Movement-Driven Development
The Politics of Health and Democracy in Brazil
Christopher L. Gibson

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Subnational Democratization of Health

After returning to democracy and codifying a universal citizenship right to health in the mid-1980s, Brazil witnessed nothing short of a historic transformation in its public health institutions and social development outcomes. During the quarter century following the exit of its military dictatorship from national power, Brazil’s largest capital cities recorded an impressive 70% reduction in infant mortality, an achievement that ranks among the most extensive improvements of any large democracy in the Global South.1 This book argues that the transformation emerged from a locally rooted process of movement-driven development (MDD) in which Brazilian civil-society activists helped to both enshrine the country’s universal right to health and reform institutions of the local state in ways that made that right more than just a grandiose, constitutional promise. To do so, these actors weakened an entrenched legacy of patronage-based health-service institutions left behind by the country’s erstwhile military dictatorship and its subnational allies, who maintained a formidable presence in local government well after the regime’s departure. Ultimately, such efforts rendered municipal governments more responsive to citizens, enhanced the capacities of local states to programmatically deliver basic forms of public health care, and dramatically improved social development outcomes such as infant and child mortality rates.

While this transformation echoes a growing consensus that the very notion of development entails society-wide growth in basic human capabilities,2 it also highlights how little is known about the kinds of civil society–state relations that can foster such holistic outcomes in democracies of the Global South. In Brazil, for instance, while marked improvements in infant and child mortality rates clearly reflect expansions in access to basic public health care and a general deepening of democratic accountability, less consensus exists about the specific ways in which elected politicians and civil-society actors have collaborated to maximize growth in such social development outcomes. Complicating matters is the fact that Brazil’s 1988 codification of a constitutional right to health left municipal governments within the country’s federalist system of multilevel governance with weighty responsibilities to deliver many of the basic public services on which that lofty promise relies. Among other consequences, even Brazil’s largest and most important cities varied considerably in the extent of developmental progress they achieved over time. This book aims to explain how and why Brazil experienced such an extraordinary, if subnationally uneven, pattern of social development, despite a recent history of rampant infant mortality and an ignominious reputation as the worldwide champion of inequality.

The study argues that, even amid such adverse conditions, practically minded civil-society actors whom I call “pragmatist publics” have propelled Brazil’s developmental strides by making subnational public health agencies more responsive to historically excluded citizens. As Brazil emerged from beneath the shadow of a twenty-one-year military dictatorship, the country’s most important public health movement—the Sanitarist Movement (Movimento Sanitário)—established an important set of civil-society institutions that became pivotal in their continuing efforts to reform the public health state. Mobilizations by movement activists and veterans with ties to a changing public health profession—known in Brazil as sanitaristas—played an outsized role in codifying the new right to health, establishing a new public health system known as the Unified Health System (Sistema Único de Saúde, SUS), and founding the new democratic office of the SUS director on all three levels of government. While existing accounts of Brazil’s social development transformation note the movement’s earlier influence in establishing a right to health and the SUS,3 they generally attribute later improvements to factors other than ongoing sanitarista control of local democratic offices that emerged alongside the SUS.4 Yet sanitaristas in many major cities leveraged SUS directorships to advance a highly consequential state-building project that significantly expanded the capacities of municipalities to deliver basic public health services. By successfully demanding subnational SUS directorships with key managerial responsibilities for realizing Brazil’s right to health—and by occupying those new offices with remarkable consistency in many cities—sanitaristas helped deepen the practical abilities of local governments to more fully enact that right over time. Ultimately, this quarter century of activism had major implications for social development outcomes throughout the country’s largest cities.

More specifically, sanitaristas managed to occupy local SUS directorships to varying extents across urban Brazil, and this variation contributed to uneven degrees of subsequent institutional change and social development in the country’s largest cities. Part of encompassing historical pathways of democratization in Brazil’s public health sector, consistent subnational office holding by sanitaristas maximized the growth of local public health states with capacities to deliver basic public health care in a programmatic and widespread fashion. Across urban Brazil, cities generally witnessed three distinct trajectories of health democratization that differed according to how fully the local public health sector became accountable to various civil-society actors and institutions. First, through a “participatory-programmatic” trajectory of health democratization in major capitals such as Belo Horizonte, Porto Alegre, and Recife, sanitaristas consistently held key offices atop the subnational public health state, where they capitalized on inconsistently ruling right parties, supportive left-party mayors, and influential popular movements to advocate, design, and execute maximal degrees of municipal state-building for basic health care provision. This pattern led to the construction of state structures that maximized the programmatic delivery of basic public health services and generally remained open to limited oversight of the sector by everyday citizens in participatory democratic institutions such as municipal health councils (CMSs) and Participatory Budgeting (OP).

