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Political and Institutional Drivers of Social Security Universalization in Brazil
Abstract
Brazil’s experience in building a relatively successful universal health system was made possible by the combination of political incentives to serve poor constituencies, which made it politically sustainable; fiscal sustainability and the great extractive capacity of the Brazilian state; and the institutional capacity to run a complex decentralized system. This chapter argues that Brazil’s Unified Health System (SUS) has faced two important challenges: finding new financial resources for the sector and promoting efficiency gains. Finding new sources of funding has involved unprecedented political costs despite the increasing saliency of public health in the public agenda. Efficiency gains are also unlikely to occur in the near future due to the recent deterioration of public sector management since 2012 and other specific factors, including the judicialization of health care.
... Source: PNAD 1981PNAD -1990PNAD , 1992PNAD -1993PNAD , 1995PNAD -1999 Pension wealth: Urban female workers by age the establishment of a relatively professional bureaucracy (Melo 2017). Surveys regarding the effectiveness of the pension system in the 1990s reveal that 93 percent of rural households reported no or very little difficulty in applying for the pension and only very short waiting periods before approval. ...
This study identifies the causal effect of pension generosity on women’s fertility behavior. It capitalizes on Brazil’s expansion of the pension system to rural workers, whose pension wealth subsequently more than tripled. Difference-in-difference, instrumental variable, and event study methods show that the pension reform reduces the propensity of childbearing of women of fertile age by 8 percent in the short run. Completed fertility declines by 1.3 children within 20 years after the reform, reducing the contribution base of the pay-as-you-go long run. The fertility response is strongest at higher birth parities, among older women, and among mothers with sons. (JEL H55, I38, J13, J16, O15)
... Social welfare, including retirement, pensions and health care, started in Brazil in the 1930s, with separate institutes for workers in specific sectors of the urban economy (industry, commerce, financial services), and later developed into a unified federal system (Malloy 1979, Melo 2014. Retirement benefits are related to one's salary and years of work, up to three minimum wages. ...
Brazil is known for its very high levels of social and income inequality, which have been reduced to some extent in the last decades, thanks to economic growth and different policies of income distribution and the expanding provision of social services such as education, health care, housing, and others. Since the mid 1990s, successive governments implemented several policies to deal with issues of poverty, education and unemployment and to create more opportunities for the poor. The positive impacts of many of these policies are undeniable, but, at the same time, there has always been the question about the extent to which these changes where a consequence of these policies or just an effect of broader processes of social change and economic development. As the country enters a period of economic recession, the question now is to what extent the effect of these policies would persist.
... With the pension reform, Brazil embarked on a path from fragmented provision to inclusive universalism that relied on changes in the population's beliefs: The introduction of the new Constitution and the move towards democracy were embedded in new political organizing principles and a new and inclusive political language so that citizens could believe in the announced reforms: The success of Brazil's Constitution is exemplified in the political competition based on universal access to elections, 5 greater political stability, effective stabilization efforts, and the establishment of a relatively professional bureaucracy (Melo, 2017). Surveys regarding the effectiveness of the pension system in the 1990s reveal that 93% of rural households reported no or very little difficulties in applying for the pension and only very short waiting time periods before approval. ...
This study identifies the causal effect of pension generosity on women's fertility behavior. It capitalizes on Brazil's expansion of the pension system to rural workers, whose pension wealth subsequently more than tripled. Event study, difference-indifferences and instrumental variable methods show that the pension reform reduces the propensity of childbearing of women in fertile age by 8% in the short-run. Completed fertility declines by 1.3 children within 20 years after the reform , reducing the contribution base of the Pay-As-You-Go pension system in the long-run. The fertility response is strongest at higher birth parities, among older women and among mothers with sons.
