weyland, kurt - the politics of health reform in brazil

8/12/2019 WEYLAND, KURT - the Politics of Health Reform in Brazil

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PergamonWorld Developmenr, Vol. 23, No. 10, pp. 1699-1712, 1995Elsevier Science LtdPrinted in Great Britain

Social Movements and the State: The Politics ofHealth Reform in BrazilKURT WEYLAND

Vanderbilt University, Nashville, Tennessee, U.S.A.

Summary. - This paper shows how institutional factors shape the strategy and condition the success ofa social movement. In Brazils new democracy, a movement of health professionals tried to reform themedical system, which failed to provide adequate health care to the poor. Pervasive clientelism, however,prevented the movement from gaining firm mass support in society. Movement leaders therefore soughttop positions inside the state to launch equity-enhancing reform. Yet this state-centered strategy exposedthem to severe institutional obstacles, especially bureaucratic politics with its divisive impact, and stub-born opposition from clientelist networks. As a result, the movement achieved few improvements.

1. INTRODUCTIONHow much impact on public policy making do

social movements in Latin Americas new democra-cies have? What are their strategies and channels ofinfluence? In order to address these questions, the fol-lowing case study analyzes the movement for healthreform in post-authoritarian Brazil. This movementmade an ambitious effort to revamp the countrys sys-tem of medical service provision in order to satisfythe unfulfilled health needs of vast numbers of poorcitizens. Why did this effort achieve rather littlesuccess?

The wide variety of theories on social movementsin the First World (Cohen, 1985; Tarrow, 1989;Wasmuht, 1989) offers little guidance because itfocuses more on the factors explaining the emergenceof social movements than on the conditions for theirsuccess. Rarely . . have movement scholars soughtto assess how effective movements are in achievingtheir ends (McAdam, McCarthy and Zald, 1988, p.727; also Tarrow, 1989, p. 71). This is particularlytrue of identity-oriented approaches (Cohen, 1985,pp. 691-705; see Alvarez and Escobar, 1992, pp.318-319).

Even the approaches most interested in the policyimpact of social movements, all of which are variantsof resource mobilization theory (Cohen, 1985, pp.674-690; Tilly, 1978, chapters 3-4), emphasize soci-etal factors and pay scant attention to the state.Scholarship informed by this theory assumes, forexample, that social movements seek allies amongpolitical parties and other movements in society, notinside the state. They depict social movements asparts of society that confront or pressure the state

from outside (Gamson, 1990; Piven and Cloward,1979; Cohen, 1985, p. 665; Tarrow, 1989, chapter 5).

Given the centrality of the state in Latin America,theories on social movements in the region necessar-ily focus more on the state. Since these movementsmust rely on the state to improve public services andsatisfy the needs of the poor, they have to establishcontacts to public agencies to advance their proposals.In order to expand their own turf, some state agen-cies even become allies of social movements(Cardoso, 1988, pp. 370-374; Jacobi, 1989, pp.100-111; Boschi, 1987, chapters 2, 7). Reflectingthese practices, the literature on social movements inLatin America has paid considerable attention to thestate. With some exceptions,* however, theorists stillsee the state and social movements as separate. Intheir view, the impetus for positive change emerges insociety, not inside the state. The state is the object ofmovements pressure, not the protagonist of reform(Eckstein, 1989; Kowarick and Bonduki, 1988;Krischke, 1987; Slater, 1985; 1994).

2. THE MAIN ARGUMENTI argue that such a society-centered approach does

not provide an adequate understanding of the efforts

* 1 would like to thank Wendy Hunter and two anonymousreviewers for many helpful suggestions, and the ocialScience Research Council as well as the UniversityResearch Council of Vanderbilt University for generousfinancial support for my field research. Final revisionaccepted: May 7, 1995.


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1700 WORLD DEVELOPMENT

of Brazils health reform movement to affect publicpolicy. Members of this social movement penetratedthe state itself in order to launch reform projects.State officials recruited from social movements thusbecame major protagonists of attempts to satisfy theunfulfilled needs of popular sectors. In this way,movement leaders tried to compensate for the diffi-culty of gaining firm, wide-ranging support in societythat could serve as a base for attaining their goals. Yetthis state-centered strategy also had limitations andrisks, such as involving the movement into bureau-cratic politics and clientelist machinations. As aresult of these problems, the movement in fact failedto shape public policy and to achieve most of itsgoals.

In order to account for this choice of a state-cen-tered strategy and for its rather limited success, thisarticle advances an institutional constraint argument.Applying insights of sociological institutionalism(March and Olsen, 1989), it points to formal andinformal institutional patterns that have restricted thehealth reform movements chances for resourcemobilization and skewed its political opportunitystructure in unfavorable ways. Organizational obsta-cles have limited the influence the movement couldgain in Brazilian society and inside the state.

Specifically, pervasive clientelism has envelopedmany of the poor and disadvantaged. This has rein-forced the inherent difficulty of mobilizing them forcollective action and prevented them from providingpowerful support for health reform. Unable to gain amass base in society, leaders of the health reformmovement occupied positions inside the publicbureaucracy from which they could launch their pro-gressive efforts. But this shift from a society-centeredto a state-centered strategy exposed the movement tonew institutional obstacles.

First, members of the movement gained posts indifferent public agencies. They soon absorbed theseagencies organizational interests and were drawninto the rampant bureaucratic politics that ravages theBrazilian state. The resulting conflicts weakened themovement and limited its success. Second, the effortsof movement members to enact programmaticreforms jeopardized clientelist politicians use of theestablished health care system for purposes of pohti-cal patronage. If the poor had their needs fulfilledthrough equity-enhancing reform, they would be lessdependent on favors granted by patrons in exchangefor political support. Reform that provided benefits asa matter of universal right thus posed a deep threat tothe electoral sustenance of many powerful politicians.Therefore, clientelist politicians in the governmentand in Congress soon offered strong resistance toequity-enhancing change and pressed for the dis-missal of members of the health reform movementfrom the public bureaucracy. By undermining themovements state-centered strategy in this way, clien-

telist politicians posed the most important obstacle tohealth reform.