Second, through a “programmatic” trajectory of health democratization in capitals such as Curitiba and Fortaleza, sanitaristas consistently held key offices atop the subnational public health state, where they capitalized on inconsistently ruling right parties and acquiescent center-party mayors to similarly maximize service-delivery capacities in the primary health sector. Although such cities generally lacked the more deeply democratic monitoring of the sector in the cases just mentioned, office-holding sanitaristas never the less mobilized even centrist mayors with few ideological convictions to build roughly similar state capacities for widely and programmatically delivering basic forms of public health care. Finally, amid consistent right-party rule and a continued, dictatorship-era pattern of patronage politics, a “minimalist” trajectory of health democratization in Salvador and Rio de Janeiro saw traditional politicians obstruct sanitaristas from frequently occupying SUS directorships, effectively preventing their state-building ambitions from becoming material realities. This pattern led to a relatively incapacitated local state that lacked the ability to programmatically and widely deliver basic public health services as well as sustained participatory democratic oversight of the sector.

These three trajectories of democratization in the public health sector—participatory-programmatic, programmatic, and minimalist—also help to explain the “robust” or “nonrobust” development outcomes that major capital cities had achieved by the end of the period. The concept of a robust development outcome describes the experience of cities, whose degree of change in development between 1988 and 2014 exceeded what initial development levels at the beginning of the period would have otherwise predicted. Thus, while all cities experienced improvements in development indicators such as infant and child mortality, cities with robust development experienced unexpectedly high degrees of change over time. In all major capitals, these development trajectories reflected both sanitarista efforts to enact a constitutional right to health through local state-building and significant reactions to those efforts from other civil-society and political-society actors. And while national political actors and dynamics conditioned these local politics in nontrivial ways, the variable influence of local sanitaristas and their allies in the face of such reactions helped produce subnationally uneven local state capacities to improve human capabilities across urban Brazil. More specifically, while the outcome of robust development can be traced to both a participatory-programmatic trajectory in Porto Alegre, Belo Horizonte, and Recife and a programmatic trajectory in Curitiba and Fortaleza, the contrasting outcome of nonrobust development in Rio de Janeiro and Salvador emerged from a minimalist trajectory that more clearly echoed Brazil’s nondemocratic past. Thus, subnational variations in post-1988 patterns of health democratization help account for major contrasts between the contemporary records of social development achieved throughout Brazil’s largest capital cities.

1. Why Study Growth in Public Health and Social Development?

Deeper understandings of Brazil’s social development transformation are critical for scholars, policy makers, and citizens interested in understanding the origins of society-wide human well-being and how civil society and democratic governments can foster it over time. Because Brazil witnessed one of the Global South’s largest improvements in society-wide health outcomes during recent decades, it presents a theoretical opportunity for explaining a pattern of contemporary social progress that has been both unusual and not fully explored.5 The project’s findings thus offer insights for those interested in the human condition and how it can improve over time as well as for social scientists of inclusive social and health policies, their origins, and their ultimate effects on society-wide health. The book’s analysis of subnational cases in Brazil also addresses larger questions about how societies struggling with ingrained inequality and exclusion can overcome patterns of political domination that may otherwise undermine social development and delivery of basic public services.

Few observers anticipated Brazil’s impressive developmental strides, which initially drew little interest in an English-language literature on public health and health policy, welfare, and social development that has long emphasized countries of the Global North. Indeed, early analyses of the first decade following Brazil’s return to democracy cast the country as a case of largely failed efforts at health care reform (Weyland 1998). Such accounts at first seemed to confirm the diagnosis of Brazil as a country suffering dire and path-dependent institutional and developmental consequences of Portuguese mercantilist colonialism.6 In addressing years leading up to and including the three decades following Brazil’s restoration of formal democracy, however, this book’s argument about MDD departs from the expectations of such frameworks, which struggle to fully account for Brazil’s twenty-first-century strides in social development. Although subnationally uneven colonial legacies clearly persist across the country,7 Brazil witnessed marked progress in social development within capital cities of its northeast region such as Fortaleza and Recife, which bear particularly deep scars of colonialism. Thus, explanations are still needed for how and why basic health care provision and social development outcomes improved in such cities despite their longstanding histories of political clientelism and exclusion of most citizens from access to many public services.

