The Role of Professionals in Policy Reform:

Cases from the City Level, São Paulo

Monika Dowbor
Peter P. Houtzager

ABSTRACT

A new generation of social policies in Brazil and elsewhere in Latin America are
being read by scholars as first and foremost the result of top-down initiatives by
state elites and technocrats. This article explores what role, if any, middle-class
professionals have played and how this role might be framed in analytical terms.
The article examines the trajectory of two of the most important new social
programs that target the poor in the city of São Paulo, Brazil: the family health
program PSF and Renda Mínima. It compares the city-level reform dynamics
that have shaped the trajectory of the programs over 18 years. It finds that net-
works of reformist middle-class professionals that traverse public and private
institutions played a substantial role in the creation and evolution of the new
programs.

R ecent social sector reforms and a new generation of antipoverty initiatives in

Latin America are being read by scholars as first and foremost the result of top-
down initiatives by state elites and technocrats. In contrast, middle-class profession-
als, as a bounded social phenomenon and analytical category, rarely, if ever, feature
in generalizations about (or theory-driven explanations of) the causes and paths of
reform in Latin America. The region’s middle-class professionals, such as social
workers and public health specialists, feature well below the analytic radar, with
some notable exceptions (e.g., Tendler 1997; Sugiyama 2008; Falleti 2010a; Keck
and Abers 2006). This article explores what role middle-class professionals have
played in creating and sustaining two of the most important new social programs in
Brazil, and how this role intersects with that of reformers “from above” and move-
ment pressure “from below.”
Current explanations of how these reforms came about are based largely on
comparative national-level studies that take a political-economy approach, with
some light institutionalist touches. Unlike twentieth-century social policy reform, in
which mobilization of large, organized classes from below (such as working classes
and campesinos) played a critical role, policies formed in the 2000s, such as income
guarantees and supports and universal healthcare, are explained by top-down initia-

Monika Dowbor is a researcher at the Centro Brasileiro de Análise e Planejamento

(CEBRAP) and a postdoctoral fellow at the Centro de Estudos da Metrópole (CEM), São
Paulo. mdowbor@gmail.com. Peter P. Houtzager is a research fellow at the Institute of
Development Studies. p.houtzager@ids.ac.uk.

© 2014 University of Miami

DOI: 10.1111/j.1548-2456.2014.00240.x
142 LATIN AMERICAN POLITICS AND SOCIETY 56: 3

tives by state elites and technocrats. Studies argue that few if any organized actors
had an interest or capacity to pressure for such inclusionary programs from below.
Mobilization from below by industrial workers and public sector employees,
such as teachers, nurses, and public administrators, was a significant factor in resist-
ance to neoliberal reforms of existing pension and social insurance systems. Social
policy reforms, such as altering public pension schemes or making access to health-
care universal, are driven by politics within the upper reaches of the state, shaped in
turn by the architecture of national sectoral institutions and trends in political econ-
omy (Haggard and Kaufman 2008, chap. 7; Kaufman and Nelson 2004a, 475). The
“executive,” the state or policy elites, or simply technocrats, are the primary agents
of reform (Grindle 2000; Kaufman and Nelson 2004b; Melo 2008).
This article seeks to contribute to this explanation in two distinct ways. First,
it looks at the role of a uniquely situated and largely overlooked social group—
public sector professionals—in the introduction and maintenance of a new genera-
tion of social policies. Second, it complements the current national or regime-level
focus with an in-depth exploration of the local dynamics of reform, in particular
those in the urban center of São Paulo (population 10.5 million).
Why are reformist professionals potentially potent groups in public sector
reform? The professions vary greatly, including their presence in the public sector,
and the same professions can have very different trajectories in different countries.
Nevertheless, two features stand out, and the degree to which they are present may
increase their role. First, all professional groups, not just those prominent or prima-
rily in the public sector, control the specialized knowledge of their field and arbitrate
what are considered good and bad policies and practices. This form of societally
legitimized expertise is a major source of power. This expert knowledge is a source
of influence not only in the formal design of policy, but also in the broader political
process of building support for reform, not least as other actors seek to stretch the
legitimacy of professional expertise over their policy agendas.
Second, horizontal professional networks, when they span public and private
institutions and multiple levels in a single institution, can contribute powerfully to
substantial institutional change. These networks facilitate the flow of ideas, infor-
mation, political proposals, and policy solutions. They also facilitate multilevel
activism, as members can coordinate between local offices and national ministries or
agencies. A small number of individuals in a professional field can become particu-
larly influential “inside” and “outside” their own field. These individuals occupy
prominent positions in multiple fields, and a part of their power resides in their abil-
ity to link fields and act as bridges.
This study examines what role two professional networks—labor economics
and public health, the well-known sanitaristas—have played in creating and sustain-
ing two important new social programs in Brazil. Renda Mínima, the Minimum
Family Income Guarantee Program, is a city government social policy adopted in
2001 as other cities, states, and the federal government (and ultimately the nation-
wide Bolsa Família program) were introducing diverse types of income support pro-
grams. It is a cash transfer program, and it seeks to universalize access to primary
 DOWBOR AND HOUTZAGER: PROFESSIONALS AND REFORM POLICY 143