Thus, social movements in Latin Amenca may endup between a rock and a hard place. While perva-sive clientelism reduces the promise of a society-cen-tered strategy, a state-centered strategy also facesenormous difficulties, stemming from bureaucraticpolitics and clientelist machinations. As a result,social movements may have limited impact on publicpolicy.3

The institutional constraints 1 emphasize createstrong obstacles, but not absolute impediments tosocial movements efforts to influence policy.Clientelism, for instance, makes reform unlikely, butdoes not block it invariably. Committed political lead-ers who concentrate a high level of authority can con-trol clientelism (Tendler and Freedheim, 1994) oreven use it to effect change (Grit-idle, 1977). But sucha concentration of power is rare in Latin America; itprevails only in institutionalized authoritarian sys-tems such as Mexico (Grindle, 1977), or on a limited,regional scale, as in the Brazilian state of Ceara(Tendler and Freedheim, 1994). On a national scale,and under democracy, which provides the most propi-tious setting for social movements efforts to influ-ence public policy, political authority is dispersed inLatin America, and a multitude of clientelist networkscompete for power. Under these conditions, reformprojects are drawn into the rivalries among clientelistnetworks. Since none of these networks manages toprevail, innovative projects are commonly obstructed.Thus, while my institutional constraint argument isprobabilistic, not deterministic, exceptions are rare.

With this institutionahst argument, I complementexplanations pointing to resistance from the socioeco-nomic forces that would bear the cost of equity-enhancing change (Teixeira, 1988). The privatemedical sector, in particular, defended the establishedhealth system, but it did not succeed in blockingreform on its own. Opposition from private hospitalsand doctors was not decisive, especially when theconflict broadened in scope (Schattschneider, 1975,chapter 1) and electoral politicians came to seeequity-enhancing change as a threat to their politicalsurvival. These politicians strongly resisted healthreform in order to defend their control over patronage.Clientelist networks -crucial informal institutions inBrazilian politics - thus posed more formidableobstacles to change than class forces. While socioeco-nomic factors certainly matter, institutional structuresare indispensable for explaining the dearth of equity-enhancing reform in Brazils new democracy.

This article substantiates the institutional con-straint argument through an in-depth examination ofthe Brazilian case. It analyzes the emergence of thecountrys health reform movement (section 3), itsunsuccessful efforts to mobilize mass support in soci-ety - obstructed especially by clientelism - (section


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SOCIAL MOVEMENTS AND THE STATE 1701

4 and its consequent shift to a state-centered strategy(section 5). Section 6 shows how members of thehealth reform movement occupied top state postsunder the new democracy and launched somereforms, but also became ensnared in bureaucraticpolitics. Section 7 analyzes how the movement soughtallies, especially inside the state. Section 8 explainswhy its major reform initiative ran into widespreadopposition, particularly from clientelist politicians.As section 9 demonstrates, the movement succeededin including progressive principles in Brazils newconstitution, but it failed to have many of these man-dates translated into specific legal norms (section 10).Based on the meager results of these reform efforts,the conclusion emphasizes the strength of the institu-tional obstacles which social movements in Brazilsdemocracy face.3. THE EMERGENCE OF BRAZILS HEALTH

REFORM MOVEMENTBrazils health reform movement arose in the mid-

197Os, reacting to the highly unequal health care sys-tem which the military regime (1964-85) hadinstalled. This inequality rested on the uneven natureof the countrys socioeconomic development.Conservative modernization, reinforced by theauthoritarian governments, concentrated the benefitsof rapid growth disproportionately in the middle andupper class of urban centers in Brazils Southeast.While poorer people gained in absolute terms, theyfell behind in relative terms. Sharpening income con-centration was reflected in a health system that pro-vided fairly good, sophisticated services to the middleclass, but neglected basic care for the disadvantaged.

The structure of Brazils health care model exacer-bated this inequality. It provided mainly curative ser-vices for the sick and neglected preventive measuresdesigned to keep people from falling ill in the firstplace. The military regime stimulated the rapidgrowth of the private health sector, which specializedin curative medicine. Considering public agenciesinefficient, the government contracted more and moremedical services from the private sector (Braga andPaula, 1986; Oliveira and Teixeria, 1986, part II).This privatization reinforced inequality. Followingdemand (rather than need), the private sector main-tained facilities disportionally in middle-class neigh-borhoods of urban centers. This concentration limitedeffective access to health care for the urban poor andmost of the rural population (MPAS, 1975;Rodrigues, 1987). Contracts with the private sectoralso led to much fraud and waste of public resources.They gave private hospitals and practitioners irre-sistible incentives to perform unnecessary treatments- or even to charge for treatments never performed(Mello, 1977, pp. 121-209).

Narrow rules of entitlement further aggravatedinequality by excluding large portions of the popula-tion from adequate health care. Most medical serviceswere provided by the social security system, whichcovered mainly workers and employees in the formalsector of the economy. Since the mass of the urbanpoor and the rural population did not pay direct socialsecurity taxes, they qualified only for minimal ser-vices. Due to these legal restrictions, many pressinghealth needs of the poor went unmet. Yet the middleand organized working class received rather sophisti-cated and costly medical attention.

Health professionals and experts from academiaand research institutes critized this unequal andwasteful model of health care ever more vocally. Inthe mid-1970s. they formed a sanitary movementdemanding profound reform, which created as itsorganizational headquarter the Brazilian Center ofHealth Studies (CEBES) and as its mouthpiece thejournal Debate on Health (S&de em Debate . Thissocial movement attributed the problems of the estab-lished system to its heavy reliance on the private sec-tor.4 It therefore called for strengthening the publicsector in order to guarantee all citizens equal rightsand effective access to health care and to shift theemphasis from curative treatments to preventive mea-sures, such as vaccination and sanitation. The healthpolicy the sanitary movement proposed would helpespecially the poor and satisfy their basic needs. Itwould also limit the explosion of health spending bydiminishing the need for the expensive treatmentof people falling ill with diseases that were easy toprevent.5

4. THE EFFORT TO FIND MASS SUPPORTThe medical experts and professionals who initi-

ated the health reform movement sought support fortheir far-reaching goals. They tried to gain a massivefollowing in society, especially among the poor,whose needs they claimed to represent.6 This strategyof mobilization was not, however, very successful.Poverty made many of the poor concentrate on theneeds of their families or neighborhoods. Clientelismstrongly reinforced their focus on small-scaledemands, exacerbated divisions among them, andrestricted support for a national-level movement.

From the mid-1970s on, movement membersworked with local communities, especially in the poorperipheries of large cities. They tried to convince theless well-off that a comprehensive health reform wasnecessary to guarantee their well-being (Jacobi, 1989,pp. 73, 112-113, 128-137; Sader, 1988). Limitedmeasures, such as the building of a health post in theirneighborhood, which the clientelism pervadingBrazils political system might provide sooner orlater, would not be sufficient.


