Has politics shaped the terms ‘accountability’ and ‘participation’?

Over my lifetime, I have observed several changes in terms and meanings of words within the political arena. Political parties, international agencies and public institutions often absorb words and expressions born from social movements or among leftist academics.

We could compare this process to the children’s game which in Brazil is called “telefone sem fio” (“Wireless Telephone”), where one person whispers a message in the ear of the next person and so on through a line of people. The final message is invariably altered through this process. An even better comparison would be a vaccine, which uses the attenuated form of a virus and no longer causes a disease.

In a similar way, some old “revolutionary” words or expressions are totally attenuated today. These include words such as: freedom, constitution, social rights, civil rights, human rights, citizenship, union, women, gay, sex, equity, inequity and many others. Political parties use most of those words in their speeches and there is an increasing need to explain and clarify their meaning as they do not mean the same thing to everyone.

I would like to reflect on two words that I think are important to those of us contributing to the Unequal Voices project: accountability and participation. ‘Accountability’ and ‘participation’ are two concepts that have become key to development programmes. The meaning of these terms has changed over time and the words associated with these concepts vary in different languages.

I started to think about this issue after reviewing the paper written by our colleagues for the Unequal Voices project, ‘Accountability processes in the construction of the Brazilian Unified Health System’ which will be published shortly.

The words: accountability and participation

The meaning of words is linked to what they represent in a given society.

‘Accountability’ is a word often used by social movements in English-speaking countries to explain the process of getting feedback from politicians and public institutions on their commitments to society, among other meanings. The word itself has no single translation to Latin languages. In Brazil, for instance, we translate ‘accountability’ using a set of words that better represent the meaning of accountability to our society: transparency, ‘responsibilization’, reporting, feedback, participation.

The social movements in Brazil played a very important role in the process of construction of the Brazilian Unified Health System (SUS) after almost 20 years of dictatorship. The issue of participation was considered crucial to the way that accountability was built within the SUS. At that time, participation in the social movements was so strong that Brazil’s new Constitution of 1988 not only considered health as a right but also as an obligation of the state. Social participation was also embedded in the architecture of the SUS through the creation of joint committees at local, state and national levels. There was strong social participation in these joint committees, unlike what we observe today.

The Brazilian Unified Health System in Brazil

Almost 30 years after the new Brazilian Constitution and the SUS the words ‘accountability’ (used in English) and ‘participation’ can now be easily identified in a search of the relevant Brazilian academic literature. There are a large number of articles analysing those key pillars of the SUS. The review carried out for the paper reveals the disturbing fact that the SUS participatory mechanism has been used for political purposes.

At the local, state and national levels researchers observed that society representatives, in many cases, were not nominated by the community but by the politicians. This fact led me to call for the need to review the meaning of the terms ‘participation’ and ‘accountability’. A genuine ‘participation’ of social movements and civil society within the political arena is never a political given but a hard-won battle that is still being fought.

Low and middle-income countries aiming to improve their accountability processes in the area of health should take into account this key point about participatory mechanisms. They need to be aware that emerging terms in the political arena often have a history. To avoid cases of cooptation of civil society representatives by political mechanisms civil society needs to be aware of the situation, able to question and transform it.


“Participação” e “accountability” são termos oriundos dos movimentos sociais acabaram cooptados pelo discurso político-eleitoral. A participação social desempenhou um papel muito importante no processo de construção do Sistema Único de Saúde (SUS) após quase 20 anos de ditadura. Também foi incorporada na arquitetura do sistema através da criação de comitês conjuntos a nível local, estadual e nacional. Atualmente, há uma grande quantidade de artigos acadêmcios que analisam os principais pilares do SUS e um dos elementos observados é a utilização dos mecanismos participativos do SUS para fins políticos.
Este fato levo a rever o significado dos termos “participação” e “accountability”. Uma verdadeira “participação” dos movimentos sociais e da sociedade civil na arena política nunca é uma disputa política, mas uma batalha duramente conquistada que ainda está sendo travada.
Os países de baixa e média renda que visam melhorar seus processos de responsabilização na área da saúde devem levar em consideração esse ponto-chave sobre mecanismos participativos. Para evitar casos de cooptação de representantes da sociedade civil por mecanismos políticos, a sociedade civil precisa estar ciente da situação, capaz de questioná-la e transformá-la.

Luiz Eduardo Fonseca works for the Centro de Relações Internacionais em Saúde (Centre for International Relations in Health), at the Oswaldo Cruz Foundation (FIOCRUZ), the Brazilian Ministry of Health’s institute of science and technology in health. Luis Eduardo is a member of the international reference group for the ESRC-DFID funded Unequal Voices project, part of the Accountability and Health Programme at IDS. 

This article was originally published on 11 July 2017 on http://www.ids.ac.uk –  http://www.ids.ac.uk/opinion/has-politics-shaped-the-terms-accountability-and-participation

Photo credit: Pan American Health Organization/Flickr



Is accountability for health equity a blaming dance?

Alexandre Calandrini, from Unequal Voices, shares some reflections on the first day of the ‘Unpicking Power and Politics for Transformative Change: Towards Accountability for Health Equity workshop held at the Institute of Developing Studies (IDS)from 19-21 July.

Who is to blame?

In India, informal healthcare providers prescribe antibiotics to patients, sometimes even when it is not recommended. This can increase microbial resistance to these drugs, potentially leading to the spread of extremely serious infectious diseases.

Suppose you are an Indian health executive manager, who would you blame?

You could choose to blame informal healthcare providers. If so, you could decide to punish them by forbidding them to prescribe antibiotics. Weeks later, your local newspaper starts to question why infectious diseases are on the rise and more and more people dying from them. You might then realize that in India, as in many other places, a huge part of health care is delivered by informal providers. Forbidding them to prescribe antibiotics might address the antibiotic resistance, but it also then stops them from treating common infectious diseases, such as pneumonia or pharyngitis. In other words, you protect them against super infections, but make them an easy prey to treatable ones!