education and healthcare for children under the age of 16. The Programa Saúde da
Família (PSF, or Family Health Program) has different origins. It began in 1994 as
a federal program targeting poor rural areas of Brazil, implemented by municipal
governments. The city of São Paulo opted into the program in 2001, only one of a
handful of large cities to do so. PSF provides primary care to the poor and is meant
to be a gateway to the National Unified Healthcare System (Sistema Unico de Saude,
SUS), established by the Constitution of 1988 to guarantee citizens’ right to health.
The two programs target the poorest 20 percent of São Paulo’s population.
Our research in São Paulo found that the city’s political leaders at various stages
made basic choices about how (and whether) to pursue the directives and goals set
by national reforms in social policy and to pursue their own policy initiatives. In
doing so, they allied with different professional groups, and different groups in par-
ticular professions that had longstanding ties to their parties. Progressive econo-
mists, particularly those specializing in labor economics, played a central role in
introducing the municipal minimum income grant program Renda Mínima.
Reformist public health professionals helped introduce the PSF in the city. We also
found that contrary to the argument that participatory institutions, because they
facilitate pressure from below, will play an important role in distributive reforms,
São Paulo’s participatory governance councils and participatory budget have played
a very limited role in building support or sustaining the programs.1
One of the contributions of our analysis, therefore, is to identify some of the
subnational dynamics of social policy and institutional reform. Research on Latin
America’s social sector reforms has had a national-level or sectoral focus, but here we
zoom in to the city-level dynamics of reform (Sugiyama 2008).2 The uptake of
national reforms by local governments is neither mechanical nor automatic, as local
officials must interpret national mandates and make complicated political choices.
Particularly in the case of federal systems such as Brazil’s, municipal-level govern-
ments have considerable autonomy about whether and how they meet national man-
dates.3 City governments, such as that of São Paulo, make policy in health and social
assistance, experiment with new benefits and forms of service delivery, and negotiate
relations with a wide array of actors involved in provisioning services and benefits.
Our focus on professional networks and the dynamics of their involvement in
social policy reform is not meant to displace political economy explanations. It is
meant to fill in what we feel is an important gap in our current work: to demonstrate
that the professional networks of public sector workers can and have played a vital role
in shaping the direction of public sector reform in ways that have been inclusionary.
Our claims are therefore limited. We do not contend that public sector professionals
are likely in general to be important actors in reform (or policy innovation). The two
cases we examine in the city of São Paulo, however, provide secure foundations for a
smaller claim: that professional networks can be important forces of social sector
change, and deserve greater attention than they have received in recent studies.
Beginning with a brief explanation for the focus on the city of São Paulo and a
description of the fieldwork conducted, this article proceeds to show how “the pro-
fessions” have been omitted in studies of social sector reform and to lay some con-
144 LATIN AMERICAN POLITICS AND SOCIETY 56: 3

ceptual foundations for the analysis that follows. The two programs and their polit-
ical trajectories provide the case studies. The conclusions suggest that the role
reformist professionals play in different national and subnational context is likely to
be highly variable, depending, among other things, on the trajectories of their
respective professions and that of the political regime.

MULTILEVEL FIELDWORK IN THE

CITY OF SÃO PAULO
Our focus on São Paulo reflects both our deep knowledge of the city and our facility
in access to the major actors that would allow us to trace, over a two-decade period,
the political trajectories of Renda Mínima and PSF, and the city’s status as Brazil’s
largest and most politically diverse metropolis. Its 10.5 million residents (measuring
by the municipal boundaries) and a mighty technological-industrial base make it the
country’s most important political and economic center. It has, furthermore, a long
tradition of left political parties, urban movements, and community activism, and it
is the historical birthplace of the country’s labor movement. As Avritzer (2009, 14)
and others observe, these actors have shaped and continue to shape political events
far beyond the city boundaries, such the country’s democratic transition and the rise
of participatory institutions.
The city also has a tradition of participatory councils linked to left-leaning
actors, dating to the 1970s, and recent municipal governments have experimented
with a number of participatory governance institutions, including participatory
budgeting (2001–4) (Coelho et al. 2010; Houtzager and Gurza Lavalle 2010; Gurza
Lavalle et al. 2005; Tatagiba 2004; Pólis 2007). Civil organizations in São Paulo
have, furthermore, achieved notable influence in various areas of public policy since
the 1990s (Avritzer 2004).
Our fieldwork took place from 2006 to 2008. A team of senior and junior
researchers based at CEBRAP, including the authors, conducted research at multi-
ple analytic levels: summary narratives of the national-level reforms in health and
social assistance based on the secondary literature and interviews; case study research
on PSF and Renda Mínima at the city level; and a detailed analysis of the participa-
tory governance councils for health and for social assistance.
We conducted 44 interviews with leading protagonists in the two reforms in
2006–7. Of these, 15 interviews were with members of the relevant professions, 13
of whom had held public sector positions (as civil servants or appointees). We also
interviewed 21 representatives of civil society (leaders of social or popular move-
ments, trade unions, and nongovernmental organizations), 5 public sector managers
(nonprofessionals), and 3 elected members of the city council. These categories are
permeable; some interviewees have moved back and forth between them, and others
have played bridging roles across categories. For the brief tally here, we categorize
these individuals by the most prominent roles they play in our case study narratives.
We also made extensive use of party, secretariat, and other data and internal
and official documents, as well as the secondary literature in Brazil and abroad. Our
 DOWBOR AND HOUTZAGER: PROFESSIONALS AND REFORM POLICY 145

findings on the role of participatory governance councils come from detailed

research in the archives of the Health and Social Assistance councils.

MOVING SOME CONCEPTUAL BOUNDARIES

Studies of social sector reform in Latin America, differences in explanatory approach
notwithstanding, tend to subsume reformist professionals into other categories of
actors, such as (negatively) internal or vested interests or (positively) reform-minded
state elites or technocrats. The loss of professional networks in such large and amor-
phous categories makes invisible what we believe is their significant contribution to
recent changes in social policy and the institutional architecture of the state’s social
sector. The political-economy and institutionalist approaches that are most
common in the literature further obscure this contribution when they assume the
existence of relatively well bounded state and societal actors that pursue clearly
defined interests, and assume that these interests can, for the most part, be identified
deductively. This assumption hides forces of change that spill over, or across, the
analytic categories of state and society.
Broadly speaking, the literature takes one of two positions on which social
actors have been the forces behind reform over the past two decades. Most studies
argue that initiatives to alter the institutional architecture of social insurance (i.e.,
pensions and health insurance), basic public services (education, health, and so
forth), and the addition of new social protection (minimum income guarantees or
conditional cash transfers) have been initiated and pushed through from above, by
state or policy elites, exceptional leaders, or “the executive.” Reforms were top-
down, Kaufman and Nelson suggest, because, in the classic formulation, “the costs
of social sector reforms were prompt, clear, and concentrated on well-organized
interests, while gains were usually delayed, uncertain, and diffused across much of
the public” (2004a, 475). Facing opposition from well-organized interests and a lack
of public pressure from below, political leaders carried out reforms from the higher
reaches of the state.
A wide array of studies suggest, however, that increased electoral competition,
as a result of democratization in the region during the 1980s and 1990s, has played
a significant role in shaping the choices of these elites as they compete for new or
marginalized constituencies (Melo 2008, 169; Haggard and Kaufman 2008, 13–
17). Pressure from “below”—from organized interests in civil society—has prima-
rily taken the form of opposition to social insurance reforms that threaten to strip
benefits and security from the industrial working class and public sector workers
(Grindle 2000; Kaufman and Nelson 2004a; Haggard and Kaufman 2008).
Another set of studies argue that without broad-based coalitions pressuring polit-
ical and state elites from below, reform that makes states more responsive to the poor
is not possible. These studies explore the failure of the poor, the working class, and
others to coalesce into effective reform movements. This failure is attributed to polit-
ical-economy effects of neoliberal globalization or to the nature of state and political
institutions (Weyland 1995; Roberts 2002). Related but from a different perspective,
146 LATIN AMERICAN POLITICS AND SOCIETY 56: 3