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Yet these mobilizational efforts faced an uphillbattle. Poor Brazilians have certainly formed manysocial movements to demand relief from their healthproblems. Most of the poor, however, have focusedtheir attention on improvements for their families orlocal communities. The hardships of their lives haveforced them to devote almost all energy to their ownsurvival (Durham, 1984; Mainwaring, 1987, pp.141-142). The pervasive clientelism that envelopsmany of the poor has reinforced this tendency to focuson interests of restricted scope, not on national-levelgoals. Poor people often consider petitioning withhigher-status patrons for small-scale benefits as theonly realistic way to obtain gains. In this way, theycompete (rather than cooperate) with other poor peo-ple requesting similar favors for themselves(Cardoso, 1988, pp. 377-378). In contrast, efforts toexert powerful pressure through collective organiza-tion, especially on a supra-local level, would chal-lenge the patron (such as local politicians or theiragents) and therefore risk repression. Clientelism hasthus helped to keep the poor divided and made massmobilization difficult.Poverty and clientelism, which reinforce eachother, have impeded the health reform movementfrom ever gaining a mass base. Support for the move-ment has remained limited to Brazils major urbancenters, especially . o Paulo and Rio de Janeiro,where clientelisms hold is weaker than in Brazilsvast rural areas and smaller towns. Yet even in thesemore mobilized settings, the health reform movementhas not been able to count on massive, solid support.While claiming to speak for the impoverished, it hasnot managed to establish a firm organization integrat-ing its intended beneficiaries. The movement hasremained an initiative mainly of health professionalsand experts from the urban middle class.

5. THE SHIFT TO A STATE-CENTEREDSTRATEGYThe failure to mobilize strong support in society ledthe health care movement to pursue a more state-centered strategy (Campos, 1988, pp. 181-194; Cohn,1989, pp. 131-140). The weakness of the sanituristusmass base turned the state into the only possiblelaunching ground for change. Members of the sanitarymovement therefore tried to occupy leading positionsinside the public bureaucracy. Sympathetic observershave even claimed that this state-centered strategy hasdetracted from efforts at mass mobilization and thusperpetuated the movements weak support in society(Campos, 1988, pp. 181-194); Cohn, 1989, pp. 133-

140).This effort to penetrate the state already had somesuccess under the last authoritarian government (ledby General Jogo Figueiredo, 1979-85), because the

deficiencies of the established health care modelthreatened important state interests. Above all, theexplosion in health care costs exacerbated the fiscalcrisis of the state, which became ever more pressingwith the recession and debt problems erupting in theearly 1980s. These financial difficulties also endan-gered the autonomy and power of the agencies admin-istering health care, especially the Ministry of SocialSecurity and Welfare (MPAS) and the NationalInstitute for Health Care of the Social SecuritySystems (INAMPS), a parastate agency under MPASsupervision. The Ministries of Finance (MF) andPlanning (SEPLAN) used the fiscal crisis to claimcontrol over the health care budget, which the MPAShad administered on its own. In addition, the predom-inance of the private sector limited the power of pub-lic health agencies. Strengthening the state, as thesanitary movement demanded, would augment theresources of these agencies and enhance their offi-cials career chances.Important state and agency interests thus coincidedwith some goals of the health reform movement.Therefore, movement members gained some high-level positions inside the public bureaucracy alreadyin the last phase of authoritarian rule (Rodriguez,1988, p. 27). This was surprising, given the ideologi-cal distance between a conservative military regimeand a left-leaning reform movement. Yet the effect ofthis incipient penetration on public policy wasexceedingly limited. For instance, a major overhaul ofthe health care system was blocked in 1980 by oppo-sition from the private medical sector, state officialsand clientelist politicians.8 Thus, the sanitarisfusstate-centered strategy achieved only minimal successunder the military regime.

6. EARLY SUCCESSES AND PROBLEMSUNDER CIVILIAN RULEBrazils return to civilian rule created a more aus-

picious setting for the state-centered strategy of thehealth reform movement. In fact, a number of move-ment members gained important positions in the pub-lic bureaucracy. They thus obtained the opportunity tolaunch their progressive initiatives. In the beginning,they indeed seemed to be on the path to success. Butdifficulties stemming from bureaucratic rivalries soonemerged.The demise of authoritarian rule in Brazil seemedto open the door for significant health reform. As partof a broad alliance of forces, the Purfido doMovimento Democratico rasileiro (PMDB), themain center-left force that had opposed the authoritar-ian regime, assumed power in March 1985. For years,it had demanded equity-enhancing change in manyareas, including health care. Certainly, the new gov-erning alliance included the conservative Partido da


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Frente Liberal (PI ), whose members - includingthe new President, Jose Samey -had stopped only in1984 to support the military government. The demo-cratic transition nevertheless seemed to give center-left and even leftist forces considerable opportunitiesto advance their reform goals.

The health reform movement used all availableavenues for advancing its goals. Most importantly, itpressed hard to have its members appointed to topstate positions. This effort at invading the upper eche-lons of the public bureaucracy was quite successful; itfocused on the main agencies in the charge of healthcare, namely the Ministry of Social Security andWelfare (MPAS), its executive agency, the NationalInstitute for Health Care of the Social SecuritySystem (INAMPS), and the Health Ministry (MS). Asleading members of the movement, EleuterioRodriguez Neto became Secretary-General of theMS, Jose Saraiva Felipe Secretary of MedicalServices in the MPAS, and HCsio Cordeiro Presidentof INAMPS. While party politicians were appointedministers, reform-minded experts had a strong voicein the second echelon. This institutional penetrationseemed to open the door to the profound healthreform which the movement had long advocated. Yetit also involved the sanitary movement in the vicissi-tudes of bureaucratic politics, which rages inside theBrazilian state. Thus, the state-centered strategy was adouble-edged sword.9

Members of the movement gained positions in dif-ferent states agencies, which were often locked inlong-standing bureaucratic rivalries over influenceand resources. Trying to demonstrate good job perfor-mance and thus further their career prospects, the newstate officials soon absorbed the organizational inter-ests of their agencies. In this way, they were drawninto bureaucratic politics. This wrangling createdtensions inside the sanitary movement and led to com-peting reform efforts. The worst conflict centered onwhether the Social Security Ministry (MPAS) or theHealth Ministry (MS) should supervise INAMPS.Due to the traditional linkage of health care to socialsecurity in Brazil, MPAS controlled INAMPS, whichwas in charge of administering curative services.Funded generously through social security taxes,INAMPS expanded the public provision of curativetreatments, while the MS, in charge of preventive pro-grams, had to operate with meager budget allocations.For many years, the MS had hoped to get control overINAMPS and its enormous resources.

