliberative democracy where the decisions are mandatory, even though there is an empowering process in progress as part of this statecraft blueprint. The institutionalization of the social assistance policies starting from the Constitution of 1988 represented a turning point in this field, since it was the first time that this kind of protection and services were considered as part of the social rights. The construction of a new and compatible institution was not a straightforward process. Initially, there was a clear governmental refusal to materialize this constitutional prescription and to create the SUAS Unified Social Assistance System, in the same participatory and decentralized basis of the health system. Only after strong pressure from civil society and professional organizations the government passed in 1993 the social assistance law (LOAS), the first step in the institutionalization process. But during this first decade and even afterwards the public agenda concerning social assistance has changed from the constitutional universal system with rights guarantee to a target model to fight poverty. The constitutional model is represented by its most important program, namely the Continuous Cash Benefits (BPC - Benefcio de Prestao Continuada), which covers the elderly or handicapped persons in poverty. The target model is represented by the Family Grant Program (Bolsa Famlia), which offers conditional cash transfer to the poorest families. For Lobato (2009:722) the permanence of these hybrids is deemed to jeopardize the fairness and the citizenship model proposed in the 1988 Constitution. While the BPC is a legal right, the Family Grant is a discretionary benefit. The assigned duality has a peak expressed by the existence of two Ministries for social assistance matters during a short period after being unified. The priority given to the target model goes beyond this double organization, because it also involves the debate about the role of the state in social protection. During the 90s the predominance of the position in favor of the minimum state assigned the implementation of the conditional transfers program to the NGO partners. The priority to fight poverty through cash transfer benefits was well established since then, although the role of the state in leading this program was only strengthened in recent years. This permitted to move forward in the institutionalization process either in the central or in the local levels, and the SUAS left its former characteristic of being a copy of the SUS. It was truly developed in a peculiar blueprint, completely matching the needs of its proper field.

14

In spite of the convergence in social assistance policies, some differences still persist, 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 revenue under of the minimum wage, for the Family Grant it is under minimum wages per capita. Other important difference between the two lines of social assistance programs is the fact that some benefits are automatically conceded as part of the citizenship conditions while others are submitted to conditional requirements. Whereas the former are institutionalized as citizens rights, the latter are associated to governments 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, the existence 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 a universal 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 in 1995 to R$ 312 billion in 2005, a rise of 74% in 11 years. However the social expenditure performance varies in an ambivalent way among the social policies. In this period, while the social insurance expenditure grew from 44% to 51% and social assistance had an augmentation of 1% to 6%, the health participation diminished from 16% to 11% and education was reduced from 8% to 6% (Castro, 2009:111). This data reveals that the universal policies, health care and education have not been the main concern of governments in the last years. Poverty reduction and social insurance were the priorities. The impact of social protection on poverty reduction is one of the most outstanding results of the social policies, associated with the economic growth and the recovery of the minimum wages purchase-power. These recent phenomenon have provoked the enlargement of the middle class with the upward mobility of millions of families from the lowest strata to the middle class (while the lowest stratum E had a reduction of 45.50% from 2003-2009 and the D was reduced in 11,63%, the middle strata C and B increased by 34,32% and 38,51% respectively (Neri, 2010). The diagram of the income distribution can demonstrate this change in a period of five years, calling the Brazil as the country of the C class.

15

2005

2010

Classe AB 42.195.056 Classe AB 26.421.172 Classe C 62.702.248 Classe DE 92.936.688 Classe DE 47.945.964

Classe C 101.651.003

Fonte: Folha de So Paulo, 24/03/2011. Brasil o novo Pas da classe C

This result on income distribution trough the synergic combination of distributive policies and economic growth is stupendous, and the consolidation of the prevalence of a middle class is not only a product of the democracy, but a central requirement for its sustainability. Even though this kind of distribution only considers income, ignoring the profound disparities in other basic assets among the Brazilian population, it is impossible to ignore its impact in this society. Nevertheless, the possibility to include the emergent class into the universal systems of social protection will be the great challenge to the institutionalization of the WS in Brazil from now on. If the country fails to do so, we can expect less poverty but a persistently unequal society.

Conclusion The construction of the WS in Brazil since the Federal Constitution of 1988 represents a unique experience in three different aspects: first, because it represented a movement to universalize social rights through a comprehensive public social security system -- encompassing social insurance, health and social assistance policies -- at a time when the sustainability of the WS was questioned worldwide; second, because the WS institutional building-up process had to cope with several restrictive political and economic constraints that resulted in a different arrangement regarding the constitutional blueprint; third, because, as it was designed by social movements and political actors, this system operated a transformation in the administrative processes and structures, innovating with the creation of democratic participatory mechanisms. This proposal represents a rupture with the previous social protection institutional framework that followed the Latin American pattern of combining the stratified inclusion of formal workers with a great degree of social exclusion for the others. Besides this institutional and political heritage, the economic and political context did not contribute to the success of this experience, since the prerequisites for a successful WS development pointed out by the literature were absent. The analysis of this reforming process was based on the identification of three inherent components and their dynamics: the process of subjectivation, with the