... En el contexto del restablecimiento de la democracia en el caso brasileño, una coalición social amplia, "los sanitaristas", propuso una reforma desde abajo, ambiciosa y democrática, encaminada a reducir la segmentación institucional y a establecer un derecho universal a la salud, que se incorporó a la Constitución de 1988. La coalición sanitarista y sus aliados participaron en un complejo proceso de negociaciones entre élites de fuerzas políticas de centro-izquierda y centro-derecha, y pusieron en marcha un importante proceso de unificación del sistema de salud con objetivos universalistas que permitió la incorporación de sectores excluidos históricamente, particularmente los rurales (Fleury, 2007: 149;Melo, 2014: 3, Barba y Valencia, 2016. ...
... In this angle, the INSS: Scheduled Appointments Program pro- duced significant diminishment of waiting times (2008); the Retirement Program within 30 min (2010); and the Program to the Application of Benefits -2011. The investigation of different reports feature projects, for example, Broadband internet in state-funded schools by the Ministry of Education -2010; the Network of Tele-assistance to remote regions which enhanced access to par- ticular human services by the Hospital of the Federal University of Minas Gerais -2012; and the mail station turn around logistic of the Brazil- ian Post and Telegraph Company of 2014 (Melo 2017). ...
Administrative reform and public service reorientation appear to be the keywords in the development agenda of the emerging economies in their quest toward achieving a market-driven, flexible and forward-looking public service which can adequately meet up with the challenges pose by the contemporary world. This is motivated by the fact that it is increasingly becoming clearer that the fundamental objective and the driving force of the traditional bureaucratic administrative models have grossly become inadequate in meeting up with these challenges. To this end, this paper is an attempt geared toward a comparative analysis of the workability of the reform strategies adopted in Malaysia, Philippines, Brazil and Nigeria. The paper revolves around the ecological theoretical model in which factors such as legal norms, culture, politics, the state of the economy and societal values appears to play a vital role in shaping and molding the character, the orientation and the performance of each of the countries in their quest toward a quality driven and result oriented public service. The paper adopts content analysis which was achieved through a thorough review of secondary data peculiar to each of the countries.
During the last three decades, the social security and health systems of the dual welfare regimes of Latin America (LA) have undergone thorough reforms, they have also developed numerous conditional cash transfer (CCT) programmes and social pension schemes. The purpose of this work is to classify the reforms, showing which actors and paradigms were behind them, determining to what extent the reforms have had an effect on social well-being, and whether they have promoted or restricted the building up of rights and social citizenship. To accomplish such an objective, we analyze the impact of these reforms on five countries: Brazil, Colombia, Mexico, Panama, and Venezuela.
En el campo de las políticas sociales, la focalización y el univer- salismo suelen oponerse porque cada uno deriva de experiencias y momentos distintos en el desarrollo del capitalismo y de las instituciones de bienestar.2
La base teórica e ideológica del paradigma de la focaliza- ción es el liberalismo, y se remonta a los primeros días de las leyes de pobres inglesas, y parte de la premisa de que los canales fundamentales para satisfacer las necesidades de un individuo son el mercado privado y la familia. Por ello, este enfoque considera que sólo cuando estos pilares del bienestar fallan es legítimo que las instituciones estatales y de la política social (en adelante PS) entren en acción.3 La PS focalizada ofrece beneficios básicos y temporales a los pobres y vulnerables que logran demostrar que son incapaces de satisfacer sus necesi- dades de bienestar a través de su propia iniciativa. Este tipo de políticas selecciona rigurosamente a sus beneficiarios, utili- zando pruebas de medios y condicionalidades. Sin embargo, la provisión de servicios no es necesariamente pública, porque se considera legítimo hacerlo a través del mercado o de organiza- ciones de la sociedad civil4 (Mkandawire, 2005, pp. 2-3; Peyre, 2007, p. III; Barba, 2013, p. 528).
En contrapartida, el paradigma universalista que surgió a fina- les de la Segunda Guerra Mundial, considera que todos los ciuda- danos –sin distinción de clase, posición en el mercado, trayectoria y desempeño laboral, prueba de medios o contribución financiera– tienen derecho a acceder a los servicios sociales. Esta perspectiva descansa en la solidaridad interclasista, en impuestos universales y en sistemas públicos unificados de protección social y enfatiza una amplia desmercantilización del bienestar social (Esping-Andersen, 1990, p. 47; Barba, 2013, p. 528).