work on participatory democracy and citizen participation argues that new institu-
tional arrangements that give ordinary citizens access to decisionmaking centers help
to make the state responsive to classes of poor people (Avritzer 2002; Coelho and
Nobre 2004; Wampler 2010; Santos 1998; Fung and Wright 2003; Heller 2001).
Where did the professions go in these different accounts of social service sector
reform? In the first and more common account, professionals are defined either by
their position in the public bureaucracy or by their public sector unions. They are
conflated with public sector employees or bureaucrats, which leads to the conclusion
that the primary interest of groups such as doctors, teachers, or social workers is the
growth of public bureaucracy and protection of a range of civil service benefits
(Nelson 2004, 33).4 In other instances, however—sometimes in the same study—
professionals identified as “public health specialists” are clubbed together with
senior bureaucrats, state elites, or members of “change teams,” who lead reform
from above (Grindle 2000). In yet other work, reformist professionals are defined as
a social movement or part of social movements (Weyland 1995; Falleti 2010b). In
general, however, they are portrayed as “powerful internal interests” suspicious of
reforms and, once mobilized, powerful opponents (Batley 2004, 51).
What we see from studies of waves of public sector reform before the 1980s,
however, is a great variation in the role professionals have played in modernizing the
state and increasing its capacity to act. It is this variation over time and across coun-
tries that needs to be explained.

EXAMINING THE LOCAL FACE

OF NATIONAL REFORMS

The trajectories of Renda Mínima and PSF in São Paulo are closely intertwined with
several national-level reforms. The first of these reforms originated in the democratic
transition of the 1980s and sought, among other things, to deepen democracy and
increase social inclusion. By 1993, each social sector had its own implementing leg-
islation, which created a complex tapestry of laws and rules that reflected the influ-
ence of the various actors in each service sector. A second set of reforms in the mid-
1990s focused primarily on cost savings and making public administration more
efficient in response to the growing fiscal crisis of the state. Inspired partly by New
Public Management (NPM) rather than the political struggles for democracy and
social inclusion (Bresser Pereira 1997), the changes in public administration sought,
with some success, to recentralize significant authority from state and municipal
government in strategic areas, challenged state provision of public services by dele-
gating provisioning to public nonstate organizations—i.e., nonprofit service
providers—and perhaps less successfully, limited recent gains in citizen participation
to the exercise of accountability over service providers (Melo 2008).
These seemingly contradictory pressures intermingled from the mid-1990s on
and led to different combinations of devolution, citizen participation, and the plu-
ralization of public service providers across social policy domains and even programs
within a single policy domain.
 DOWBOR AND HOUTZAGER: PROFESSIONALS AND REFORM POLICY 147

Renda Mínima and PSF are new programs that seek to make ambitious
national promises a reality for poor urban communities—to universalize access to
new constitutional social rights for the poorest quarter of the population, and par-
ticularly those on the edges of the formal labor market who had been excluded from
previous (early-twentieth-century) social policies. The programs have required sub-
stantial institutional reform along the way. Contrary to past social policy models,
they have adopted forms of service delivery that minimize the state’s administrative
role and are compatible, if not always inspired by, New Public Management. PSF
relies heavily on not-for-profit service providers—denominated social organizations
by legislation in the 1990s—rather than line agencies to deliver services; Renda
Mínima (and its federal counterpart, Bolsa Família) provide low-income families
direct cash transfers through the banking system.
The programs therefore embody in unexpected (and perhaps contradictory)
ways the spirit and features of both waves of reform: the constitutional promise of
inclusive citizenship and the shift from a developmental state to what Bresser Pereira
(1997) calls a managerial state. As Kaufman and Nelson (2004a) and Melo (2008)
observe, the politics of the expansion of benefits can be quite different from those
of seeking to contract welfare expenditure through privatization or institutional
conversion, as many social insurance reforms attempted to do in the 1990s.

Renda Mínima and PSF

The programs also differ in the type of goods they offer and in how these are deliv-
ered. Renda Mínima is one of a series of minimum income guarantee programs in
Brazil established first by municipal administrations and then by the federal and
state governments to tackle poverty on a large scale. Renda Mínima in the city of
São Paulo was proposed in 1992 but created only in 2001, when it quickly became
the city’s first large-scale antipoverty program and the largest of the country’s
municipal initiatives. It provides a monthly income grant to families with children
under the age of 16 and, in 2009, a per capita income of less than R$175 (US$91
at the time).5 It requires that the families fulfill a corresponding obligation: ensure
that all school-age children attend at least 85 percent of their classes and that chil-
dren under the age of 6 complete the government’s vaccination schedule.6
The Ministry of Health created the PSF in 1994 as part of a national strategy
to redirect the country’s healthcare model.7 Municipal governments implement the
program, which is funded through a combination of federal transfers and municipal
contributions. The program is executed through health teams composed of, at a
minimum, one general medical practitioner (family doctor), a nurse, an assistant
nurse, and six community health agents. The figures suggest that the city has 1,196
PSF teams that cover roughly 4.1 million people (40 percent of the population)
(Bousquat et al. 2006, 1938).
Both programs come formally under the jurisdiction of participatory governance
institutions—the Municipal Health Council and the Municipal Council for Social
Assistance—allowing us to compare the impact of participatory governance institu-
148 LATIN AMERICAN POLITICS AND SOCIETY 56: 3

tions in both cases. This research design therefore provides a relatively tough test: if
reformist professionals play a significant role in such different sectors and types of
reforms, it is quite likely they will do so in other sectors undergoing significant reform.