16

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 the correspondent structures and mechanisms. In this paper special attention is given to the latter process and its associations and oppositions to the other two. The stresses and contradictions occurred in the institutionalization of the WS were visible in the inobservance of many constitutional prescriptions concerning the Social Security framework and also in the transformations of its fund arrangement and budget management. Besides, the legacy of a corporative social protection model was capable of keeping the social insurance as the dominant policy, reserving the bulk of the funds for the less egalitarian policy. The different legacies of the three social security branches in terms of knowledge and capacities, degree of institutionalization, political supporters, governmental priorities, and relations with private sector were determinants of the path followed by each one. The advances in the institutionalization of the constitutional model could be observed in several aspects of the three policies, as the introduction of non-contributive pensions for rural workers, the cash transferring programs to fight poverty, the expansion of health system in the small municipalities. The most expressive transformations 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 constitutional guidelines open up space for the progressive introduction of other interests and structures in the original design, reshaping in practical terms the WS proposal. The result is a hybrid design with hidden mechanisms that progressively introduced new flows and articulation between public and private sectors in the social policies field. Instead of a rupture with the constitutional SS design, we can observe its piecemeal transformation in order to give rise to a combination of a public system with universal social rights coverage and a hidden mix of this proposal with a flourishing associated market of goods and services. As a result, we can find rights without benefits (in case of non access) and benefits without rights (in cash transfer programs). The important outcomes of the social policy investments are appearing in the ascendant mobility process in course nowadays. This phenomenon is also consequence of the recent economic growth phase. Paradoxically, the emergence of better contextual conditions to implement the WS original design is occurring in a moment where the institutionalization process has taken another route, in some aspects far away from the constitutional principles. The inclusion of the new lower middle class into the market is responsible for the popularity of Lulas government across contradictory span of the political actors spectrum. However, the widening of the inclusion of the poorest populations through target policies is not enough to promote their inclusion in the public sphere assuring the citizen status. Without this social and political inclusion through social rights and redistributive policies capable of assuring better living conditions for the population, it will be impossible to reduce urban violence and other symptom of cohesion lack. It requires, as in other countries of the region, the challenge of transforming the rights-in-principles into rights-in-practice (FOWERAKER and LANDMAN, 1997:19). The quality of the public universal social protections system of health care and education will be the next challenge for WS consolidation. But it will require a big change in the governmental priorities, assigning financial resources and implementing performance-oriented management in order to achieve better quality standards. Although the economic constraints persist, they were slightly reduced in this new

17

scenario, but the political restriction worsened with the clustering of many powerful vested 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 to injustices 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 economic restrictions to face fiscal debt is now a menace to the sustainability of their traditional social protection policies. It is time to develop a theory of the WS less Eurocentric and more capable to cope with the new challenges. A decolonized analysis of the Latin American experiences can be valuable to identify the identity of some constraints as well as the disparities in the degree of social rights institutionalization and also in the civil society mobilization. These identities and differentials could permit design distinguished political scenarios for the reshaping the WS. Bibliography

Castel, Robert (1995). Les Mtamorphses de la Question Sociale. Paris: Gallimard. Castro, Jorge (2009). Poltica Social: Alguns Aspectos Relevantes para Discusso, in Brasil, MDSCF (Ministrio do Desenvolvimento Social e Combate Fome), Concepo e Gesto da Proteo no Contributiva no Brasil. Braslia: UNESCO, pp. 87-132. Crtez, Soraya (2009). Conselhos e Conferncias de Sade: Papel Institucional e Mudana nas Relaes entre Estado e Sociedade, in Sonia Fleury, Lenaura Lobato (eds.), Participao, Democracia e Sade. Rio de Janeiro: Cebes, pp.102-28. Costa, Nilson R. (2009). Social Protection in Brazil: Universalism and Targeting in FHC and Lula Administrations in Cincia & Sade Coletiva, 14(3): 693-706 Comentys by Pereira, Carlos, pp. 714-715. Esping-Andersern, Gosta (1990). The Three Worlds of Welfare Capitalism. Princeton: Cambridge Polity Press. Esping-Andersen, Gosta (1995). O Futuro do Welfare State na Nova Ordem Mundial, Lua Nova Revista de Cultura e Poltica 35: 73-112. Fagnani, Eduardo (2008). Os Profetas do Caos e o Debate Recente sobre a Seguridade Social no Brasil, in Eduardo Fagnani, Wilms Henrique e Clemente Ganz Lucio (eds), Debates Contemporneos Previdncia Social e do Trabalho. So Paulo: Unicamp, CESIT, LTR Editorial, pp. 31-43. Fagnani, Eduardo (2009). Tension Between Paradigms: Notes on Social Policy in Brazil (1988-2008), Cincia & Sade Coletiva, 14(3): 710-12. Filgueira, Carlos e Filgueira, Fernando (2002). Notas sobre Poltica Social em Amrica, INDES, BID, Washington. Mimeo. Filgueira, Fernando and Luna, Juan Pablo (2009). Societies, Social Policies and Political Representation: A Latin American Perspective, International Political Science Review, 5: 471-85. Fleury, Sonia (1994). Estado sem Cidados: Seguridade Social na Amrica Latina. Rio de Janeiro: Fiocruz Editora. Fleury, Sonia (2001). Dual, Universal or Plural? Health Care Models and Issues in Latin America: Chile, Brazil and Colombia in Carlos Molina and Jose Nuez del Arco (eds), Health Services in Latin America and Asia. Washington DC: InterAmerican Development Bank, pp 3-36.