Explaining such surprising outcomes also matters for humanistic reasons, because growth in society-wide well-being denotes improvement in what Amartya Sen calls the capability of all people to pursue lives they have good reasons to value (1999). Social scientists of development in the Global South have long been preoccupied with explaining economic dimensions of development using indicators such as GDP per capita that are not always or necessarily tied to society-wide improvements in human welfare. The outcomes examined in this book, however, unambiguously capture expansion in this notion of development as freedom. Declining infant and child mortality rates are clear indicators of what Sen understands to be the master capability of avoiding premature death. Further, the broadening of rights-based access to even basic forms of health care similarly captures the expanded freedom of all individuals seeking to prevent and treat illnesses that would otherwise impede their ability to live lives of their own choosing. Thus, scholars and policy makers of Brazil, Latin America, and the Global South more generally all stand to benefit from understanding the conditions under which such capabilities have improved so dramatically in recent decades. This book offers one such account that places these social development outcomes front and center and examines the conditions under which they have improved the most over time.

Assessing the subnationally uneven growth of such outcomes also sharpens our inferences about what maximizes improvements in public health and social development. Unlike much of the research on health care reform and welfare state programs in advanced industrial democracies of the Global North, work on social and health policies that target low-income populations in the Global South has not often embraced how the local level on which such policies are implemented constitutes a theoretically and analytically important unit on which to appraise their efficacy. Although states and especially municipalities play the leading role in financing and delivering primary health services in multilevel systems of democratic governance such as Brazil’s, research on such interventions has tended to treat them homogenously as ones that emanate downward from the national level via wavelike processes of diffusion in which particular qualities of subnational units have little relevance.8 Such approaches may conceal both significant local variations in public health and development outcomes as well as potential clues about what has caused such deviations. They may also miss an opportunity to forge deeper understandings of the subnational conditions under which the municipalities that hold chief responsibility for enacting a nationwide right to health can maximize the provision of public services that bring such lofty promises closer to material fruition. Knowing the diverse ways that municipalities attempt to ensure such rights to even basic forms of health care, how effective these interventions have been in improving actual health outcomes, and why and how some major capital cities have devised more effective ways of delivering such services than others is all fundamental for illuminating the politics of rights-based social policies and their human consequences. Subnational analysis is also particularly well suited to answering broader questions about government effectiveness in democratic settings and the conditions under which social movements with a nationwide presence can best advance such efforts locally. This book contributes to such pursuits.

Additionally, improved access to health care and social development in Brazil has important implications for our understanding of democratic politics and its local rhythms. The country’s expansion of rights-based provision of basic public health care shows how local states have forged stronger ties of accountability to sizable majorities of the citizenry that were previously excluded from accessing such services. And beyond just these improved patterns of access to services, new public responsibilities of SUS managers arose alongside participatory democratic institutions such as municipal health councils (CMSs) that assumed comanagement authorities for the health sector and opened new spaces for citizens to express their voices and participate in health-policy-making. For any country in the Global South, much less one emerging from beneath the shadow of a decades-long military dictatorship, such transformations not only represent impressive policy accomplishments but also show that history need not become fate. Still, this remarkable trajectory of progressive social change points to key unanswered questions about their origins. What kinds of state-society configurations can maximize social development outcomes such as access to public health services and the reduction of premature death? What, if any, forms of civil-society mobilization are most likely to have concrete consequences for health-policy enactment and social development expansion?

2. Alternative Explanations

Existing scholarship offers several plausible, alternative explanations for Brazil’s social development transformation in recent decades. Although theoretical frameworks of state-directed development, power constellations, and policy diffusion all emphasize political-society and state actors to a greater extent than does this book’s explanation of MDD, such alternative explanations contribute much to the understanding of Brazilian development and cannot be dismissed out of hand. This study argues, however, that such existing accounts offer, at best, an incomplete basis for explaining changes in development and institutions throughout contemporary, urban Brazil, in part because fuller understandings of civil-society agency are needed to assess whether and how they can inform such processes.