BRINGING MINIMUM INCOME GUARANTEES

INTO THE STATE

A loose network of progressive economists and their political party allies sought for
over a decade to bring minimum income guarantees into the city government of São
Paulo. In a first for Brazil, the Workers’ Party (PT) of São Paulo included an income
guarantee in its platform for the municipal elections of 1991. The party lost that
year’s elections and those of 1996, but it finally won in 2000. The PT gave progres-
sive economists in its ranks a chance to enter the city administration and shape
policy toward the urban poor. The Renda Mínima program that was established in
2001 exceeded all other social assistance programs in São Paulo in the size of popu-
lation covered and in budget share within a year.8

Progressive Economists and Partisan Politics

There is a consensus among protagonists of Brazil’s minimum income guarantee

story that prominent Brazilian economists who obtained their doctoral degrees in
the United States during the 1970s carried back to Brazil the debate between Milton
Friedman, Robert Solow, and James Tobin over negative income taxes (Suplicy
1992, 2006; Fonseca 2001). Minimum income guarantees, Antonio Maria da Sil-
veira argued as early as the mid-1970s, were preferable to the longstanding food and
nutrition programs to combat poverty and other forms of service delivery because
they offered minimum interference in the market, gave recipients greater choice,
and were not as costly to deliver. Income guarantees were also less susceptible to cor-
ruption and clientelism, considered endemic problems in existing programs and
services. Economists differed, however, over what form minimum income programs
should take.9
Two projects emerged. The first was for a universal citizen (or basic) income. It
is closely associated with Eduardo Suplicy, a faculty member of the Fundação Getúlio
Vargas Economics Department, a Michigan State–trained economist, and a senator
since the late 1980s.10 Suplicy connects three partially overlapping spheres: profes-
sional, elite, and political. He is a member of the loose network of progressive Brazil-
ian economists, as well as of the elite São Paulo industrialist Matarazzo family, and
the first PT senator ever elected (in 1988). He brought into the PT the idea of
income guarantees, and once elected to the senate, he introduced legislation for a
national minimum income guarantee program. The legislation proposed a citizen
income that would be a universal right of individuals and foresaw the elimination of
most social assistance programs, deemed as wasteful and inefficient (Suplicy 1992).11
The second, and ultimately dominant, project was narrower in scope, focusing
on breaking the cycle of intergenerational transmission of poverty. Labor econo-
 DOWBOR AND HOUTZAGER: PROFESSIONALS AND REFORM POLICY 149

mists such as José Márcio de Camargo (1991) argued that minimum income guar-
antees needed to target families with children, ameliorating immediate economic
distress so that children could be kept in school and acquire the education (and
health) that would help them rise out of poverty, rather than contribute to house-
hold income by working at an early age (Fonseca 2001, 177).
Income guarantees became a new focus in a number of economics departments,
such that of the State University of Campinas (UNICAMP) in São Paulo, its Center
for Social and Labor Economics in particular (CESIT), and the Federal University
of Rio de Janeiro (UFRJ). Labor economists tied to a variety of parties, including
prominently the PT and PSDB, and to a variety of international organizations, such
as the World Bank and the International Labor Office, produced competing models
of such programs. It was Suplicy, as the PT candidate in his home city of São Paulo
in 1991, who proposed the first municipal Renda Mínima program in his platform.
Income guarantees were not a visible campaign issue, but when the PT took
office, the new mayor, Marta Suplicy (wife of Senator Suplicy at the time), and the
powerful finance secretary opened the doors to the proponents of income guaran-
tees. The administration brought in a leading member of a new generation of labor
economists, Marcio Pochmann, Ph.D. 1993, who had written his doctoral disserta-
tion at CESIT-UNICAMP on labor policy and income guarantees.

Social Workers and Renda Mínima

The team Pochmann assembled to create and run Renda Mínima echoed the deep-
seated suspicion among parts of the left of social assistance, the field that had
emerged to care for the vulnerable poor. The team explicitly juxtaposed its approach
to combating social exclusion and poverty with the longstanding social assistance
model, in which small-scale projects that sought to meet the immediate needs of a
particular vulnerable population would segment and be executed by fragmented
networks of nonprofit organizations that were perceived as paternalistic and vulner-
able to forms of political clientelism (Pochmann 2002, 2004). Pochmann wanted a
“fundamental break” in the type of good provided by the state and in the institu-
tional form of its delivery.
A substantial reform movement in social assistance, led by social workers, psy-
chologists, and professors in social work departments at prominent universities,
such as the Catholic University of São Paulo (PUC-SP) and the Federal University
of Brasília, shared some of the economists’ critiques of their field but saw a very dif-
ferent road ahead (Dowbor 2009). Leading intellectuals in university social work
departments, research centers, and other institutions developed a professional proj-
ect that would, in many ways, replicate the health sector’s SUS; that is, a policy field
anchored in the state, rather than civil society, with strong public institutions. The
proposed Unified National Social Assistance System (SUAS) would break with a
historical pattern of extreme pluralization of service providers and a “conservative,
paternalistic, and charity-based model of tending to the vulnerable” that robbed the
poor of their dignity and agency (Sposati 1997).
150 LATIN AMERICAN POLITICS AND SOCIETY 56: 3

Most SUAS activists failed to see the rise of minimum income guarantees as
they pursued their professional project. Some leading social workers sought to dis-
credit income guarantees as a “neoliberal” effort to reduce the role of the state and
(paradoxically from the economists’ vantage point) as a new kind of assistencialismo
that would keep the poor disempowered. And a few argued that such programs were
inherently a part of social assistance and should fall under the control of the people
who actually worked with and knew the poor, the professionals of social assistance
(Sposati 1997). This last group would, in the São Paulo administration, seek to win
control of Renda Mínima.
In the new PT administration, the core disputes between the labor economists
and social workers were whether income transfers should be accompanied by social
assistance programs for specific populations, some of which had become known as
“exit doors” in the field; whether the program should be located in the Secretariat for
Social Assistance or in a new, independent administrative unit; and what role should
be played by civil society organizations that worked with the target population.
The economists prevailed on all fronts. At the crucial foundational moment,
year 1 of the administration, a new department was created within the influential
Secretariat of Finance to pursue Renda Mínima, along with a series of smaller “labor
market reinsertion” programs. This institutional location of the new Department of
Development, Work, and Solidarity (Secretaria do Desenvolvimento, Trabalho, e Sol-
idaridade, SDTS) ensured both proximity of the team responsible for its develop-
ment to the most important figures in the administration—the secretary of finance
and the mayor—and their institutional autonomy from the Secretariat for Social
Assistance. The finance secretary and the mayor provided important blindagem
(armor) against pressures from the social welfare professionals and their allies in civil
society, as well as from city politicians seeking the inclusion of their constituencies
in the program (Schwengber 2007; Paz 2007; Sposati 2007).
As would be the case for PSF, an important electoral rationale favored the
income-transfer component of the initial Renda Mínima program. Electoral pres-
sure meant that the administration’s new programs had to begin producing visible
results within the second year of the four-year term and to hit full stride in the third
year. More pragmatic members of the mayor’s cabinet doubted that the large, slow
social assistance machinery could be turned around to implement the very large and
radically different programs in the time available.