Las PS universalistas son concebidas como mecanismos para transformar la realidad social y construir una sociedad más equitativa (Titmuss, 1974, p. 145). Los servicios sociales universalistas erosionan las barreras formales que discriminan a los pobres porque reemplazan el doble estándar de los pro- gramas focalizados que ofrecen servicios de segunda clase para ciudadanos de segunda clase (Titmuss, 1965, p. 19). Por ello, promueven la igualdad de estatus y de derechos, garantizan los mismos beneficios sociales, con la misma calidad,5 a todos los ciudadanos, independientemente de su posición de clase o laboral y su situación en el mercado6 (Skocpol, 1995, p. 251; Esping-Andersen, 1990, pp. 47-65).
This book systematically analyzes the economic dynamics of large emerging economies from an extended Comparative Capitalisms perspective. Coining the phrase ‘state-permeated capitalism’, the authors shift the focus of research from economic policy alone, towards the real world of corporate and state behavior.
On the basis of four empirical case studies (Brazil, India, China, South Africa), the main drivers for robust economic growth in these countries from the 2000s until the 2010s are revealed. These are found, in particular, in mutual institutional compatibilities of ‘state-permeated capitalism’, in their large domestic markets, and beneficial global economic constellations. Differences in their institutional arrangements are explored to explain why China and India have been more economically successful than Brazil and South Africa. The authors highlight substantial challenges for the stability of state-permeated capitalism and assess the potential future growth, sustainability and likely pitfalls for these large emerging economies.
Opening further avenues for empirical and theoretical research, this book raises questions for the future of the global economic order and should appeal to academics, graduate students and advanced undergraduates in politics, economics, economic sociology and development studies. It should also prove a worthwhile and provocative read for development practitioners and policy-makers.
Due to copyright restrictions I cannot provide the full text of the book. For more information see
https://www.routledge.com/State-permeated-Capitalism-in-Large-Emerging-Economies-1st-Edition/Nolke-ten-Brink-May-Claar/p/book/9780429261145
In contrast to China and India, Brazil shows some marked deviations from the model of a state-permeated economy. While it shares a focus on a large domestic market, crucial institutional complementarities and a substantial ability for coordination between state and business, it still suffers from the remaining residual dependency on Western capitalism. From this perspective, Brazil moved into a promising direction during the rule of the Labour Party. However, the Labour Party governments were unable to fully unfold the institutional complementarities in state-permeated capitalism in order to make the Brazilian economy more independent from external pressures. They suffered from a limited ability to use the large domestic market for the support of domestic Brazilian companies, from negative consequences of financialization, and from numerous frictions for domestic economic coordination due to the forceful presence of foreign multinationals in economic sectors that are key for productivity development.
The paper explores theoretically and empirically Brazil’s tax revenue from a political and political economy perspective. The absence of ‘big bang’ reforms to the tax code and tax administration suggests that policy models are less directly relevant to explaining the rise in the tax/GDP ratio. The paper makes the argument that public consent to the hike in taxes is explained by a combination of democratisation, strong preferences for redistribution, fiscally responsible centre-left coalitions, and bureaucratic capacity. New political incentives under democracy combined with high state capacity and a powerful presidency with the political resource necessary to pass an agenda of social reforms to sustain this new equilibrium of high taxation and high redistribution. The current level of taxation and spending in the country in a context in which poverty and inequality is high (although declining rapidly) has prompted concerns about the fiscal sustainability of this equilibrium. The paper argues against pessimistic accounts of this dilemma - such as the arguments based on the concepts of fiscal illusion and inequality traps - and advances an optimistic perspective based on the notion that a new fiscal contract seems to be emerging.
