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This research note assesses participatory health governance practices for HIV and AIDS in Brazil. By extension, we also evaluate municipal democratic governance to public health outcomes. We draw from a unique dataset on municipal HIV/AIDS prevalence and participatory health governance from 2006–17 for all 5,570 Brazilian municipalities. We use negative binomial regression and coarsened exact matching with treatment effects to estimate the influence of community health governance institutions on HIV/AIDS prevalence. Municipalities with participatory health councils experience 14% lower HIV/AIDS prevalence than other municipalities, all else equal. Family Health Program coverage, municipal state capacity, and municipal per capita health spending are also associated with systematically lower HIV/AIDS prevalence. We conclude that participatory health governance may combat HIV and AIDS through municipal spending, education, and community mobilization. Municipal health councils can facilitate these strategies and offer opportunities for improving well-being around the world.
Brazil's constitution (1988) granted municipalities the responsibility of providing social services. Many observers anticipated that this newfound authority would produce policy diversity, as local governments would tailor programs to constituents' needs. Instead, many municipalities chose to replicate programs made famous elsewhere. What explains this diffusion of social policies across Brazil? In particular, what motivates policy makers to emulate “innovative” policies? This study compares three approaches that seek to explain political behavior: political self-interest, ideology, and socialized norms. It draws on two policies, Bolsa Escola, an education program, and Programa Saúde da Família, a family health program, in four exemplary cities, to uncover the mechanisms that led to diffusion. Surprisingly, political incentives, such as electoral competition, cannot explain diffusion. Rather, ideology and socialized norms, transmitted through social networks, drive policy emulation. Diffusion occurs when politicians are ideologically compelled to replicate these programs and when policy specialists seek to demonstrate that they follow professional norms.
Conditional cash transfer programs (CCTs) have emerged as an important social welfare innovation across the Global South in the last two decades. That poor mothers are typically the primary recipients of the grants renders easy, but not necessarily correct, the notion that CCTs empower women. This article assesses the relationship between the world’s largest CCT, Brazil’s Bolsa Família, and women’s empowerment. To systematize and interpret existing research, including our own, it puts forth a three-part framework that examines the program’s effects on economic independence, physical health, and psychosocial well-being. Findings suggest that women experience some improved status along all three dimensions, but that improvements are far from universal. A core conclusion is that the broader institutional context in which the Bolsa Família is embedded—that is, ancillary services in health and social assistance—is crucial for conditioning the degree of empowerment obtained.
There is a broad body of literature that demonstrates empirically that the extension of primary education is strongly associated with sustaining economic growth in the developing world (Brown and Hunter ; Ravallion ; Kohli ; Glewwe and Kremer ; Hanushek ).
Access to health care is at the core of efforts to improve well-being. At the most fundamental level, infants must survive birth and children need to live beyond their first five years of life in order to benefit from human development programs, such as public schooling. To live a dignified life, people must also be able to maintain their health by avoiding deadly diseases and receiving life-saving treatment. In many countries around the world, childbirth is a risky endeavor for women. Therefore, women must also be able to survive the birth of their children. All to say that individuals need to lead healthy lives if they are to eventually develop capabilities that allow them to more productively engage the market, politics, and civil society (Sen 1999; McGuire 2010; Nussbaum 2011). Over several decades, the international development community has increasingly linked health to issues of human development and economic development.
Brazil is known for its vast internal diversity. Whether we consider its historical patterns of colonization, industrial development, internal migration, or ecological diversity, Brazil offers amazing contrasts. During the 1990s and 2000s some Brazilian municipalities were the sites of an amazing array of reforms: universal health programs, participatory budgeting programs, public policy councils, and conditional cash transfer programs flourished across Brazil. Multiple Brazilian municipalities were internationally recognized for creating innovative policy and institutional solutions to address a wide range of social and political problems, such as extreme poverty, low rates of vaccination, and a disengaged citizenry (United Nations 1996). However, patronage, clientelism, administrative malfeasance, corruption, and poor provision of public goods continue to plague many citizens and municipalities and limit efforts to improve well-being. In this chapter, we narrow the analytical lens to three municipalities to examine how participatory institutions, inclusive social policy, and local state capacity work on the ground to advance well-being.