Pressure from Below and Participatory Institutions

The political battles to implement and expand the program were fought primarily
by economics professionals and their allies among the political leadership. With one
important exception, the demands on the city’s administration bypassed the existing
participatory governance councils, such as the Municipal Council for Social Assis-
tance (COMAS), which is meant to oversee social assistance programs (Pólis 2007).
Local leaders and some organizations did attempt to pressure the government
to expand the program at different moments, but demands also were made directly
 DOWBOR AND HOUTZAGER: PROFESSIONALS AND REFORM POLICY 151

on regional administrations, the secretariats, the mayor, or indirectly through the

mediation of vereadores (city assembly members), and largely bypassed participatory
councils such as COMAS and the Forum for Social Assistance (Lisboa 2007; Ser-
afim 2007). That pressure, moreover, came from individual initiatives by local lead-
ers, usually to bring the program to their clientele or to demand the inclusion of spe-
cific families, rather than from networks of organizations seeking to broaden the
program’s coverage or engage in social accountability.
COMAS, which brings together representatives from government, nonprofit
service providers, and user organizations or movements, is formally charged with
making policy and oversight in the area of social programs. As the largest program
for the low-income households that social programs target, COMAS might be
expected to be significantly involved at least in oversight. Our survey of COMAS
meeting minutes and resolutions over the course of seven years found that it appears
to have been proactive in various areas during the PT administration; then, under
the PSDB-DEM administration, it focused its energies mostly on boundary main-
tenance and regulation of the network of nonprofit providers contracted by the city
government to service the poor. Renda Mínima, however, was discussed only twice
in the seven years, and no resolutions were passed approving, modifying, or in any
other way addressing the program (Serafim 2007).

Growing Roots in Hostile Turf

The PT was voted out of power in 2004, and a center-right PSDB-DEM alliance
took office the following year. The institutional structure that had been created to
implement the program was disassembled, and the key supporters of Renda Mínima
in the city apparatus left. The program survived, however, even while many others
from the department were discontinued.
The newly elected mayor, José Serra, was from the PSDB, a party that openly
competed with the PT to get credit for the rise of income guarantee programs in
Brazil (Melo 2008). Serra himself was a prominent economist, and straddled the
economics profession, party politics, and government.12 As national minister of
health, he had introduced a federal income transfer program, Bolsa Alimentação, in
2001. Serra left the mayor’s office early to become governor of the state of São
Paulo, but his more conservative DEM vice mayor did not act against Renda
Mínima. The DEM party was weak in São Paulo, and the city’s unexpected mayor
relied heavily on the new Governor Serra for political support. The program shifted
into the Secretariat for Social Assistance, in an apparent victory for the social work-
ers. It was, however, housed in its own, semiautonomous unit run by staff with
expertise in complex processing tasks, rather than in social work (Hora 2007).
152 LATIN AMERICAN POLITICS AND SOCIETY 56: 3

SANITARISTAS AND THE POOR: UNIVERSALIZING

ACCESS TO HEALTH CARE
Reformist public health doctors and nurses in Brazil, known as the sanitaristas, are
seen as the founders of Brazil’s new system of universal healthcare, the National Uni-
fied Health System (SUS), in the 1980s and the federal government’s Family Health
Program (PSF) in the 1990s. The latter was the dominant strategy to universalize
access to public healthcare.13 These healthcare professionals indeed played a central
role in designing SUS and PSF at the federal level and in engineering its political rise.
They have also been central to municipal-level efforts to implement it locally.
The analysis of PSF at the level of municipal government undertaken here con-
firms the centrality of the sanitaristas as founders of PSF, but it places their role in
context. It reveals some of the contradictions in their role and the importance of a
range of actors in the local design, implementation, and consolidation of the pro-
gram. The support of political parties of the center-left and center-right, the PT and
PSDB, and their leaders for a program such as PSF cannot be reduced to electoral
calculations alone, but electoral competition without doubt disciplined their deci-
sionmaking. The electoral ambitions of the PT and the aspirations of segments of
the sanitaristas overcame the opposition to PSF from other parts of the sanitaristas,
health sector unions, and sections of the popular health movement. When the
municipal administration came to see PSF as ineffective in electoral terms and put
it on a secondary plane, its maintenance and expansion in coverage were driven by
other actors: the NGOs executing the program and the user population.14

Alliances and Institutions in the Foundational Moment

Reformist public health professionals in São Paulo were the political force responsi-
ble for the implementation of PSF in the city. These professionals were participants
in the movimento sanitário, the nonpartisan movement largely responsible for the
universalisation of access to public healthcare. The sanitaristas’ reformist project
emerged under military rule (1964–85) and was put into practice first through local
programs and later national ones, as these professionals were able to “occupy spaces”
in the health sector’s administration (Escorel 1998; Dowbor 2008; Falleti 2010b).
Beyond the strategies that sought to influence the policymaking process, the san-
itaristas took advantage of sector events and promoted new ones to debate and dis-
seminate their policy reform project, forge ties to sympathetic groups, and add new
layers of support to their proposal. The national health conferences are an example
of public (state-supported) and technical events the sanitaristas appropriated for their
reformist ends, as the gatherings became a forum open to society at large. The Brazil-
ian Congress of Public Health (Congresso Brasileiro de Saúde Pública) illustrates, in
turn, the type of events the sanitaristas themselves held. These professionals also
maintained their ties and reproduced their shared (collective) identity by establishing
new forms of organization through which they could make specific demands or
mobilize for new opportunities or risks. Among these were the Plenary of the
 DOWBOR AND HOUTZAGER: PROFESSIONALS AND REFORM POLICY 153