Before 1985, the sanitary movement had alwaysadvocated such a transfer of INAMPS from thepurview of MPAS to the MS. In this way, the provi-sion of curative treatments by INAMPS could be inte-grated into a comprehensive health system that wouldprivilege preventive measures. Yet after demandingthe transfer as late as early 1985 (Escritorio Tecnico,1985, pp. 27-28). the movement members appointed

to INAMPS and MPAS suddenly came to oppose thisreorganization, incurring the wrath of movementmembers appointed to the MS (Rodriguez, 1988, pp.46-47; Felipe, 1988, p. 67; interview Cordeiro, 1988).Thereafter, these two groups often went separateways. This conflict created lasting resentments andweakened the reform movement internally.

Despite these problems, members of the sanitarymovement used their new top positions inside thestate to promote health reform. Those appointed toposts in INAMPS started in 1985 to remove the rulesand regulations that excluded large parts of Brazilspopulation from full health care coverage.Announcing that every citizen had the same right tohealth care, they universalized legal entitlements andeliminated discriminatory rules which restricted theactual provision of medical services in Brazils vastrural regions. These rule changes, which gained sup-port from trade unions and even the private healthsector, did not arouse any open opposition (0 Globo,1986; interview Cordeiro, 1990; INAMPS, 1988, pp.10-l 1; Cordeiro, 1988, p. 229; Felipe, 1988, p. 69).They completed the gradual extension of health carecoverage that had been underway for decades and thateven the military regime had promoted (Malloy,1979, pp. 83-l 32).The reformist experts knew full well, however, thatlegal changes as such would have very limited impactunless the poor gained better effective access to med-ical facilities. This goal, however, was much moredifficult to achieve; it required a profound revampingof the established health care system. The members ofthe sanitary movement in INAMPS and MPAS under-took such a reform effort, but had only very limitedsuccess. As a result, many long-standing problemshave persisted, undermining the effective impact ofthe initial rule changes. As INAMPS presidentCordeiro himself admitted at the end of his tenure,the regional discrepancies in the provision of [med-ical] services and the extent of unsatisfied need forcare in the poorest regions were maintained(INAMPS, 1988, p. 10).

7. THE DIFFICULTIES OF HEALTH REFORMAND THE SEARCH FOR ALLIESIn order to advance the needs of poor Brazilians,

the members of the sanitary movement in INAMPSand MPAS tried to reorient health care away from anemphasis on curative treatments and toward anemphasis on preventive medicine. They attempted toestablish stricter public control over medical busi-ness, which preferred the existing system with all itsdistortions. But medical business had considerablebargaining power and successfully resisted the firstreform effort. This induced the health reform move-ment to seek allies, which it found especially insidethe state, among municipal and state governments.


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In the sanitary movements view, the state shouldguide health care provision to favor the needs of theless well-off. Since the private medical sector satis-fied only those needs that were backed by ability topay, it provided many of its services to better-off peo-ple in urban centers while neglecting the poor. Forthis reason, members of the sanitary movement whogained top posts in INAMPS proposed subordinatingmedical business to planning and supervision by thestate. In this way, the private health sector wouldbecome an agent of state goals.

This plan aroused strong opposition from healthbusiness, which profited handsomely from the estab-lished system. Trying to defend its latitude and bar-gaining power, the private medical establishmentinsisted on defining its relationship to the INAMPS asa contract among equals. The health reformers, incontrast, demanded superiority for INAMPS so that itcould direct the activities of medical business(Cordeiro, 1988, pp. 169-176).

The new, reform-minded INAMPS leadership triedto advance these goals in long negotiations with asso-ciations of private hospitals. Yet the profit-seekinghospitals persisted throughout 1986 in their opposi-tion. In December of that year, MPAS MinisterRaphael de Almeida Magalhaes finally tried to decreeunilaterally new rules for contracts with the privatesector, which stipulated the states superiority.Medical business flatly refused to accept this imposi-tion, however, especially the governments right tointervene in private facilities under ill-defined condi-tions of public need. The private sector simplyrefused to sign the new contracts. Since the statedepended on private providers for the maintenance ofhealth care, it could not enforced its will (Cordeiro,1988, pp. 165-189; MPAS, 1986, p. 19174; inter-views Magalhles, 1988, and Ferreira, 1989; Es&ode S&o Paul0 1986 and 1987).

The reform-minded health experts sought politicalallies because bilateral negotiations did not allowthem to subordinate the private sector to their plans.Interestingly, they gained their most powerful supportnot from society, but from inside the public bureau-cracy itself, namely from municipal and state govem-ments. Their state-centered strategy and theirproposal to decentralize the health system wasappealing to subnational governments. Indeed, as onthe federal level, members of the sanitary movementhad responded to the lack of a mass base by seekingleading positions in state and city governments, fromwhich they backed national reform efforts. Thus, inline with my main argument, the weakness of societalpressure for health reform helped to turn subnationalstate agencies into the major supporters of progres-sive change.The sanitary movements restricted following insociety could provide moral backing for reformefforts, but did not have sufficient influence on policy

making. Particularly, the Eighth National HealthConference (March 1986), convoked by movementmembers inside the MS, espoused the goals of healthreform to the public. But the rather drastic proposalsadopted by the conference, including the gradualtakeover of health care by the state, only reinforcedthe fierce resistance of the private sector, whichdecried all reform efforts as steps toward the social-ization of medicine (Folha de Srio Paula, 1986;Federacao Brasileira de Hospitais, 1989; interviewFerreira, 1989).

These plans also found only limited resonanceamong movement members inside the public bureau-cracy, who had scaled back their original goals. Theirexperiences in top state posts had convinced them thatattempts at radical change were unrealistic; theywould be foiled by active opposition from medicalbusiness and clientelist politicians and by passiveresistance from the health care bureaucracy itself,which would defend its established routines and orga-nizational interests. Compromises with opponentsand lukewarm supporters were unavoidable. Workingwithin the public bureaucracy thus had a deradicaliz-ing effect.O Because of this cleavage between move-ment members inside and outside the state, temporarypressure for reform from society had only a limitedimpact on public policy making.

Since the reformist experts in state positions couldnot face down private sector opposition on their ownand since the societal wing of the sanitary movementcould not provide much help, they turned to alliesamong municipal and state governments. The subna-tional governments had for years demanded a decen-tralization of Brazils health system, which, as alegacy of authoritarian rule, was controlled by thenational government. States and municipalitieswanted to take away from INAMPS the responsibilityfor administering medical services (ConselhoNational, 1985). In this way, they tried to gain morefunds and increase their autonomy.