Before individually addressing alternative explanations, two salient points about this study’s theorized explanation of MDD merit emphasis here. First, the study focuses on a meso-level of generality that highlights major capital cities as especially relevant political units of analysis within the vast and heterogeneous geography, population, and society that is contemporary Brazil. Serving as important hubs within major cities that comprise approximately one-third of Brazil’s more than 210 million people, these large capitals constitute a sizable and substantively relevant sample of comparable units in a country in which 86% of residents live in urban areas.9 As such, this approach complements both macrolevel studies that usefully cast Brazil in a cross-national light but risk homogenizing its internally heterogeneous subnational politics and society as well as microlevel studies that illuminate relevant processes within one or a few subnational cases but struggle to speak capably about Brazil as a whole. The former approach risks compromising internal validity by systematically overlooking Brazil’s internally diverse record of development and institutional change, reifying the country’s heterogeneous local politics, masking subnational drivers of its recent progress, and correspondingly misidentifying sources of these recent shifts. The latter approach provides compelling explanations for one or a few cities or states, but it provides an inadequate basis for generalizing about the country as a whole. By contrast, this study rejects efforts to assess the entire country based on one or a few similar cases of cities or states, and it eschews both single case-studies of cities or states that struggle to inform the understanding of countrywide dynamics and national-level studies that—especially in a country of continental size such as Brazil, with many and diverse sub national units—can suffer from “whole-nation bias” (Snyder 2001). Second, the study rejects both voluntarist and overly structural accounts that prove similarly incomplete for explaining institutional change and development in contemporary, urban Brazil. It instead seeks to reconcile historically focused arguments about the path-dependent legacies of prior eras alongside alternative theoretical perspectives and growing empirical evidence about the nontrivial roles of civil-society actors in profoundly transforming Brazilian society more recently. In doing so, the study not only rejects voluntarist approaches that risk romanticizing and exaggerating the agency of political- and civil-society actors but also aims to rethink the nature of political agency in a context for which scholars have offered path-dependent explanations emphasizing structural reproduction of institutions created during distant historical periods. Although these longer-term structural impediments figure into the analysis that follows, they will be framed within a larger context alongside more recent civil-society agents who have mediated these distant historical influences in nontrivial ways.

2.1. STATE-DIRECTED DEVELOPMENT AND ECONOMIC GROWTH

Crystallized through impressive studies by brilliant scholars such as Atul Kohli and Lant Pritchett, expectations drawn from the distinct “state-directed development” and “wealthier is healthier” paradigms similarly struggle to explain Brazil’s social development improvements. Although not crafted to explain social development outcomes per se, state-directed development theories emphasize the cohesive state structures that (typically authoritarian) political leaders constructed to promote twentieth-century economic development (Kohli 2004). The technical capacities of such state structures to execute the goals of political leaders at their apex have sometimes been linked with surprising reductions in infant mortality rates (IMR) such as those facilitated by decidedly illiberal dictators like Chile’s Augusto Pinochet (McGuire 2010). Nevertheless, this framework’s focus on illiberal rulers as drivers of change offers little insight into Brazil’s social development transformations, which instead arose from a more democratic mode of state-society relations that originated amid the departure of its dictatorship. Indeed, sanitarista visions of an equal and universal citizenship right to health were anathema to a military regime (1964–1985) that had solidified a patronage-fueled health sector that systematically excluded the vast majority of the country’s population from access to basic health services. Also molded by an earlier era of generally illiberal, corporatist rule by President Getúlio Vargas (1930–1945, 1951–1954), the health sector reflected Brazil’s larger, Bismarckian social-policy regime, which replicated such exclusion in most other public-service sectors. Even as Brazil returned to democracy in the 1980s, the legacies of these eras lingered in the form of traditional subnational politicians, who typically hesitated to establish new state institutions for free public provision of basic public services such as primary health care. In sum, where sanitaristas and other progressive actors managed to construct new state capacities to deliver such care as a citizenship right to health, they typically did so despite the locally ruling patronage politicians and conservative economic forces that marked Brazil’s illiberal era of state-led development.