Like its practice, democracy is a rich, muddied, and highly contested concept. Many democratic theorists highlight the central role of participation, contestation, and citizenship as core principles (Marshall 1950; Dahl 1971; Pateman 2012).Dryzek reminds us that democracy is “dynamic and open-ended,” which allows for formerly excluded citizens to expand their access to rights, public goods, and deliberative policy-making venues (Dryzek 2000: 29). We showcase the ways that multiple features of democracy contribute to well-being by developing theory that connects participation, citizenship rights, and an inclusive state apparatus to well-being.
The core of this book’s argument is that three democratic pathways – participatory institutions, rights-based social policies, and an inclusive state apparatus – help explain local variation in well-being. Each pathway directly connects core features of democracy to local governance and public goods provision, which in turn contribute to performance surrounding poverty reduction, health care, women’s empowerment, and education.
Income, employment, and income equality are critical components that help individuals and communities improve their well-being. Individuals need access to resources such as cash to purchase goods and services like food, housing, and health care. Governments around the world seek to expand access to income and employment, with many also citing the importance of reducing income inequality. The current global diffusion of cash transfer programs illustrates the central importance of providing a basic income to better enable individuals and families to live their chosen, dignified life. Each of these areas connects directly to citizens’ living standards and capabilities, and to their ability to exercise agency. In this chapter, we focus on the direct, economic aspects of well-being when we discuss poverty; this complements our emphasis on health, education, and gender empowerment in subsequent chapters.
The complexity, richness, and messiness of democratic politics generates opportunities for governments to expand citizens’ basic capabilities, agency, and rights. In turn, these advances contribute to individual and collective well-being This book demonstrates how multiple pathways within democratic regimes connect participatory institutions, rights-based social policies, and inclusive state capacity to human development. Of course there is no simple formula that permits citizens and governments to advance human development. We find that the slow, often cumbersome work of building democracy through participation, citizenship, and inclusive state capacity are crucial to initiate and sustain efforts to improve well-being. Each of these pathways can have a positive independent influence, but we find the strongest outcomes when two or all three pathways are activated simultaneously.
At the broadest level, our theoretical framework and mixed-methods approach demonstrate how a more comprehensive, fuller examination of democratic practice permits us to explain how governments, civil servants, and citizens work together to produce social and political change.
Brazil experienced significant social, political, and economic transformations during the second half of the twentieth century. The country weathered multiple political regimes, with democratic periods (1946–1964, 1985–present) interrupted by a military dictatorship (1964–1985). Rapid industrialization generated jobs, wealth, and a new national capital (Brasília), and led to massive urbanization as rural residents streamed into cities seeking employment and a better quality of life. Tens of millions of Brazilian citizens gained access to formal employment during this era, which provided the necessary public and private wealth to expand access to health care, education, and basic infrastructure. But Brazil also remained a highly unequal country throughout its impressive economic expansion. The majority of the population lacked access to essential services and resources, including decent housing, clean water, sewage, and a basic income. In this chapter, we explore how Brazil built the foundations for the democratic pathways that would prove fundamental for improving well-being in the twenty-first century.
One of the greatest challenges in the twenty-first century is to address large, deep, and historic deficits in human development. A crucial question we explore in this book is how democracy – with all of its messy, contested, and time-consuming features – works to advance well-being and improve citizens’ lives. Broad evidence demonstrates that democracies provide more public goods and higher standards of living, on average, for citizens than authoritarian countries (Przeworski et al. 1999: 264–265; Lake and Baum 2001; Besley and Kudamatsu 2006; Brown and Mobarak 2009; Acemoglu et al. 2013; Harding and Stasavage 2014; Hodgson 2017; Gerring et al. 2015). We move beyond the conventional explanations – elections, political competition, and partisanship – to develop theory connecting core dimensions of democracy – participation, citizenship, and an inclusive state – to improvements in well-being. In doing so, we illuminate how these dimensions form “pathways” that help citizens and governments achieve better human development outcomes.
Over the last three decades, governments and international development agencies have recognized the importance of women’s status and gendered exclusion for the overall population’s well-being. Women are more likely to face poverty and greater social, economic, cultural, and political barriers to address their vulnerabilities than men. A focus on women and girls is normatively justified given that they constitute more than half of the world’s population. Yet beyond their numerical size, there is growing consensus that women’s status affects development outcomes for everyone (Sen 1999; Nussbaum 2011). Historical and existing barriers for women and girls to fully develop as individuals – due to patriarchy, paternalism, and other forms of gender discrimination – violate international human rights norms and hinder instrumental goals to further broader human development. For instance, research reveals that gender discrimination that creates barriers to girls’ education has negative spillover effects in a number of domains related to development.