Since its inception, the sanitary movement alsoadvocated a decentralization of health care(Rodriguez, 1988, pp. 28-29, 3945). In its effort topromote preventive measures, it wanted to shrinkINAMPS, which had always preferred expensivecurative medicine, and to break the strangleholdwhich the private health sector had imposed onINAMPS. Under the military regime, there weremany links of favoritism between medical businessand INAMPS officials. Decentralizing attributionswould cut these links and break the power both ofINAMPS and of the private health sector. This wouldmake possible a profound revamping of the healthsystem.

Members of the sanitary movement in leading pub-lic posts therefore saw state and municipal govem-ments as important allies for their reform efforts. Inthe eyes of the progressive experts, the subnational


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governments would pay more attention to the basichealth needs of the poor because the citizenry couldbetter control them than the distant federal govem-ment. Popular movements, which have mostly a localscale, would exert more influence on municipal andstate governments than on the national government.By decentralizing the administration of the state, thesanitary movement hoped to augment the influence ofits fledgling societal wing (Cordeiro, 1988, pp. 31-36,95-97, 104-108). Thus, the demands of the healthreformers in the national government overlapped withthe organizational interest of state and municipalgovernments.

8. THE REORGANIZATION OF THEHEALTH SYSTEM

MPAS Minister Magalhaes drew on support fromthe subnational governments to attempt a major reor-ganization of the health care system in mid-1987.Conservative forces, however, offered fierce resis-tance. Above all, clientelist politicians saw healthreform as a threat to their political sustenance andsuccessfully tried to evict members and supporters ofthe reform movement from leading state positions. Asa result, the reorganization made only haltingprogress and did not serve as the first step in theplanned overhaul of the Brazilian health system.

For Minister Magalhaes, an alliance with state andmunicipal governments was highly attractive. Anambitious politician, Magalhles was a leader of themore progressive wing of the main government party,PMDB. This center-left party had taken power in1985 in coalition with the conservative PFL, whichPresident Jose Sarney had helped to found. In 1987,the PMDB current to which Magalhaes belongedentered into conflict with Samey, who was movingmore and more to the right. Particularly, Sameysagenda for the Constituent Assembly, which con-vened in early 1987, differed in important ways fromthat of the PMDBs center-left wing. In order to winsupport from state governors, who had considerableinfluence over the constitutional delegates from theirstates, the president used his command over patron-age as a carrot and stick Jornal do Brusil, 1987a,1987b, 1987~; 0 Globe, 1987).

Sameys efforts posed a threat to several state gov-ernments, which the PMDBs center-left wing con-trolled. Minister Magalhaes apparently wasconcerned about protecting his fellow party membersfrom presidential blackmail. The decentralization ofhealth care could further this goal by transferringlarge amounts of resources to the state governments.This could compensate for any politically motivatedcut-off of other federal funds by the president. Whiledefinite proof is impossible to attain, the importanceof patronage in Brazilian politics (Geddes, 1994,

chapters 2-3) makes it highly likely that this politicalgoal was one of MagalhBess main motives in sud-denly decentralizing health care in mid-1987.

By then, the MPAS also had an organizationalinterest in decentralization: It hoped to preempt thetransfer of INAMPS to the Health Ministry (section6). While decentralization would reduce the MPASpower, it would preserve the ministrys control overresource allocation, one of the main sources ofbureaucratic and political influence. Therefore, thedecentralization was preferable to a complete loss ofINAMPS. The Health Ministry was indeed pressingfor a transfer of INAMPS to its own purview.Advancing the sanitary movements initial agenda,members who held positions in the MS supported thisgoal. More importantly, President Samey seemed toregard this transfer as a way to boost his own politicalfortunes. Since the conservative Health Ministerswere his loyal friends while the center-left heads ofMPAS supported his critics, a transfer of INAMPS tothe MS could have given him more control overpatronage, thus bolstering his political prospects.

The desire to preempt this transfer and protect cen-ter-left state governors from presidential wrath proba-bly triggered Minister Magalhaes abrupt decision toinitiate the decentralization of health care in mid-1987. By transferring many INAMPS attributionsand facilities to state and municipal governments, hecreated the Unified and Decentralized HealthSystem (SUDS) (MPAS, 1989). The surprisingenactment of this reform did not allow the oppositionto coalesce. Yet the private medical sector saw thedecentralization as a threat to its privileged positionand soon tried to undermine the farther-reachinggoals of health reform. INAMPS bureaucrats alsooffered fierce resistance in order to defend the sur-vival of the administrative structure they controlled.

More importantly, President Samey came to viewthe reorganization as a trick to limit his own politicalclout. Many other conservative politicians, who relyheavily on clientelism, especially members of thePFL, also felt threatened. Clientelist politicians guar-antee their electoral support by handing out smallbenefits, especially to the poor. In order to obtainpatronage resources, they count on placing their fol-lowers into the health care administration, who in turnhand out benefits to their patrons political supportersand withhold them from their adversaries. In this way,these intermediaries have induced many poor peopleto vote for their patrons, building a solid base forclientelist politicians.i2 Until MagalhPes formedSUDS, the patronage sustaining these networks hadbeen controlled ultimately by President Samey. Thishad given Sameys conservative friends privilegedaccess. Yet the decentralization of health care threat-ened to disrupt these patronage networks. Most stateand many municipal governments were in the handsof center-left forces since the PMDBs landslide vic-


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tory in the elections of 1986. The decentralization ofhealth care therefore jeopardized the access of conser-vative politicians, especially members of the PFL, tohealth care patronage (F&a de Srio PC&O, 1987;Jomal do Brasil, 1987d).Health reform as such posed a danger to clientelistpoliticians. They feared that any substantial improve-ment in health care would reduce the dependency ofthe poor on patrons. This would weaken their owndomination over large numbers of voters and under-mine their electoral sustenance. Many conservativepoliticians therefore joined President Samey in hisopposition to the decentralization, and to comprehen-sive health reform in general.These clientelist forces relentlessly attacked theinitiators of the reorganization, including members ofthe sanitary movement. Leaning on President Samey,they gradually succeeded in removing many reform-ers from top posts in the public bureaucracy. Facingheavy pressure,13 Minister Magalhaes resigned inOctober 1987. In March 1988, Samey dismissedINAMPS president Cordeiro, a leader of the sanitarymovement; he put a conservative crony in office, whostarted immediately to sabotage the decentralization.With this and other dismissals, the health reformmovement lost much of its institutional basis insidethe public bureaucracy and was put more and more onthe defensive. Its state-centered strategy had drawn itinto bureaucratic fights and battles over patronagewhich posed severe obstacles to its reform efforts. Itstactic to broaden the scope of the conflict over healthreform by allying with center-left state governors hadbackfired by arousing suspicions from conservativeclientelist politicians, who feared for their controlover patronage - the base of their political survival.As a limited policy issue turned into a battle over thedistribution of power between major political forces,the sanitary movement lost the initiative and its pro-gressive efforts encountered fierce resistance. Sharpcompetition over patronage obstructed equity-enhancing reform.