The article analyses a form of judicialization of public policies in the health field. It has as its object lawsuits initiated against Belo Horizonte Municipality arguing for the provision of services or the acquisition of inputs not obtained in the public system via institutional access routes. The argument is that the individualized quest for the guarantee of the right to healthcare via the judicial path is a form of reproduction of the tensions produced in democratic societies between the social and the individual conceptions of citizenship. By ensuring access to goods by means of individual suits, the Judiciary interferes in the making of public choices taken on by public-sector managers, thus regulating opportunities for consumption according to a concentrating logic. And so the assertion of a constitutional right superposes the political right of the majority, represented by the Executive, to make choices as to the goods that are the object of public policies, with a relatively significant financial and budgetary impact.
The literature on the effects of globalization on social policy and welfare, and the parallel literature on the effects of democracy, operate in mutual isolation to a surprising degree. This article extends the debate on the welfare state in the developing world by examining the social policy reactions of democratic and authoritarian governments to globalization. Using unbalanced panel data on 57 developing nations, and considering social security and health and education spending, the authors examine whether democratic and authoritarian regimes exhibit similar or different social spending priorities in the context of increasing economic openness. The results show that social spending in “hard” authoritarian regimes is more sensitive to the pressures of globalization than in democratic or intermediate regimes.
This report analyzes the structure of family health spending in Brazil between 1987 and 1996, using a survey taken in 1996 survey of health spending by households. This report also tries to identify, although indirectly, the impact that universal access to health care had on family spending by income. Although the analysis found that the these measures did not narrow the gap between spending on health care by poor families and more affluent families, it did yield important lessons that will be helpful in crafting future health policies.
This paper explores debates in social policy choices and whether such provisions ought to be guided by principles of 'universalism,' or more selectively through targeting. The author discusses the forces behind the shift from universalism toward selectivity in using social policies to combat poverty in the developing countries. He reviews lessons from such policies and considers the administrative difficulties of targeting in the poor countries. The paper focuses on the cost-effectiveness of poverty reduction efforts, the political economy bases of policy choices, and the consequences of policy choices for individual incentive.
Drawing on recent work and data on social protection in the developing world, this essay evaluates the current state of the art and suggests several important new lines of research. We first examine the historical origin and evolution of social protection systems in developing countries, arguing that insufficient attention has been paid to the authoritarian roots of developing nations' social policy. As a preliminary effort to remedy this shortcoming in the literature, we offer a political logic for the observed variation in the character of institutions of social policy established by nondemocratic regimes. Next, we explore recent research examining linkages between models of economic development and welfare regimes in developing countries. Finally, we turn to the study of the political determinants of the social policy reforms that occurred in the final decades of the twentieth century, arguing that variation in reform across policy areas has been more complex than is generally appreciated in the literature. To explain this variation, we develop a theory that identifies the political coalitions supporting different policy outcomes.
This chapter argues that political competition in new democracies can play an important role in the formation, implementation and sustainability of anti-poverty programmes. Much of the current literature on the determinants of policy success stresses that politics matters. However, politics in this context is usually discussed with reference to hard-to-specify concepts (such as political leadership), to the indirect effects of democracy (such as transparency and the increased flow of public information) or to increased civic engagement and popular participation. While I recognize that in some contexts these factors do play a role in explaining development success and institutional change, public policy decisions are primarily made by political actors in formal political institutions who are driven by concerns with political survival. In democracies this essentially means the ability to win elections. This statement is a truism for established industrial democracies, but is a neglected dimension in current analyses of public policy in developing countries. Most authors who focus on domestic politics in new democracies have focused on how the electoral process is governed by a clientelistic logic that undermines efforts at reforming existing programmes or introducing new programmes (for Brazil see Samuels, 2003). Political competition is seldom viewed in a positive light.
This book is one of the first attempts to analyze how developing countries through the early twenty-first century have established systems of social protection (i.e. pension and poverty programs, and public health and education systems) and how these systems have been affected by the recent processes of globalization (i.e. greater exposure to international trade and capital markets) and democratization. The book focuses on Latin American - a pioneer in social policies in the developing world - to identify factors associated with the evolution of welfare state policies during the pre-globalization period (1920-1979), and studies how globalization and democratization in the last 25 years have affected governments' fiscal commitment to social spending. © Alex Segura-Ubiergo 2007 and Cambridge University Press, 2009.
