Natasha Borges Sugiyama addresses a vitally important question for those seeking a better understanding of anti-poverty and social welfare policy in Brazil. What forces drive the spread of progressive, equity-enhancing social sector reforms in that country? Conventional theories that attribute prime motivation on the part of politicians and policy-makers to electoral self-interest, she argues, are of limited relevance nowadays. Focusing on reforms in education and health, Sugiyama contends that social progress in these sectors, traditionally sources of clientelistic political patronage, has been transformed by two other major diffusion factors. First, she argues a case for the influence of left-of-centre ideology on the part of well-meaning mayors and technocrats drawn naturally towards such progressive change in the wake of constitutional change. This is expanded and built upon, she maintains, through a second driving force of professional networks, especially in Brazil's health sector, responsible for consolidating new ‘socialised norms’ in favour of reform.
The study concentrates on two major, ‘well regarded’ areas of social reform in Brazil, judged to have delivered substantial benefits to poorer sectors of the population. The Bolsa Escola (School Grant) programme started life in the mid-1990s in the federal district of Brasília, paying mothers a monthly stipend to encourage primary school attendance. The Guaranteed Minimum Family Income Programme in Campinas included education and health conditionalities. The Bolsa Escola was later scaled up to national level under President Fernando Henrique Cardoso, and in 2004 Lula incorporated it into the Bolsa Família (Family Grant, BF) conditional cash transfer programme. With its administration decentralised to municipal level, the BF now reaches some 13 million poor families and is the world's largest cash transfer scheme.
The Programa Saúde da Família (Family Health Programme, PSF) emerged out of several local experiments in preventive, basic health-care provision, encouraged by the Ministry of Health and complemented by a community health worker programme. This primary health-care model, based on working with families to map out needs and requirements at the grassroots level, challenged the dominance of Brazil's secondary, curative health approach. It drew from the ‘Family Doctor’ model established by the municipal government of Niteroi, which had been guided by Cuba's experience, and from the state of Ceará. Starting in the north-east in 1994, by 2011 the PSF covered 95 per cent of Brazilian municipalities, and it is credited with having drastically reduced rates of infant mortality and morbidity.
The research that underpins these findings has been extremely thorough. Based on large-scale surveys and interviews, it uses ‘event history analysis’ to test the impact of political incentives, ideology and social networks on diffusion, using a database for 224 cities with populations of over 100,000. Interviews with 120 policy-makers involved in health and education were undertaken in four major municipalities: Belo Horizonte, Brasília, Salvador and São Paulo. Quantitative investigation and verification has thus been combined with qualitative analysis to identify policy-makers’ own perceptions of their motivations.
The book makes a welcome and convincing argument that social policy-making is a complex process in which it cannot be assumed that ‘actors follow conventional rational choice assumptions about electoral self-interest and pursue policies to win elections and political influence’ (p. 151). Be that as it may, in stressing ideology and social networks as major drivers of diffusion, there is a risk that the electoral dimension may be underplayed, in some contexts at least. It should not be forgotten, for example, that the popularity of Lula in his 2006 re-election campaign for the presidency, especially among poor north-easterners, was attributed in some measure to his highly visible promotion and expansion of the BF just months before the polls. On the health side, even if mayors have rarely adopted reforms for crude electoral purposes (as convincingly argued in the case of the PSF, for example), once taken up, many politicians nonetheless have subsequently used reforms to build up their political standing.
There is, however, a more subtle issue at stake that transcends crude electioneering. Poorer Brazilian citizens increasingly perceive social protection and welfare services as their right, an entitlement rather than a favour. In future this could well give voters bargaining power right across the political spectrum as they express their frustrations with the failure of the state to deliver basic services. This was clearly evident in the 2013 public demonstrations across major Brazilian cities. In her very fluently written, informative and persuasive tome, Sugiyama concludes with a hopeful message: that the coming together of ideological beliefs and the reinforcement of professional norms augurs well for the future of social policy-making in Brazil. Although the author does not specifically suggest it, perhaps we could even see the emergence of a sort of ‘progressive path-dependence’ (if I might use that term) in which social reforms are sustained, if not necessarily generated, by a degree of people power through the ballot box. No doubt further research will shed light on this encouraging prospect.