Scholars have also argued for the beneficial effects that economic growth can have on social development indicators such as IMR. As the “wealthier is healthier” hypothesis goes,10 the improvement of average household income during the period that I examine should have improved the access of poor Brazilians to better nutrition, health care, running water, sewage, sanitation, and other established vectors of IMR reduction. Nevertheless, the unequal distribution and timing of that economic growth makes this hypothesis considerably less persuasive for the Brazilian context. Scholars have suggested that Brazil’s impressive social development strides since democratization are not attributable to economic growth alone, which was tepid during and immediately before the 1985 to 2002 period in which IMR improved the most.11 And because a consistently high IMR during Brazil’s dictatorship coincided with a period of considerable economic growth, it is difficult to argue that industrialization or per capita growth in GDP can account for social development outcomes during that earlier period or the contemporary one examined in this book. Further, the statistical analysis presented in chapter 3 finds no strong, statistically significant effect of per capita income on IMR levels in Brazil’s largest capitals. This raises the question of how much the benefits of economic growth extended to poorer segments of the population, which remained exposed to disproportionately high epidemiological risks that exacerbate childhood mortality. At a minimum, this study offers no evidence that urban social development is exclusively traceable to economic growth.

2.2. POLICY DIFFUSION, NETWORKS, BUREAUCRATS, AND PROFESSIONALS

The study’s account of MDD describes a mechanism of institutional change that also contrasts with those articulated by policy diffusion accounts and other approaches that similarly de-emphasize the solidary underpinnings and outward civil orientations of Brazil’s sanitaristas. In conventional diffusion frameworks, outcomes like those examined in this study are posited to emerge from a wavelike spread of generally homogeneous “policy models” throughout units that share certain features. For example, Natasha Borges Sugiyama (2012) cogently argues that the presence of a local sanitarista network in a given city accounts for governments’ adoption of Brazil’s flagship primary public-health-care program, the Family Health Program (PSF). Nevertheless, the diffusion frameworks underlying such analyses have been persuasively criticized for overlooking the reactivity, adaptation, and reinvention that typically occurs in the interplay between somewhat malleable policy templates and the heterogeneous political units that seek to enact place-specific variants of them (Chorev 2012). The application of such a framework to the Brazilian public health sector is further confounded by evidence suggesting that local-actor configurations have transformed and adapted developmentally beneficial programs like the PSF to operate differently in different municipal contexts and have supplemented them with other platforms for primary public-health-care delivery.12 In addition to other theoretical limitations addressed in chapter 2, the framework offers little analytic leverage for explaining subnational variation across the sample of all major Brazilian capitals examined by this study because all of these cities featured sanitarista networks but only some experienced maximal degrees of institutional change and development.

To more fully account for considerable variation in local institutional change and development across a sample of major cities that exhibits no substantial variation in the mere presence of a sanitarista network, this project pursues another approach that instead examines the conditions under which such actors can matter for similar outcomes. Results suggest that it is not merely the presence of sanitaristas in a local context, or just their intra-institutional mobilizations within national politics, but their consistent office holding atop the subnational public health state that maximized institutional change and social development outcomes. Further, such outcomes are not attributable to any mechanistic adoption or downward dissemination of nationally formulated policies throughout the variable, subnational political contexts that constitute Brazil’s highly decentralized federalist democracy. Instead, it was these actors’ occupations of local state offices that maximally transformed local state institutions and constructed the otherwise missing local state capacities required to reformulate and adapt those programs to best fit local, heterogeneous circumstances.