Universalism in social policy is politically challenged and normatively contested. This book examines how the principle of universalism can be understood and how it has been put into practice in various national contexts. Universalism is contrasted with the idea of diversity which has gained strength as a result of growing affluent middle classes and of multiculturalism in highly developed welfare states. The book deals with varieties of universalism and inspires a re-thinking of the normative basis of the welfare state - Stein Kuhnle, University of Bergen, Norway and Hertie School of Governance, Berlin, Germany. © Anneli Anttonen, Liisa Häikiö and Kolbeinn Stefánsson 2012. All rights reserved.
The rise of social assistance in Brazil has been remarkable. The 1988 Constitution signalled a renewed ‘social contract’ leading to citizenship-based social assistance providing guaranteed income to older and disabled people in poverty. Municipal activism in the 1990s extended the provision of direct transfers to all households in poverty through Bolsa Escola and other programmes later consolidated into Bolsa Família. This article studies the origins and evolution of social assistance institutions in Brazil, paying due attention to the role of ideas and politics.
Social contracts about inequality and redistribution are country-specific. We rely on a model of inequality and redistribution where multiple steady states can emerge in given country. We link the model to the recent literature on beliefs and argue that beliefs are a major determinant of which equilibrium results. We show that changes in beliefs may shift the equilibrium in a country over time. We present evidence that beliefs are typically very stable over time, yet argue that Brazil has recently undergone a dramatic shift in beliefs which we show is associated with a change in the country's social contract in the past thirty years. The transition from one social contract to another has taken place through a process which we call 'dissipative inclusion', where redistribution and social inclusion are effectively achieved but accompanied by distortions, inefficiencies and rent dissipation.Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.
The provision of social insurance in Latin America has undergone rapid and significant changes in recent years. After a strong swing toward private solutions in the 1990s, many countries have moved decisively in the opposite direction in the 2000s. Publicly-funded initiatives – including tax-financed, non-contributory benefits – have taken on new prominence in the “policy-mix” of public and private offerings in a wide set of countries. Surprisingly, this return of the state has enjoyed broad-based popular support. Why? Using survey data from eighteen Latin American countries, this paper documents the decisive role that employment vulnerability and income sensitivity play in determining the recent, individual-level demand for public (rather than private) provision of social policy. It finds that exposure to labor-market risks, both at the individual and household-level, is strongly associated with support for public options. In contrast, household income – long held to be a major factor in social insurance preferences – has differing effects across policy areas, with a non-linear influence on public health plans, but no clear effect for pensions.
Universalism is a category that is widely used both in mainstream theorizing on welfare states and in feminist scholarship. Yet, scientific analyses of the concept and politics of universalism are rare. The article looks at the idea, principle and politics of universalism in the contexts of income security and welfare services. Universalism turns out to be a complex concept with different dimensions and meanings. It is an important ideology behind social policy, and universal solutions have successfully resolved class- and gender-related conflicts in the Nordic countries. Universalism is also an integral part of woman-friendly social policies.
Policy in Brazil changes by accretion rather than by substitution. Schmitter 1971, 256 In the last two decades, Brazil's health care system has undergone two major transformations: universalization and municipalization. Prior to 1988, the administration of the health care system was centralized in the federal government. The member states and the municipalities had a minimal role in the management and delivery of health care. National funding was channeled, via contracts, to the private sector, and inequalities in the provision of services were pervasive. A large portion of the population did not have access to health care, either because they were uninsured or because there were no health facilities in the areas where they lived. Two decades later the system has been radically reconfigured. In the new health care system, coverage is universal, access is free, public services are integrated, and the delivery of health care is decentralized. The private sector continues to exist alongside the public sector, but its importance as a contractor for the public system has diminished significantly. The Brazilian states and some of the large municipalities are responsible for high-complexity health services, and all of the municipalities – more than fifty-five hundred in total – deliver basic health care services. This development is puzzling in light of existing theories that all point to insurmountable political barriers to universalization in a context such as Brazil. Several features of the previous system should have dampened efforts in this direction.
