Participatory health councils and good governance: healthy democracy in Brazil?

Abstract

IntroductionThe Brazilian Government created Participatory Health Councils (PHCs) to allow citizen participation in the public health policy process. PHCs are advisory bodies that operate at all levels of government and that bring together different societal groups to monitor Brazil’s health system. Today they are present in 98% of Brazilian cities, demonstrating their popularity and thus their potential to help ensure that health policies are in line with citizen preferences. Despite their expansive reach, their real impact on health policies and health outcomes for citizens is uncertain. We thus ask the following question: Do PHCs offer meaningful opportunities for open participation and influence in the public health policy process?MethodsThirty-eight semi-structured interviews with health council members were conducted. Data from these interviews were analyzed using a qualitative interpretive content analysis approach. A quantitative analysis of PHC data from the Sistema de Acompanhamento dos Conselhos de Saude (SIACS) database was also conducted to corroborate findings from the interviews.ResultsWe learned that PHCs fall short in many of the categories of good governance.Government manipulation of the agenda and leadership of the PHCs, delays in the implementation of PHC decision making, a lack of training of council members on relevant technical issues, the largely narrow interests of council members, the lack of transparency and monitoring guidelines, a lack of government support, and a lack of inclusiveness are a few examples that highlight why PHCs are not as effective as they could be.ConclusionsAlthough PHCs are intended to be inclusive and participatory, in practice they seem to have little impact on the health policymaking process in Brazil. PHCs will only be able to fulfil their mandate when we see good governance largely present. This will require a rethinking of their governance structures, processes, membership, and oversight. If change is resisted, the PHCs will remain largely limited to a good idea in theory that is disappointing in practice.

Primary health care and sustainable development goals

“… 48 Despite the existence of participatory health councils in 99% (1972/2000) of all Brazilian cities, there still exists a lack of full citizen and community empowerment in health policy decision-making. 49 , 50…”

Community Engagement in Support of Moving Toward Universal Health Coverage

“…In the long term, when community engagement mechanisms do not promote the ability to make and implement decisions, this creates frustration that undermines participation; paradoxically, the ability of community engagement to hold existing government structures to account requires the support from those very same structures. 64 The second power balance issue lies within communities and societies. Although participatory mechanisms are supposed to provide a voice for marginalized groups, success in achieving equitable outcomes depends on power distribution, level of participant motivation, and presence of facilitating groups.…”

Public participation in health. A review of reviews

“…Los consejos de salud, u órganos similares de participación, se han venido utilizando como canales formales de participación en muy diversos países y continentes, pero se ha puesto en duda su utilidad 4,12 . La evaluación de estos consejos es coincidente al señalar que en todos los países estudiados, los gobiernos y sus estructuras sanitarias no han sido diligentes en el apoyo a estas estructuras de participación, se han centrado en temas poco controvertidos, no han sido transparentes en su sus mecanismos de actuación y han tenido escasa influencia en las decisiones adoptadas, siendo su papel consultivo 21,[44][45][46] . Además, en muchos países se ha comprobado que solo han participado representantes de ciertos grupos de la sociedad civil 21,46 .…”