National Health Councils (Plenária Nacional de Conselhos de Saúde), state associa-

tions of municipal health secretaries, or more recently, the Popular Education for
Health Association (Associação de Educação Popular em Saúde) (Dowbor 2012).
The sanitaristas included members of several center and left parties. Affiliation
with political parties transformed some of these public health doctors into public
figures capable of successfully competing for elected office and occupying the central
decisionmaking positions of the sector’s administrative structure. In the 1990s, the
professionals worked to expand the implementation of PSF nationally during the
center-right PSDB government and subsequently the center-left PT government.
This cross-party engagement was replicated in the city of São Paulo, again with the
PT and PSDB.
The PT municipal administration (2001–4) implemented PSF in São Paulo in
contradiction to its own government plan, developed by diverse groups tied to the
party and active in the health sector (IFF 2000). The directives of the government
plan were formulated before the election by doctors, a group of sanitaristas, the pop-
ular health movement, unions of health workers, and NGOs, and emphasized a pri-
mary care model of multiprofessional teams contracted through civil service exami-
nations (Saúde e Sociedade 1992, 6–8). The authors of the PT-São Paulo health plan
considered the PSF to be a competitive alternative, and the plan became the target
of severe criticism: it was denounced as simplified healthcare targeting the poor and
as provoking the privatization of SUS health services, given that it could be imple-
mented by contracting civil society organizations.
Criticism from local actors notwithstanding, once elected, the new PT mayor
changed course, abandoned the initial government plan, and adopted PSF as the
city’s principal health policy. The choice of PSF can be explained by its electoral
promise: a program that could be implemented relatively quickly and that would
reach large numbers of residents. Bringing free, integrated healthcare to a large share
of the city’s poor neighborhoods had obvious electoral appeal in a city where 28 per-
cent of the population was considered poor (IBGE 2000) and had precarious access
to public healthcare (Coelho and Pedroso 2002). Sanitarista advocates for PSF
argued for 60 percent coverage of the population in four years; that is, extending it
to the entire population that relied on SUS. This promise of full coverage helps
explain the adherence of a group of sanitaristas to PSF; they saw in PSF the realiza-
tion of universal access to basic healthcare services, one of the pillars of the political
project for which they had been fighting for decades.
The large scale and rapid implementation of the program was possible a priori
because of its administrative and financial structure. PSF has a number of features that
facilitate its implementation. It allows for diverse forms of contracting the health team
members, such as hiring medical staff through third parties, such as NGOs.15 This
allows local governments to circumvent the required public exams for hiring civil ser-
vants, a process that tends to be slow and costly to public coffers and that operates
under the constraints imposed by the national Law of Fiscal Responsibility.16
The Ministry of Health funds PSF through earmarked transfers that increase
substantially as the size of the population covered by the program passes the 70 per-
154 LATIN AMERICAN POLITICS AND SOCIETY 56: 3

cent mark. This puts large cities at a disadvantage. This progressive nature of the
incentive partly explains the far lower coverage in the state capitals and large cities,
which are very unlikely to reach the 70 percent threshold, compared to small and
medium-sized municipalities in the early 2000s (Caetano and Dain 2002). A study
conducted in 2001 revealed that among municipalities with more than 100,000
inhabitants, 24 percent had coverage for zero percent of the population, another 24
percent had coverage of 10 percent, and the remaining 39 percent had coverage of
between 10 and 50 percent. The great majority of the state capitals, in turn, regis-
tered 0 to 10 percent coverage rates (Caetano and Dain 2002, 14).17 These figures
strongly suggest that federal incentives were not a sufficient condition for the imple-
mentation of PSF in the large cities (Sugiyama 2008, 85).
The mayor’s choice of PSF, to the detriment of the original proposal, put the
administration on a collision course with parts of the popular health movement and
the public sector health worker unions. These were the two principal civil society
actors of weight in the sectoral arena, and they shared similar opinions on PSF, par-
ticularly criticizing the execution of the program by private entities. The two prin-
cipal participatory institutions in the sector, the Municipal Health Council and the
Municipal Health Conference, offered little support to the program. Given the
importance of the program and the scale of its coverage, it is surprising that these
two agencies expressed few indications of either their reservations about PSF or their
support. The deliberation over PSF fulfilled, on the one hand, the institutional pro-
cedures foreseen for the introduction of these types of programmatic actions, which
legally required the approval of the council. On the other hand, given its ideological
commitment, the administration’s health team always fought for popular participa-
tion in the management and delivery of health care. Nevertheless, at no moment did
the Municipal Health Council become a protagonist in the management of PSF.
The administration, however, found strong support for its choice among public
health doctors and nurses. The program’s implementation was charged to one of the
most reputable sanitarista doctors affiliated with the PT. The ambivalent opinions
were overcome by the reputation of this health secretary, who called on professionals
with previous experience with PSF elsewhere.18 These professionals made up the coor-
dination team and occupied the principal positions in the regionalized structure of the
secretariat. Furthermore, the health secretary identified a select group of public health
doctors and nurses, in theory all committed to the public health program, to be the
coordinators of the health districts, which were quite autonomous from other parts of
the municipal administration. The importance of the district coordinator’s commit-
ment to PSF is reflected in the data on implementation of family health teams. For
example, in two districts that are distinct in socioeconomic terms, Cidade Tiradentes
on the city’s poor periphery and Butantã in its far more affluent center, the number
of teams was 11 and 7, respectively, while in Itaquera, the lower-middle-class area that
was the birthplace of the popular health movement, there were only 3 teams.
Throughout the first phase of implementation, the coordinators, the directors,
and the secretary of health conducted an extensive campaign of disseminating the
program among health users and the popular movement. The secretary participated
 DOWBOR AND HOUTZAGER: PROFESSIONALS AND REFORM POLICY 155

in ten popular assemblies organized in different regions of the city to explain the
PSF model. The directors of health districts debated the implementation priorities
with the population and thereby contributed to its dissemination. The project envi-
sioned equitable implementation throughout the entire city: the first criterion to be
used for implementation was based on the map of social exclusion, and favored the
most excluded regions. In 2003, PSF reached 600 health teams and covered 2 mil-
lion users. This rapid expansion was possible because of the type of employment
contracts used by the 12 health social organizations, among them charities, univer-
sities, and community organizations. The implementation of PSF dramatically
expanded the coverage of primary care in a short time (three years), particularly in
the poorest segments of the municipality’s population, which encompassed more
than 50 percent of the target population (Bousquat et al. 2006, 1938).