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Fleury, Sonia (2009). Brazilian Sanitary Reform: Dilemmas between the Instituing and the Institutionalized, Cincia & Sade Coletiva, 14(3): 743-52. Flora, Peter and Alber, Jens. (1981). Modernization, Democratization, and the Development 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 Econmica Aplicada) (2005). Radar Social. Braslia: IPEA. IPEA (2009). Receita Pblica: Quem paga e como se gasta no Brasil, Comunicado da Presidncia. Brasil: 30 Junho. Katzman, Rubn and Wormald, Guillermo (eds) (2002). Trabajo y Ciudadana: Los Cambiantes Rostros de la Integracin y Exclusin Social en Cuatro reas Metropolitanas de Amrica Latina. Montevideo: Ford Foundation y Universidad Catlica de Uruguay. Lobato, Lenaura et all (2007). Avaliao do Benefcio de Prestao Continuada, in Jeni Vaitsman e Romulo Paes e Souza (orgs), Avaliao de Polticas e Programas do MDS Resultados, Volume 2. Braslia: MDS/SAGI, pp. 257-84. Lobato, Lenaura (2009). Dilemmas of the Institutionalization of Social Policies in Twenty Years of the Brazilian Constitution of 1988, Cincia & Sade Coletiva, 14 (3): 721-30. Marshall, Thomas H. (1967). Cidadania, Classe Social e Status. Rio de Janeiro: Zahar Editores. Mesa-Lago, Carmelo (1978). Social Security in Latin America: Pressure Groups, Stratification and Inequality. Pittsburg: University of Pittsburg. Neri, Marcelo Crtes (coord.) (2010). The New Middle Class in Brazil: The Bright Side of the Poor. Rio de Janeiro: FGV/IBRE, CPS. OECD (2011) Growing Income Inequality in OECD Countries: What Drives it and How Can Policy Tackle it? OECD Forum on Tackling Inequality, Paris, 2 May, 2011 Offe, Claus (1984). A Democracia Partidria Competitiva e o Welfare State Keynesiano: Fatores de Estabilidade e Desorganizao in Claus Offe, Problemas Estruturais do Estado Capitalista. Rio de Janeiro: Biblioteca Tempo Universitrio, pp. 356-85. Oliveira, Francisco (1988). O Surgimento do Antivalor, Novos Estudos CEBRAP 22: 9-28. Rimlinger, G. (1971). Welfare Policy and Industrialization in Europe, America and Russia. New York: John Wiley and Sons, Inc. Salvador, Evilsio (2008). Questo Tributria e Seguridade Social in Eduardo Fagnani, Wilms Henrique e Clemente Ganz Lucio (eds), Debates Contemporneos Previdncia Social e do Trabalho. So Paulo: Unicamp, CESIT, LTR Editorial, pp. 387-402. Santos, Nelson R. (2008). Vinte Anos do SUS: Por Onde Manters Chamas da Utopia? in Bruno Dantas at alli, Os Cidados na Carta Cidad, Vol V. Braslia: Senado Federal, pp146-68. Santos, Wanderley G. (1979). Cidadania e Justia. Rio de Janeiro: Editora Campus. Schwarzer, Helmult (2009). Previdncia Social: Reflexes e Desafios. Braslia: Ministrio da Previdncia social.

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Sposati, Aldaza (2009). Seguridade Social e Incluso: Bases Institucionais e Financeiras da Assistncia Social no Brasil in Lenaura Lobato e Sonia Fleury (orgs.), Seguridade Social, Cidadania e Sade. 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.

ANNEX I

20

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% Government 50% Society Policy Formation Mechanism

Federal (elected)

Ministry

- Central Fund - National Policies and Programs - Target Programs Human resources Health care centers and Hospitals Financial resources

National Health Council

National Health Conference

States (elected) 26 + 1 DF

State Secretary

- State Fund - Regional System Coordination - Reference Services

State Health Council

State Health Conference

Tri-partisan Commission

Bi-partisan Commission

Municipalities (elected) 5.507

Municipal Secretary

- Municipal Funds - Municipal System Coordination Management of Delivery Network

Levels of Autonomy A Management of the Local Health Care System B Management of the Primary Health Care Program

Municipal Health Conference Municipal Health Council

Consortium

21