Now, let’s say you decide to blame the pharmaceutical industry instead, as they are the ones teaching (or pushing?) these informal providers to prescribe these drugs in what Abhay Shakka might describe as ‘fancy hotel’ seminars. Perhaps the way forward is to harshly punish “big pharma”. The next day, you are asked to leave the office, for whatever reason, except the actual reason which might be that a powerful politician made a call given that they happened to be financed by your most recently-acquired enemy.

Ok. Maybe blaming the microbes or the fatalistic understanding that people may die eventually from difficult-to-treat diseases is a more reasonable position which would allow you to hold onto your job.

Would you be satisfied with that? Probably not.

Let’s move then to how to regulate the private sector in the post-Soviet mixed health system of Mongolia. How would you do it?

That is the question Uranchimeg Tsevelvaanchig presented in the Pluralistic Health System session. She reinforced the need of a system perspective that defines the complimentary role of these early stage private providers, in a consistent policy, that not only focuses on isolated regulation, but combines it to a proper understanding of incentives. This immediately made me think on the Private sector regulation in Brazil, which has only started a few years ago, with an already huge health market in place. What if we (in Brazil) had strategically considered the private sector role right in the bginning of our Sistema Único de Saúde (and not simply stating its existence in our Constitution of 1988)? Perhaps we could have achieved a much more synergistic public-private mix than the one we have today. Well, I can´t go back in time. However, I can definitely learn from the Mongolian case, in search for insights.

What is accountability for health equity?

If you ask me what accountability for health equity is, I confess I would hesitate to give you a precise answer, simply because there isn’t a definitive one. This was another lesson from the session on historical concepts, definitions and language issues around accountability. As John Gaventa (IDS) put it (in a much better way than I’m able to recall), whichever way we frame the title (Social Participation? Social Accountability? Transparency?) – all still relevant for various reasons – the most important issue is to keep discussing what is under this umbrella term: social and health inequalities, democracy, and power: to, with and over.

As a medical student, my peers would probably show strong reservations about my presence in such an event. Not that I would blame them (I’m tired of reproducing the “blaming game”).It is hard. Sometimes the world’s problems are too big for you (shall I throw in the towel?). But then you notice that a solution for a problem you may be facing in your country seems to be popping up in China or India, and you think to yourself: “What if…?”.

As Vera Schattan Coelho told me during the workshop: “That’s IDS: a way to add complexity to our usual thinking”. Can’t wait for what comes out of this workshop.

Alexandre Calandrini is a medical student of Universidade Federal de São Paulo, Brazil 

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Equidade e Coprodução em Saúde: Aprendendo com Brasil e Moçambique

Em 2004, o World Development Report do Banco Mundial afirmava que “os serviços de saúde falham para as pessoas pobres não devido à falta de conhecimento para prevenir e tratar doenças, mas porque os sistemas de saúde estão presos a uma rede de relacionamentos pouco transparente e responsiva a essas pessoas”. Apesar de esforços substanciais travados por mais de uma década em diversos países para enfrentar essa situação a afirmação permanece válida, e a busca por soluções segue urgente.

Desigualdades em saúde são um fato amplamente conhecido em países em desenvolvimento, aparecendo como causa e consequência de outros problemas relacionados à pobreza. Mesmo em países que, em anos recentes, vivenciaram rápido crescimento econômico e aumentaram significativamente os investimentos em saúde o progresso na redução das desigualdades segue lento. Isso é verdade especialmente na África e na Ásia. Para enfrentar essa situação os novos Objetivos de Desenvolvimento Sustentável da ONU destacam a importância de garantir que bons serviços de saúde cheguem a todos os cidadãos e cidadãs, sem exceção.

Se é grande o conhecimento sobre fatores sociais e econômicos que geram e perpetuam desigualdades na saúde, o mesmo não pode ser dito sobre fatores políticos e institucionais. Sabemos que apenas contar com as eleições não é suficiente para enfrentar a desigualdade – mecanismos de responsabilização e rendição de contas mais regulares e diretos também são essenciais, e têm sido implementados em diversos países. Falta, no entanto, entender em detalhes o que leva ao sucesso ou ao fracasso desses mecanismos, em diferentes contextos e para diferentes grupos sociais.

É exatamente esse desafio que o  Cebrap, a N’weti e o Institute of Development Studies estão se dispondo a enfrentar em um novo projeto de pesquisa a ser desenvolvido no Brasil e em Moçambique. Este projeto se propõe a investigar as relações entre a trajetória das desigualdades na saúde e  dinâmicas tanto eleitorais, quanto da administração pública como, ainda, da participação social, tanto em centros urbanos quanto em áreas rurais. Com isto pretende-se identificar as dinâmicas que têm contribuído para a redução das desigualdades em saúde sob diferentes condições políticas e institucionais. Para além de avanços conceituais e metodológicos, o projeto também investirá em conexões e espaços de colaboração entre grupos que estudam, formulam e implementam políticas públicas de saúde no Brasil e no Sul da África, promovendo interações constantes entre especialistas e gestores públicos.

Não existem fórmulas mágicas para enfrentar as desigualdades em saúde. As soluções dependem do contexto. Certamente há, no entanto, lições que diferentes países podem aprender uns com os outros, assim como abordagens que apresentam maiores chances de sucesso. Nesse sentido, Brasil e Moçambique, países que têm cooperado entre si e implementado políticas inovadoras na área de saúde, certamente têm muito a ensinar e aprender.

Descobertas e aprendizados desse projeto serão publicados regularmente aqui neste blog.