| Titre : | Crafting Universal Health : bureaucratic Agency in the Evolution of Brazil’s Health System |
| Auteurs : | Andreza Davidian ; Adriano MASSUDO, dir. ; Nicolas Sirven, dir. |
| Type de document : | Thèse |
| Année de publication : | 2024/12/17 |
| Description : | 261p. / tabl. |
| Langues: | Anglais |
| Mots-clés : | Doctorat ; France ; Politique santé ; Santé publique [généralité] ; Sécurité sociale ; Réforme ; Décentralisation ; Administration |
| Résumé : |
The Brazilian universal health system provides comprehensive healthcare services to over 150 million people across South America's largest territorial area, making it one of the largest in the world. Understanding how this was accomplished offers insight into the process through which a universal and decentralized health system was established in a country once labeled as the most unequal in the world. This dissertation examines the role of the federal bureaucracy within the Ministry of Health and the public health experts (sanitaristas) who have consistently operated within the state to build and consolidate the Unified Health System (SUS). To address this, the study conducts a case analysis tracing the trajectory of healthcare universalization from the 1970s – when the gradual reform process began to gain momentum – through the political crisis of 2016. Building on theories of institutional change and an agency-based framework for public policies, and set against the backdrop of discussions on welfare development in Latin America, this research challenges (i) skeptical views suggesting that significant changes in social policy regimes are unlikely without broad mass political support or large-scale social movements, and (ii) assumptions that progressive bureaucrats are powerless in systems undermined by state inertia, entrenched patronage, and pervasive clientelism, as seen in Brazil. Instead, it argues that the strategic intervention of the public health experts, both before and after the 1988 reform, was crucial in developing collective agency and institutional capacity within the sector. Far from being mere bureaucrats, they crafted innovative policy instruments to improve the system, leveraging resources such as technical expertise, managerial skill, political acumen, and strong ties to the public health community. The study also demonstrates how public health experts adapted to shifting political environments, navigating a democratic transition and three different governmental cycles. These professionals not only contributed to the design of policy instruments that shaped decentralization and health financing but also ensured that primary care remained the backbone of Brazil’s health system. Their capacities were essential for addressing challenges and sustaining the expansionist agenda of health reform over decades. By highlighting their influence across different administrations, the research also underscores the Ministry of Health's increasing importance in coalition negotiations, particularly given its oversight of policies that impact every municipality in the country.
Ecole doctorale n° 599 droit et science politique spécialite : science politique. NNT : 2024HESP0003 |
| Diplôme : | Thèse soutenue à l'Ehesp |
| Spécialité de la thèse : | Sciences sociales, sociologie, anthropologie |
| Plan de classement simplifié : | Thèses soutenues à l'Ehesp |
| En ligne : | https://theses.fr/s379297 |
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