Facing all these obstacles, the decentralizationmade much more halting progress than planned. Thenew conservative INAMPS leadership created innu-merable bureaucratic hurdles. More importantly, theadministrative reform may have broken the rigidstructures of the established health care system, butdid not put in its place a new model that served thepoor better, as leading members of the health reformmovement admitted.14 A number of state and munici-pal governments showed little concern for improvinghealth care. They siphoned off part of the additionalresources they received and reduced their own healthspending (TCU, 1989).The sanitary movements hope that the decentral-ization would pave the way for a profound reorienta-tion of Brazils health system did not come true. Inmany states, medical business rapidly gained strong

influence on public authorities while social move-ments continued to have limited clout. The weaknessof popular movements became obvious in a govem-mental program to enlist the support of local commu-nities to control the implementation of health care.The MPAS hoped that councils with citizen participa-tion would guarantee the quality of medical servicesand prevent clientelist favoritism and discrimination.Yet despite promotion by enthusiastic governmentexperts, only 118 such community councils formed inBrazils more than 4,000 municipalities by the end of1989. In rural areas, where clientelism is most deeplyentrenched, only two councils were operative(MPAS, SAS, 1989, p. 6). Even on the local level, thepopular base of the health reform movement thus didnot make a strong contribution to national healthreform.For these reasons, the halting decentralization ofBrazils health care system did not bring about a com-prehensive reform that improved the quality of med-ical services and eliminated social and regionalinequities. With its state-centered strategy, the move-ment gained temporary access to power, but also wasthrown into the vagaries of bureaucratic politics andinto fierce conflicts over political patronage.Clientelist politicians offered the most powerfulopposition to health reform.

9. HEALTH REFORM IN THE NEWCONSTITUTIONThe sanitary movement inside and outside the statealso tried to advance its goals through the parliamen-tary arena. The elaboration of a new constitution,which began in early 1987, provided an ideal oppor-tunity. Left-leaning members of Congress who wereclose to the movement managed to include progres-sive principles in initial constitutional drafts. Yetopposition from conservative politicians and the pri-vate medical establishment, which the health reformmovement could not neutralize through countermobi-lization, weakened the constitutional reform mandate.Brazils Constituent Assembly determined notonly the basic institutional framework of the newdemocracy, but also set guidelines for economic andsocial policies, including health care. The sanitarymovement hoped to have its progressive principlesenshrined in the new constitution (Satie em Debate,1985). This would define a mandate that policy mak-ers would have to execute sooner or later. With thisgoal in mind, movement members inside and outsidethe state advised center-left and leftist constitutionaldelegates who were sympathetic to their goals. Self-

selection for committee assignments gave these par-liamentarians, who were a clear minority in theConstituent Assembly, a strong voice in the commit-tees elaborating the new rules for health care. These


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committees therefore proposed norms which embod-ied the major principles of a progressive health reform(Rodriguez, 1988, chapter 3). Rejecting the old viewof medical services as benefits reserved for affiliatesof the social security system, they declared health auniversal citizen right which the state had to guaran-tee through medical care and welfare-oriented socialand economic policies. They mandated that the stateintegrate curative and preventive measures and createa decentralized unitary health system (SUS), whichwould give priority to public facilities and contractprivate medical providers only as a last resort.

The movements success instilled fear in the pri-vate medical sector, which started a powerful counter-mobilization (Rosas, 1988). As a result, the initialdrafts were watered down during the constitutionaldebates. In response, the sanitary movement elabo-rated a peoples amendment on health reform inorder to preserve its gains and press for furtheradvances. Through this innovative mechanism, citi-zens could call for amendments which the ConstituentAssembly was required to consider. To increase theweight of such proposals, their authors tried to gatheras many signatures as possible. The peoples amend-ment on health reform, however, acquired only54,133 signatures - a minuscule number, given theenormous mass of poor people with unsatisfied healthneeds. This result revealed the low level of popularsupport for health reform, as prominent movementmembers admitted (Arouca, 1988, pp. 42-43). Themovements failure to mobilize a broad organized fol-lowing in society again limited its accomplishments.

The reformist effort of the sanitary movement wasalso hindered by intensifying rifts in its midst. To aconsiderable extent, these tensions resulted frombureaucratic politics. The fight over which ministryshould control INAMPS and the huge allotment offunds devoted to health care was especially fierce.Having festered for years (sections 6 and 7), this con-flict became most acute and consequential during theconstitutional debates.

Particularly, movement members in MPAS andINAMPS supported their agencies goal of creatingan integrated social security budget which wouldfinance all of social security, health care, and welfare,and which the MPAS as the collector of social secu-rity taxes would control. Movement members in MS,in contrast, advocated a separate fund for health careadministered by the MS, as this ministry as well as thesanitary movement had long demanded. They fearedthat in administering an integrated fund, MPASwould assign priority to fulfilling the quasi-contrac-tual rights of social security recipients and neglect theneeds of health care, which were not clearly stipu-lated. This had regularly happened during economiccrises, when MPAS had always slashed health spend-ing much more drastically than social security expen-ditures. Yet MPAS mobilized the influence which its

command over an enormous mass of patronage pro-vided and prevailed in the constitutional debates(interview Scalco, 1989; Rodriguez, 1988, pp.91-93). This conflict deepened the tensions inside themovement and weakened the cause of progressivehealth reform.

These internal rifts and the lack of firm mass sup-port, as well as the continuing pressure from the pri-vate medical sector to tone down the new con-stitutional principles, caused the reform movement tosuffer further setbacks. From inside and outside thestate, however, the movement persisted in lobbyingconstitutional delegates. Therefore, the new constitu-tion of late 1988 contained many general principleswhich the health reform movement had proclaimedfor a long time (articles 196-200). Health wasdeclared a universal citizen right, which the stateshould guarantee through the decentralized provisionof curative services and preventive measures. The pri-vate medical sector was assigned a supplementaryrole (article 199, paragraph I), but also assured of con-siderable latitude. While not reaching all of its goals,the health reform movement was quite content withthe new constitution.

10. THE NEW LAW ON THE HEALTH SYSTEMThe constitutional principles left, however, much

room for divergent interpretations. A law wasrequired to transform them into specific legal norms.Only this law would resolve the many conflicts onsubstantive issues which the Constituent Assemblyhad left undecided by passing generalities. The elabo-ration of a new law gave the anti-reform forces theopportunity to roll back the sanitary movementsadvances. Lacking firm mass support and losing evermore of its top positions inside the public bureau-cracy, the health reform movement was unable toexert strong influence in this process. Medical busi-ness, which lobbied very actively in Congress, provedmore successful. Clientelist politicians forced furtherlimits on progressive health reform. Therefore, thereformist constitutional provisions gained a muchmore conservative legal interpretation.