Countries have reached universal health coverage by different paths and with varying health systems. Nonetheless, the trajectory toward universal health coverage regularly has three common features. The first is a political process driven by a variety of social forces to create public programmes or regulations that expand access to care, improve equity, and pool financial risks. The second is a growth in incomes and a concomitant rise in health spending, which buys more health services for more people. The third is an increase in the share of health spending that is pooled rather than paid out-of-pocket by households. This pooled share is sometimes mobilised as taxes and channelled through governments that provide or subsidise care--in other cases it is mobilised in the form of contributions to mandatory insurance schemes. The predominance of pooled spending is a necessary condition (but not sufficient) for achieving universal health coverage. This paper describes common patterns in countries that have successfully provided universal access to health care and considers how economic growth, demographics, technology, politics, and health spending have intersected to bring about this major development in public health.
We examine the impact of local politics and voter preferences on the allocation of publicly subsidized (SUS) health services across 4,338 counties in Brazil. SUS clinics, doctors and nurses (per capita) are higher in counties with a higher share of uninsured in the population and with higher per capita incomes, as is consistent with a probabilistic voting model. Political participation (i.e., the fraction of the poor who vote) and the political power of the mayor (his vote share in the last election) are associated with more visible health inputs, viz., clinics and consultation rooms, but not with more doctors and nurses.
Do varieties of welfare capitalism exist in the developing world? This analysis challenges scholars of comparative political economy and international political economy who treat the political economies of less developed countries (LDCs) as more or less identical to one another or, at the other extreme, as nations marked by tremendous diversity. This paper is one of the first attempts to highlight systematic differences among the political economies of the developing world, particularly with respect to their distribution regimes. Using cluster analysis, the results illustrate that welfare efforts in LDCs are either directed towards promoting market development (a productive welfare state), protecting select individuals from the market (a protective welfare state), or both (a dual welfare state). The discovery of distinct patterns of welfare regimes in LDCs presents hitherto unknown implications for the influence of domestic politics and policies in late twentieth-century globalization.
Brazil is a country of continental dimensions with widespread regional and social inequalities. In this report, we examine the historical development and components of the Brazilian health system, focusing on the reform process during the past 40 years, including the creation of the Unified Health System. A defining characteristic of the contemporary health sector reform in Brazil is that it was driven by civil society rather than by governments, political parties, or international organisations. The advent of the Unified Health System increased access to health care for a substantial proportion of the Brazilian population, at a time when the system was becoming increasingly privatised. Much is still to be done if universal health care is to be achieved. Over the past 20 years, there have been other advances, including investments in human resources, science and technology, and primary care, and a substantial decentralisation process, widespread social participation, and growing public awareness of a right to health care. If the Brazilian health system is to overcome the challenges with which it is presently faced, strengthened political support is needed so that financing can be restructured and the roles of both the public and private sector can be redefined.
This article examines Brazils constitutional right to health and their pharmaceutical access. It states that Brazil must raise their funding for essential medicines and pursue strategies to ensure universal availability of medicines that the government has a legal responsibility to provide in order to reduce vulnerability to disease.
The authors examine the impact of local politics and government structure on the allocation of publicly subsidized (SUS) health services across municipios (counties) in Brazil, and on the probability that uninsured individuals who require medical attention actually receive access to those health services. Using data from the 1998 PNAD survey they demonstrate that higher per capita levels of SUS doctors, nurses, and clinic rooms increase the probability that an uninsured individual gains access to health services when he, or she seeks it. The authors find that an increase in income inequality, an increase in the percentage of the population that votes, and an increase in the percentage of votes going to left-leaning candidates are each associated with higher levels of public health services. The per capita provision of doctors, nurses, and clinics is also greater in counties with a popular local leader, and in counties where the county mayor and state governor are politically aligned. Administrative decentralization of health services to the county decreases provision levels, and reduces access to services by the uninsured, unless it is accompanied by good local governance.
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