The Trajectory Changes

Early in 2003, PSF stopped being the principal government strategy for primary
care and for the health system. The electoral logic left its mark on the trajectory of
the program, but this time it went against the logic of universalization. With only
two years to the next municipal elections, public opinion surveys indicated that the
administration’s highest disapproval rating was in the health sector. PSF did not
appear to have brought the necessary political dividends and, facing scarce time and
resources (Vecina 2007), the mayor decided to put the brakes on the program and
invest in other forms of care, particularly urgent and emergency care. The profile of
the next health secretary, who had vast experience in hospital care, and the policies
he implemented show that the city’s chief executive opted for policies that would
have greater electoral appeal among the lower middle class. The new policies were
restricted to those of greatest immediate impact, such as increasing the fleet of
ambulances and the number of emergency care wards.
The point at which PSF stopped being the principal strategy for the municipal-
ity’s health system and became just one of several alternatives to provide basic care
reflects the political power of the executive and the importance of electoral logic. It
also shows the relative political fragility of the reformist professionals, who were able
to keep themselves in the most important positions in the health secretariat only as
long as the direction they pursued coincided with the party leadership’s (electorally
driven) interests.
The decision to decelerate the growth of PSF was made by the highest executive
without consultations with or deliberations of the Municipal Health Council or
Health Conference. There was also no visible reaction that sought to reverse the
mayor’s decision, with the exception of the secretary of health’s departure. The
interruption of the rapid expansion of PSF was discussed in the Municipal Health
Council, but this did not lead to any decisive recommendations or vote. Despite the
earlier expansion of coverage and the positive assessment by the population served
(Martins Alves Sobrinho 2007), the popular health movement did not become a
defender of the program. Indeed, once again, the council’s secondary role in the roll-
156 LATIN AMERICAN POLITICS AND SOCIETY 56: 3

out of PSF was confirmed, a situation that persisted throughout the next adminis-
tration. An investigation that examined the minutes and resolutions of the council
from the period 2001–7 reveals that the council dedicated itself primarily to dis-
cussing and deliberating the implementation of public policies, but at no point did
it request or demand the expansion of the program (Serafim 2007).
However, the apparent lack of reaction or interest from organized actors in the
sector in the PSF’s trajectory or the drastic changes in health strategy did not lead to
a retraction of the program in numerical terms. The family health teams continued
to grow, both during the remaining time of the PT administration and in the next
administration under a center-right coalition. The sanitaristas maintained their pres-
ence only in the Department of Primary Care, which was directly responsible for
PSF, and relied on a new support base for the program. The Department of Primary
Care began to receive demands for the implementation of health teams from groups
of people in low-income regions of the city, sometimes mediated by vereadores and
sometimes by the social organizations that delivered health services. The implemen-
tation of 100 new health teams by 2004 (Vecina 2007) and another 105 in just the
first half of the new administration in 2005 was a product of these pressures.

CONCLUSIONS
This article has focused on two programs that are, in distinctive ways, the local face
of national reforms. Our analysis has highlighted the role of pressure from the
middle, by groups of reformist professionals, on state reforms that have contributed
significantly to poverty reduction. We have argued that the interests and identities
of professionals in health, social assistance, economics, urban planning, and other
fields are shaped by the networks in which they practice their professions, and not
only or even primarily by the public and private institutions for which they work.
Many of the policies and programs designed to translate broad principles of democ-
ratizing the state, universalizing healthcare and social assistance, and obtaining
NPM-inspired efficiencies have grown out of these professional networks and
entered the state through these networks.
The stories of PSF and Renda Mínima call attention to the relatively marginal
role of organized pressure from below—for example, from the popular health move-
ment or urban social movements—and of the participatory governance institutions
in promoting the programs and shaping their trajectories. Given the national
reforms to decentralize fiscal and administrative power and the creation of an
entirely new institutional arena of participatory governance, we might expect a
stronger alliance between the movement and reformist professionals.19 São Paulo
has, furthermore, a particularly large and densely connected civil society that works
with or represents the urban poor (Houtzager and Gurza Lavalle 2010). For the
most part, however, the popular health movement was a bystander, rather than a
founder, strategist, or even dissident.20
Many activists and policy actors have embraced citizen participation and partic-
ipatory governance institutions as a nonpartisan and broader alternative to electoral
 DOWBOR AND HOUTZAGER: PROFESSIONALS AND REFORM POLICY 157

politics. Brazil has become internationally known for developing an array of robust
participatory governance institutions and for its relatively well networked and influ-
ential civil society. Yet our two cases suggest that this bet on nonpartisan participa-
tory governance versus electoral politics may be a mistake where policies for the poor
(rather than the working and lower middle classes) are concerned and in contexts
with competitive electoral systems. For the ambitious new antipoverty programs in
São Paulo, the electoral process was an important mechanism for institutional
change. It played a critical role in selecting which professional groups, with their
respective policy projects, would gain access to the main decisionmaking positions.
Can we generalize from the São Paulo cases to other parts of the world and his-
torical moments? Not without caution. The role reformist professionals have taken
in Brazil differs, for example, from that of the progressives in the early-twentieth-
century United States. The latter sought to increase administrative efficiency, inclu-
sion, and democratization with reforms that helped insulate bureaucracy from the
period’s powerful political machines and economic interests. The problems of
public administration and the need for state reform in late-twentieth-century Latin
America were framed very differently. Authoritarian governments in Chile,
Argentina, Brazil, and to a lesser extent, Mexico dramatically increased the role of
the professions in the state as they sought to modernize their respective public
bureaucracies. This helped cement a close association between authoritarian rule
and professionals, known in the region as technocrats.21
In the context of democratization, reformists in a variety of professions adopted
social inclusion and democratization of the state (i.e., the executive) as a part of their
project to renovate their professions and break any association with the authoritar-
ian state. Reformist professionals who occupied, or sought to occupy, positions of
influence in state institutions introduced policies and reforms meant to broaden
access to their services and expand the definition of who could participate in deci-
sionmaking. This included, in a number of instances, participatory governance
institutions that were expected to increase the voices of marginalized social groups
and democratize the state. The possible alliance between engaged citizens and
reformist professionals against conservative and authoritarian forces in the state
appeared to override concern about potential tension between citizen participation
and professional autonomy.
The role of the sanitaristas and economists in the two programs examined here
was therefore embedded in particular historical trajectories—that of a democratic
transition after 21 years of military rule; that of the professions themselves under
authoritarian rule; and a broader international zeitgeist from the 1980s on that
favored citizen participation, new forms of social policy, and new forms of provi-
sioning public services. In a different context, at a different time, professionals in
health and economics would probably have played different roles and pursued dif-
ferent goals. The particular trajectory of state reforms and the role played by groups
of professionals in Brazil suggests that on the one hand, if they have played a sub-
stantial role in state reform in numerous instances across time and geography, on the
other hand, what role they play and how can vary.
158 LATIN AMERICAN POLITICS AND SOCIETY 56: 3