Seeking to shape the new law, members of the san-itary movement inside and outside the state joinedother experts and state officials in drafting a bill. Thisproposal stressed the role of the state in health careand wanted to subject the private medical sector tostrict public control (NESP, 1989). Yet health busi-ness protested vehemently and insisted on wide lati-tude for its activities. Similarly, INAMPS bureaucratsdrafted their own bill in order to reverse the decen-tralization of health care (interviews Figuelra, 1989;Jefferson, 1989). The Health Ministry, which was incharge of drafting the bill on behalf of the govern-ment, struck a compromise between these diametri-


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tally opposed positions (MS, 1989). Despite opposi-tion from medical business and INAMPS, the govem-ment submitted this bill to Congress in mid-1989.

The private health sector and INAMPS developeda powerful lobby in Congress to defend their interests.Since the conservative parliamentarians supportingthis lobby could not muster a majority, they engagedin obstruction. Evicted from most leading positionsinside the public bureaucracy and exhausted from themobilization efforts during the Constituent Assembly,the health reform movement did not build up strongcounterpressure. Its loose organization and lack of asolid mass base rendered it incapable of exerting sus-tained influence (interview Lefcovitz, 1990).

In order to have any law passed at all, the parlia-mentarians supporting progressive health reform hadto enter into a compromise with the conservativeobstructors. As a result, the possibility of profoundhealth reform was restricted further. The draft billpreserved the private sectors significant role in themedical system, provided it with new economic safe-guards, and gave nonstate providers of medical ser-vices direct participation in health policy making. Inaddition, while it mandated the decentralization ofmedical service provision, it preserved INAMPS as aplanning and supervisory agency. This Congressionalbill made a drastic reorientation of Brazils healthcare system impossible. Conservative forces cele-brated their victory, while the health reform move-ment lamented its defeat (F&a de S&o Paula, 1989;Cdmara dos Deputados, 1989; FENAESS, 1989).

President Collor and his first Health Minister,Alceni Guerra, however, saw this bill as a threat totheir control over funds that could serve as patronage.They disliked the Congressional decision to mandateautomatic financial transfers to state and municipalgovernments, which limited the federal governmentsability to extract political favors. Collor thereforevetoed parts of the project and forced changes thatenhanced presidential discretion over resource alloca-tion (MS, 1991, pp. 23-35; interview Arouca, 1992).These modifications kept the door open for clientelistmanipulation and outright fraud. As in the case ofSUDS, interference by clientelist politicians com-bined with bureaucratic politics and opposition fromsectoral associations to water down reform.

With these compromises, the new legal frameworkfor health care, finally enacted in late 1990, fellbehind the hopes which the 1988 constitution had cre-ated in the sanitary movement. The constitutionalprinciples received a legal interpretation that madeonly modest change possible. Medical business,established bureaucrats, and clientelist politicians hadblocked the effort at profound health reform. Theseconservative forces had survived the attack from thesanitary movement and succeeded in preserving manyparameters of the existing system.

In fact, the new legal framework was partly

responsible for the profound crisis that has afflictedBrazils medical system in the early 1990s. The lawmaintained the dependence of health care on revenuesfrom social security taxes, which the Social SecurityMinistry (MPS) administrated. Given severe financialproblems, the MPS has fulfilled first its own resourceneeds and given the Health Ministry only the meagerleftovers (MPS, SPS, 1993, p. 2; 1994, p. 10). Starvedfor funds, medical care has suffered greatly (inter-views Dellape, 1992; Jatene, 1992). Thus, bureau-cratic politics has not only helped impedeequity-enhancing reform in health care, but evenworsened the already deficient status quo.

11. CONCLUSIONAs this study shows, Brazils sanitary movement

has achieved only limited success in promotingequity-enhancing health reform. It never managed tomobilize wide-ranging, firm support in society, andits shift toward a state-centered strategy producedonly modest achievements. Leading members of themovement used their high-level public posts to enactsome rule changes, but they also faced powerful insti-tutional obstacles which blocked the effective imple-mentation of these modifications. As a result, themovement has not brought about much equity-enhancing reform. While achieving a few successes,it has clearly failed to reach its original goals.Pervasive clientelism has greatly exacerbated thedifficulties of the sanitary movement in mobilizingsupport from society. Particularistic links to patronsof higher status have induced most poor people tofocus on small-scale goals and prevented them fromjoining in national-level efforts. Although they havesuffered from the severe deficiencies of Brazilshealth care system, few of them have therefore sup-ported the sanitary movements call for a profoundoverhaul.

The lack of a solid mass base in society has ledreform-minded experts and professionals to concen-trate on penetrating the upper echelon of the publicbureaucracy. This state-centered strategy hasdiverged from the conventional expectation thatsocial movements - as part of society -pressure thestate from outside. Brazils sanitary movement hasinstead tried to occupy leading positions inside thestate, regarded the public bureaucracy as the decisiveinstrument for achieving its goals, and sought alliesamong state actors. Interestingly, some social move-ments in the First World have pursued similar state-centered strategies (Gale, 1986).Yet while this state-centered strategy providedopportunities for effecting some equity-enhancingchange, it also exposed the reform efforts of the sani-tary movement to a series of powerful institutionalobstacles. It pulled the movement into the trenches of


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bureaucratic politics and weakened its internal unityand force. It induced movement members in top statepositions, who noticed the inertia of the bureaucracy,to moderate their plans and goals, creating cleavageswith the societal wing of the movement. Most impor-tant, the state-centered strategy drew movement lead-ers into conflicts among powerful political forces overthe command of electoral patronage. As clientelistpoliticians launched a counterattack, the sanitarymovement quickly lost most of its leading positions inthe public bureaucracy, revealing its precarious base.

Thus, institutional obstacles severely impeded thesanitary movements reform efforts. As other authorshave emphasized, the socioeconomic sectors thatwould bear the direct cost of reform, especially med-ical business, also offered resistance. But this socioe-conomic opposition alone was not decisive,especially as the scope of the conflict widened toinclude a wide range of political forces, such as stateand municipal governments and, above all, clientelistpoliticians. When these politicians came to see healthreform as a threat to their control over patronage and,thus, as a danger to their political survival, they com-batted it in order to defend their established clientelistnetworks. Analyses of the fate of social reforms there-fore need to give serious consideration to institutionalfactors, such as clientelism.