2.3. POWER CONSTELLATIONS

The book’s argument about MDD also addresses explanatory limitations of the power constellations framework, which posits that enduring experiences of democracy and nationally ruling left parties can lead to crystallization of redistributive social policy in the Global South.13 The framework struggles to explain how in Brazil’s relatively young democracy, the centrist presidential administration of President Fernando Henrique Cardoso introduced health programs such as the PSF well before national rule by more left-leaning PT members. The theory of MDD better fits Brazil’s experience by highlighting how pragmatist publics helped create this program as well as a preexisting architecture of subnational democratic offices that built the local state capacities needed to maximize the program’s reach and effectiveness. Indeed, the case studies in this book show how sanitaristas sometimes mobilized the support of centrist subnational executives who were otherwise uninterested in such programs. In doing so, they also created essential capacities of the local state for enacting nationwide CCT programs such as Bolsa Família (BF), which are sometimes credited as a sole product of nationally left-leaning political parties. By building local infrastructure such as basic health clinics and by meritocratically hiring the staff needed to maximally expand the PSF, these activists have also indirectly facilitated expansion of BF, which typically depends on the PSF to deliver the basic health services that its beneficiaries must access in order to meet the program’s conditionalities. Thus, although left-leaning executives in national politics can and have introduced CCTs, the notion of MDD complements power constellations frameworks by showing that the ability of such programs to operate effectively has depended in part on pragmatist publics to help build the very local state capacities on which CCTs rely. Indeed, pragmatist publics have often mobilized such support of political society in the first place, both among left-leaning executives and a wider ideological spectrum of subnational executives.

3. Movement-Driven Development (MDD) and Pragmatist Publics

In answering how and why, after decades of underperformance, social development grew so much and so unevenly throughout contemporary urban Brazil, this study’s MDD framework stresses how particular kinds of civil-society actors can propel the democratic state-building needed to realize ideologies of universal and equal rights. Across the country’s largest capital cities, maximal gains in social development outcomes occurred when such activists more consistently occupied and leveraged new democratic offices in ways that transformed the ideology of a universal and equal citizenship right to health into material capacities of the subnational public health state to programmatically deliver basic public services. Although MDD entailed disruption of prior monopolies on local power by clientelist parties of the far right, it also featured activists who created new democratic offices atop the local public health state and wielded them to build stronger capacities for practically advancing a citizenship right to health. Epitomized by Brazil’s sanitaristas and conceptualized more deeply in this book, pragmatist publics construct and wield civil-society institutions such as democratic offices to advance their solidary projects, and they adopt a self-consciously Gramscian (2000) approach to occupying trenches of the state, where they combine Deweyan (2012) approaches to public problem-solving with the use of what I call social code-switching to mobilize politicians’ support for subtle material expressions of their universalistic ideologies. When local democracies exhibit these two conditions—both an infrequency of monopolistic control over the subnational executive by clientelist parties of the far right and pragmatist publics’ consistent occupation of democratic offices that oversee public-service bureaucracies—they are more likely to maximize social development improvements over time.

While such dynamics of MDD thus build on a foundation of formal democracy, they revolve around pragmatist publics that not only transform universalistic ideologies into constitutional and legal responsibilities of states but also establish and control new democratic offices with direct lines of accountability for enacting those responsibilities through state-building. The framework therefore proposes that Brazil’s development transformation emerged from far more than just nationwide qualities of democratization such as the restoration of competitive elections. Related, nationwide processes—especially the legal codification of a state responsibility for enacting Brazil’s citizenship right to health and the tasking of a new SUS director’s office with the authority for doing so (Federal Republic of Brazil 1990a, 1990b)—would all have been unlikely without sustained advocacy by Sanitarist Movement activists. Furthermore, by occupying and wielding municipal and state offices of the SUS director, sanitarista advocacy on the subnational level helped to materially advance otherwise abstract constitutional principles of equity and universality. Yet these efforts were more successful in some major cities than in others, and such unevenness had major practical consequences for access to basic forms of health care and for health outcomes more generally. Particularly consequential was how consistently activists held and leveraged the SUS directorship to expand three key state capacities: meritocratically recruited and well-trained public health workers, primary public health clinics, and tools for systematically targeting both workers and clinics to city regions whose residents faced the direst threats of premature death. Where they more consistently held such offices over time, sanitaristas generally maximized provision of primary public health care to previously excluded groups and disproportionately improved social development outcomes such as infant and child mortality rates. The historical evolution of sanitarista agency thus epitomizes how pragmatist publics can meaningfully contribute to overarching processes of democratization and social development.

