In Brazil, it is common to find citizens jammed together into municipal halls on neat, narrow rows of white plastic chairs, each a personal podium for the citizens cum policy-makers participating in the country’s vaunted experiments in participatory democracy. The most internationally recognised of these experiments has been in participatory budgeting, but just as significant in Brazil has been the advent of health councils, now found in nearly all of the country’s 5,000-plus municipalities. These councils are empowered by law to inspect public accounts and demand accountability, and some strongly influence how resources for health services are spent.

Who gets to sit in these new citizen assemblies: those who represent the interests of public health managers and local political elites or those who represent the genuine interests of citizens? Citizenship DRC research in three regions of Brazil reveals that many citizen groups are represented in the councils, though diversity is not guaranteed. Breaking the grip of powerful actors on the councils often depends on a public manager who is willing to champion the cause of participation, on strong civil society groups or other associations who refuse to let their constituencies be left out and on the rules and regulations that govern the election of councillors.

Rights in the age of markets

Brazil’s Sistema Único de Saúde (SUS), is a universal, publicly-funded, rights-based health system: a rarity in Latin America. Middle-class Brazilians may continue to use private health services, but the government has an obligation to serve everyone. The Brazilian “Citizens’ Constitution” of 1988 established health as the right of all, defined its provision as the duty of the state and guaranteed the right to participate in the governance of health. It laid the groundwork for the establishment of institutionalised mechanisms for citizen engagement at municipal, state and national levels. Designed and put into place during an era in which neo-liberal health reforms elsewhere in the world – and especially in Latin America – have driven the marketisation of health, Brazil’s SUS holds a number of important lessons for anyone interested in making public services more effective, responsive and accountable.

Ordinary Brazilian citizens and the health workers who serve them understand a great deal about the health problems of their communities and how these might be addressed. Brazil’s system of health councils and conferences illustrates the value of this knowledge. Each month tens of thousands of Brazilian citizens representing a spectrum of civic associations - churches, women, black, disabled and lesbian, gay, bisexual and transsexual movements, unions, non-governmental organisations, neighbourhood associations and more - meet with those who run their health services and provide their health care. They come together with a broader body of citizens, health managers and health workers every two or four years in municipal health conferences, from which delegates are put forward for conferences at the state and national levels. Hundreds of thousands of citizens took part in shaping proposals that were then debated amongst 3,500 participants at one National Health Conference in 2008. At such events, proposed amendments collated from days of group work are blazoned across giant screens, the kind used at rock concerts, while members of the crowd wave placards or chant when their desired amendment comes up for a vote.

Through this process of debate, contestation, refinement and reformulation, good ideas from citizens often survive to find a place in state and national policies. And when they do not, citizens who recognise the value of their ideas often continue to fight for them; some as health user representatives elected to represent their communities at the councils; others through their civic associations or political parties. Amid all the debate, one important consensus has emerged around the value of maintaining the national health service itself.

The democracy is in the details

The truth of the claim that participatory councils can help to make health services pro-poor depends on whether marginalised and vulnerable people are truly represented.

In all the research sites, the spectrum of participants in the health councils was quite diverse and included social movements, disabled people’s associations, religious groups, civil rights associations, trade unions and people with no associational ties. Still, some councils were more pluralistic than others.

Survey research carried out in 31 sub-municipalities of Brazil’s largest city, São Paulo, yielded important insights into the composition of the councils. Public managers, the research suggests, have tremendous influence over the outcome of councillor elections, so whether they value citizen participation or not matters. This research also reveals that more transparent procedures used to select the councillors and a strong associative life in the surrounding community will also help bring diversity to the local council. These conditions did not relate to the socio-economic profiles of areas researched.

Ethnographic and participatory research in health councils in Pernambuco and Acre, in north eastern and northern Brazil respectively, showed the significance of relationships that exist between public managers, civil society representatives and political parties. Where there is alignment around an ideological commitment to popular participation, councils can serve as a space for what one health manager termed ‘constructive co-existence’; citizens and their representatives are able to make demands on government for accountability, and government is able to engage citizens and civil society organisations in monitoring the effectiveness of public policies and the functioning of the public health system.

What makes health councils work better?

• The selection process of the councillors varies from council to council, but the more open and transparent the selection process, the more inclusive the council. Inclusive measures include making information on the election process available, listing all the associations and movements in the region, using radio or newspapers to publicise elections and granting candidatures to individuals as well as organisations.

• Discussion techniques are used to help groups to communicate and express themselves better. Some civil society groups have less information and communication material, and find participatory techniques help them articulate their demands more effectively.

• The councils who had the best performance in participation also reported the most connections with the political system and the public health system.

• The way the role of chair is interpreted can make a difference to the extent to which the council operates in an inclusive and participatory way.

• The techniques Brazilians have developed make the business of deliberating and deciding efficient and inclusive, including rules to limit the length of time people can speak, to ensure people who want to participate get a chance to speak and to vote where decisions need to be made.

• Training of councillors and the council chairs in their roles and responsibilities and providing basic information about the functioning of the health system, interpreting accounts and other technical skills can make an important contribution to improving effectiveness.

• Ensuring basic infrastructure – a big enough place to meet, an administrator to arrange meetings, keep minutes and records, allowances for monitoring visits and for attendance at conferences – is critically important to the council’s functionality, and requires an investment of resources by government.

These experiences show the value of popular participation in sustaining political commitment and popular support for the national health service. Furthermore, these sites become important focal points for the larger political and cultural battles of society, with all the antagonisms and conflict that implies. What they demonstrate is that getting people involved in shaping health provision makes more than practical good sense: it is about what it means to be a democracy.