- Movement-Driven Development: The Politics of Health and Democracy in Brazil by Christopher L. Gibson
By Christopher L. Gibson
Stanford, CA: Stanford University Press. 2019. 328 Pages. https://www.sup.org/books/title/?id=28778
There is increased scholarly attention towards understanding the development of social policies and welfare-regimes in the Global South. Theoretical models derived from the experiences of advanced, industrialized economies often have limited applicability for resource-poor or industrializing countries, many of whom have witnessed dual and, often times, contradictory demands in recent decades: electoral democracy along with various citizenship rights has become the norm, while the rise of a globalized economy predicated on neoliberal arrangements often constrain resources and options available for states to implement programs necessary to uphold these rights. These contradictory pressures is especially salient in the area of health. Most constitutions throughout the world include a right to health, yet the basis for a healthy life, including both the social conditions and healthcare services, often replicate entrenched domestic inequities.
How then do we understand broad-based improvements to health when they occur? Path dependency models offer the dismal view that the benefits of economic growth, often predicated on historic factors, gradually trickles down to the rest of the population but fail to explain how and why some places see improvements in health beyond normal economic growth. Democratic compared to authoritarian regimes appear associated with better health indicators, yet even here results are not homogenous nor automatic. Some have argued that the presence of left-wing parties or more women in power are solely responsible for the roll-out of social and health programs. All these potential explanations fail to explain why some places have made rapid progress in recent decades but not others.
Gibson, using large Brazilian municipalities as his unit of analysis, provides a compelling reason for such diverse outcomes. Brazil is an interesting case to study because its 1988 constitution includes a right to health and national laws decentralized the process of implementing a national health system. Furthermore, some large cities like Fortaleza, in the historically underdeveloped northeast region, achieved more dramatic decreases in infant mortality than other better cities with far greater resources like Rio de Janeiro. Contrary to other theoretical models, Gibson argues is that civil society actors known as sanitaristas (i.e., public health activists) engaged in "movement-driven development" to create the necessary legal framework, government organizations and offices, and programmatic actions that lead to tangible health improvements.
The presence of these public health activists alone does not explain why some cities made greater improvements compared to others, since sanitarista activism is present throughout the country. Instead, these health reformers must consistently occupy high-level managerial positions in local (and state-level) public health systems while rightwing parties remain absent from power. Consequently, Gibson identifies three possible trajectories. First, the "participatory-programmatic" path achieved health democratization through sanitarista office holding backed by leftwing parties in power combined with thick democratic institutions like local health councils and participatory budgeting practices. Next, the "programmatic" trajectory also realized significant health gains and coverages, not through leftwing and participatory politics, but when sanitaristas convinced centrist politicians about the importance of expanding basic health services. Lastly, the "minimalist" path characterized cities where conservative politicians blocked sanitaristas from occupying government positions where they could expand primary care services.
Gibson backs his argument using an impressive mixed-models approach. Regression analysis demonstrated that sanitarista office holding is strongly correlated with improvements in infant mortality rates and expansion of primary care provision compared to ruling party ideology, women's political representation, participatory budgeting, and conditional cash transfer programs. Next, a fuzzy-set analysis of eleven Brazilian capitals with over one million residents provides a causal connection between sanitaristas in managerial positions and the exclusion of traditionally conservative right-wing parties from power as necessary conditions for reducing infant mortality rates than what should be expected. Lastly, with-in case studies based on interviews and archival research demonstrate the "participatory-programmatic" (Belo Horizonte and Porto Alegre) and the "programmatic" (Curitiba and Fortaleza) trajectories devised by these public health reformers...