MDD in urban Brazil unfolded over time through three distinct pathways of health democratization, whose locally variable incarnations had major implications for social development outcomes. In negative cases of nonrobust social development such as Salvador and Rio de Janeiro, a “minimalist” variant of health democratization was insufficient to maximize improvements in public-health-care delivery and IMR reduction because pragmatist publics failed to overcome local clientelist elites’ insulation of the subnational public health state from reform pressures. In all positive cases of robust development, by contrast, pragmatist publics animated one of two “programmatic” variants of health democratization in which they more consistently wielded those offices to reform state health agencies and hold them more accountable to their public mandates and responsibilities as guarantors of a universal right to health. Ultimately, this programmatic pattern of health democratization maximized public-service-oriented state-building, actual delivery of primary public health care, and growth in social development over time. In positive cases such as Belo Horizonte, Porto Alegre, and Recife, this pattern coincided with a distinct “participatory” dimension of health democratization that yielded more inclusive venues in which everyday citizens could monitor the local public health state, but these cities’ robust development outcomes are better explained by state-building processes that are instead traceable to the programmatic dimension of health democratization. Other positive cases of robust growth in social development such as Curitiba and Fortaleza—where subnational public health states were transformed by a programmatic dimension of health democratization despite a relative absence of the participatory dimension witnessed in Belo Horizonte, Porto Alegre, and Recife—reinforce this point by showing that even a nonparticipatory trajectory of health democratization was sufficient for maximizing social development progress across contemporary urban Brazil if office-holding sanitaristas were able to impart that path with a programmatic orientation to state-building.

Thus, beyond just mobilizing extra-institutionally to codify their universalistic ideologies into constitutions, laws, and policies, Brazil’s sanitaristas exemplify how pragmatist publics also establish and occupy democratic offices accountable for enacting those commitments. After their watershed victories in codifying a constitutional right to health, for example, sanitaristas continued mobilizing for nearly three decades to transform this vision of a citizenship right to health into tangible practices of Brazil’s local public health state. An underappreciated dimension of this process was how sanitaristas created and then occupied the new subnational democratic office of the SUS director in major capital cities across the country. The mere creation of the office concentrated sanitaristas’ powers to expand the subnational public health state, which considerably influenced nationwide development outcomes as municipal governments became responsible for ensuring access to the most basic public health services. Sanitaristas also mounted subsequent campaigns to occupy and wield the subnational office of SUS manager across urban Brazil. Although their success in doing so varied across cities and drew on their reputations in wide-ranging professions of public health and medicine as well as their practical skills in statecraft, it also depended on a subtler but similarly decisive factor: their identities as civil-society activists and social-movement veterans. During the thirty years following Brazil’s return to democracy, the way that sanitaristas embedded their universalizing, equity-focused visions of a right to health within public-service institutions of the subnational state depended on these movement lineages more than existing accounts allow for. As such, they exemplify how pragmatist publics can leverage their civil-society identities and associations to cultivate society-wide solidarities around universalizing notions of the public good. Yet a deeper conceptualization of these actors is necessary to grasp the mechanisms through which they can influence the state-society politics of public health and social development.

Notes

1. Author’s calculations using data from the Brazilian Statistics and Geographic Institute (IBGE), downloaded from http://ibge.gov.br/. Last accessed June 2013.

2. Sen’s Development as Freedom (1999, 14–15) offers the definitive statement of this notion of development as the freedom of all people to pursue the lives they have good reasons to value—something that is impossible without infant survival.

3. See Escorel (2008), Falleti (2010b), and Paim (2007).

4. For instance, although the careful analysis of Touchton, Borges Sugiyama, and Wampler (2017) suggests that participatory institutions, social policies, and state capacity interact with one another to improve well-being, it stops short of assessing whether civil-society occupation of new democratic offices has driven IMR reduction.

5. See Borges Sugiyama (2012), McGuire (2010), and Garay (2016) for exceptions.

6. See especially Lange (2009) and Mahoney (2010, 242–52).

7. See, for example, Bailey (2009) and Telles and Paschel (2014, 867).

8. See, for example, Weyland (2009).

9. Author’s calculations using data from IBGE, at http://ibge.gov.br/. Last accessed June 2013.

10. See especially Pritchett and Summers (1996) and Filmer and Pritchett (2001).

11. McGuire (2010, 151–52) persuasively makes this point.

12. Escorel, Giovanella, and Magalhães de Mendonça (2009) compellingly show how the very notion of the PSF as a policy model is unsettled by local actors’ considerable restructuring of the program to fit local contexts.

13. See especially Huber and Stephens (2012), Levitsky and Roberts (2011), and Pribble (2013) for applications to Latin America.