Institutionalist arguments emphasize continuityover change, obstacles over possibilities for reform.Does this approach leave any room for progress? Canthe institutional impediments analyzed in this articleever be overcome, or is Brazil condemned to socio-political stagnation? The sobering findings of thiscase study suggest a tentative answer: given pervasiveinstitutional obstacles, isolated reform attempts bysocial movements may have little impact, especiallyon the national level. Instead, a broad-based, long-term effort at comprehensive, yet gradual institutionaltransformation is required.

Certainly, on a local or regional level, committedpolitical leaders can concentrate sufficient authorityto effect reform. In Ceara, for instance, a state inBrazils poor Northeast, a movement of medical pro-fessionals convinced an incoming governor from thecenter-left Partido ah Social Democracia Brasileira(PSDB) to implant a highly successful preventivehealth program (Tendler and Freedheim, 1994). Strictcontrols by the state government and the skillfulencouragement of community participation limitedthe corrosive impact of clientelism in this case. Thus,on a limited scale, strong political leadership canoverride the institutional obstacles emphasized in thispaper.

Such success is very difficult to extend to thenational level, however. Given the dispersion ofpower in Brazils democracy and the coexistence ofrivalling clientelist networks, the federal governmentfinds it extremely difficult to concentrate sufficient

authority for enacting reform against resistance. Atpresent, President Fernando Henrique Cardoso, aPSDB leader who took office in January of 1995,faces enormous obstacles to his reform efforts, whichinclude improvements in health care for the poorestsectors. Many of Cardosos conservative and centristallies in Congress depend for their political survivalon patronage. Reforms that threaten their control overdistributable benefits are therefore virtually infeasi-ble. Despite his strong electoral mandate, based on astunning first-round victory in the presidential elec-tion of October 1994, Cardoso has encountered wide-spread resistance. Thus, the institutional obstacles tosocial reform on the national level are exceedinglydifficult to override.

Equity-enhancing success therefore hinges on along-term effort at comprehensive, yet gradual insti-tutional transformation, supported by a solid, wide-ranging organization in society. Social movementsneed to join forces, broaden their concerns, design acomprehensive program, and participate in the elec-toral arena. They need to form an encompassing, non-sectarian, reformist party that seeks mass support(Hellman, 1992; Castatieda, 1993, pp. 200-202,363-364). Such a party could over time erode the sus-tenance of clientelist politicians by competing for theallegiance of the poor. If it wins government power,its organizational discipline and programmatic orien-tation can mitigate the divisive pull of bureaucraticpolitics. A party with these characteristics may reduceinstitutional obstacles and thus gain the capacity tomobilize sufficient countervailing power to overcomeelite opposition to reform. Yet such party can onlyemerge through long-standing organizational efforts.

In Brazil, the core of such a broad-ranging reformparty may already exist: the leftist Workers Party(PT), which has for years endeavored to includesocial movements of the urban poor, unions of indus-trial workers and rural laborers, and associations ofmiddle sectors into a fairly disciplined, programmaticparty organization (Keck, 1992; Castaheda, 1993, pp.149-155). Appealing to an ever wider range of socialsectors, the PT has demanded comprehensive equity-enhancing reform. To avoid antagonizing establishedelites, the leadership has renounced its initial radical-ism. The PT has pursued profound, yet gradualsociopolitical change, in some ways similar to earlysocial-democracy in Europe.

The PTs defeat in the presidential election ofOctober 1994 shows that its organizational network isstill limited. Yet the large increase in its congressionaldelegation - from 35 to 60 deputies - suggests thatthe party is making important advances. It took thesocial-democratic parties of Europe decades to wingovernment power. If the PI can maintain its organi-zational momentum, it may eventually repeat this suc-cess and obtain the opportunity to enact lastingequity-enhancing reform in Brazil.


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NOT S1. This article focuses only on the policy impact of socialmovements, not their effect on the consciousness of theirmembers (Cardoso, 1983, pp. 234-239; Mainwaring, 1987,pp. 147-149).2. Cardoso (1983); Mainwaring (1989), pp. 177-182,190-195; Alvarez (1990). chapter 10; review in Assies(1994). pp. 87-89.3. For a mote in-depth assessment of the achievements ofBrazils health reform movement, see Weyland (forthcom-ing), chapters 4.7.4. In recent years, the sanitary movement has adopted amore nuanced, less negative view of the private sector (inter-view Arouca, 1992).5. Mello (1977). pp. 197-212; Landmann (1977); CEBES(1985). This paper uses the sanitary movements own goalsas the measuring rod for assessing its success.6. A number of movement members, who belonged toBrazils small orthodox Communist Party (PCB), saw thismobilizational effort as part of a broader strategy to win sup-port among the poor for a move toward socialism. This sec-tor. which regarded Italys Riforma Sanitaria as its mainmodel (e.g., Berlinguer, 1988). saw its hopes dashed whenmass mobilization failed.

8. Oliveira and Teixeira (1986). pp. 270-275. A specialprogram for basic health care and sanitation in the ruralNortheast (PIASS), which reformist experts helped adminis-ter, brought some improvements for disadvantaged sectors.This success was possible because the authoritarian govem-ment could override clientelist resistance and because theprivate medical sector, which had little interest in destituterural regions, did not offer opposition. See Weyland (forth-coming), chapter 4.9. For a similar argument on the paradoxical effect of gov-ernmental responsiveness to social movements, seeMainwaring (1987) p. 152.10. Interview Felipe (1989). Compare, e.g., Cordeiro (1979)with Cordeiro (1988).11. Rodriguez (1988). pp. 7679; Felipe (1988); confiden-tial interviews with decision makers, Brasilia (1989).12. o~M~ do Brusil(1987b); Veju (1987); E&do de ScioPuulo (1988); confidential author interview with the MPASofficial administrating this patronage, Brasflia (1990).13. A leading PFL politician told this author in a confiden-tial interview (Brasilia, September 1989) that conflicts overpatronage had caused the sharp conflict between Magalhaesand this clientelist party.

7. Gay (1988). chapters 3-4; Mainwaring (1989). pp. 14. Confidential author interviews, Brasilia188-189, 195; also Hellman (1994), pp. 128-139. Even in (June-September 1989); Jornal do Brusil(1989); articles bythe highly mobilized setting of Limas shantytowns, pat- Chonny and Noronha, Felipe, and Dantas et al., in Governoterns of conservatism and clientelism persisted.. . (Stokes, do Es&o de Srio Paulo (1988).1991, p. 77).

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weyland, kurt - the politics of health reform in brazil

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