And yet, groupings of reformist professionals can be found in many professions,

in many national and local contexts. All polities periodically produce opportunities
for institutional reform, and reformist professionals, more often than is acknowl-
edged in recent social science or international development policy circles, have
played a critical role in defining the content of such reforms and seeing that they
redefine how public institutions operate and to whose welfare they contribute.

NOTES
We are much indebted to Judith Tendler for insightful conversations on public sector
reform and the sociology of organization, as well as her comments on this article. David K.
Leonard, Vera Schattan Coelho, Marta Arretche, and Mick Moore provided insightful com-
ments. Caroline Martin smoothed out kinks in the text.
1. Sugiyama (2008, 93) reaches a similar conclusion in her study of four major Brazil-
ian cities, including São Paulo.
2. On social insurance reforms see Kay 1999; Madrid 2003; on social policies, see
Kaufman and Nelson 2004b; Haggard and Kaufman 2008.
3. In Brazil, decentralization has been more extensive than elsewhere in Latin America,
and municipal governments have significantly expanded their duties and share of public rev-
enue (Eaton 2004, 39; Samuels 2000; Falleti 2010a).
4. Sugiyama (2008) is an exception, as she seeks to explain the diffusion of two social
programs in Brazil, Bolsa Família and PSF, by the ideology of decisionmakers and ties of pro-
fessional associations. She does not, however, examine the role of competitive electoral poli-
tics or take into account different drivers or consequences of electoral politics, the rotation of
professionals into public office as appointees, and the bet on potential votes in subsequent
elections flowing from the provisioning of social programs.
5. The program excludes poor individuals or poor families without children, unlike
Bolsa Família. Brazil has a constitutionally guaranteed entitlement for the elderly (over the
age of 65) or disabled (who cannot work) living in extreme poverty (income of less than one-
fourth of the minimum wage, R$95), the Benefício de Prestação Continuada, but it does not
apply to other families without children.
6. Families in the program are extremely poor, with an average monthly household
income of only R$243.76. Half the families in 2001 had two parents, but the entitlement hold-
ers were overwhelmingly women (74.2 percent). The family must have resided in the city for
two years and must prove legal custody of the children. The monthly grant is R$140, R$170,
or R$200 depending on whether a family has one, two, or more than two children, respectively.
7. First implemented in the poorest regions of the country, PSF had a vertiginous
expansion of coverage, from 1 million people in its first year to almost 30 million in 2000
and 55 million in 2002. In December 2008, PSF covered 93.2 million people throughout
Brazil (DAB 2009).
8. The program’s budget in 2006 represented 88 percent of the budget of the Munic-
ipal Secretariat for Social Assistance and Development (SMADS).
9. See Silveira 1975 and Fonseca’s discussion (2001, 101) of the evolution of this debate.
10. For Suplicy’s own account of the emergence of Renda Mínima, see Suplicy 2006.
11. The proposed legislation gave every 25-year-old Brazilian citizen with residence in
Brazil and an income below a certain level the right to 30 percent of the difference between
that level and the minimum wage.
 DOWBOR AND HOUTZAGER: PROFESSIONALS AND REFORM POLICY 159

12. José Serra received his Ph.D. in economics from Cornell and taught in the econom-
ics department at UNICAMP. He was, respectively, Minister of Planning and Minister of
Health in the Cardoso government.
13. SUS provides universal access to free and integrated care (primary through tertiary).
SUS covers 75 percent of the population in Brazil. The remaining 25 percent rely on private
healthcare. In São Paulo, 42.4 percent of the population relies on private healthcare
(FUNDAP 2009).
14. These NGOs are known as “social organizations,” after the 1998 legislation that
granted these actors a new legal status and role as providers of public services.
15. A study of PSF in 10 large urban centers points to the tendency to contract third
parties and temporary workers. This was the case in 23 of 37 contracts (MS-DAB 2002, 153).
16. The Law of Fiscal Responsibility of 2000 establishes norms of public finance that
discipline fiscal management and imposes limits on expenditures for staff costs of government
at municipal, state, and national levels, which, in practice, creates obstacles to contracting
public sector employees.
17. The incentives at the time put large cities at a substantial disadvantage: a city with
under one hundred thousand inhabitants, for example, would receive R$54,000 rather than
the initial R$30,684 when it constituted 21 PSF medical teams, while a city the size of São
Paulo, with more than ten million inhabitants, would have to set up 2,029 teams. The federal
transfer does not cover the full cost of a PSF team, and because salaries are higher in the city,
the municipal government has to contribute substantial resources of its own.
18. The secretary of health was one of the people responsible in the PT “for the theme
Social Security (social assistance, social security, and health) during the Constituent Assembly
(1986–88). Subsequently he became the PT’s representative on several Congressional com-
mittees, including the Budget Committee of the Lower House (Câmara dos Deputados) and
commissions for constitutional amendments. He was also responsible for relations with min-
istries, the National Health Council, professional associations in health, social security and
social assistance, as well as state and municipal government health secretariats, etc.” (Martins
Alves Sobrinho and Capucci 2003, 210).
19. In the case of the popular health movement this is striking, as the sanitaristas played
an important role in its creation in the 1970s and 1980s, and maintain relations with local
community leaders to this day.
20. We do not suggest that pressure from below or participatory governance institu-
tions are irrelevant across issues in either health or social welfare, but rather that they are not
necessarily arenas where the interests of the poorest quarter of the population are represented
and addressed. Furthermore, in the case of health but not of social assistance, community-
level collective actors and their networks did negotiate the implementation of PSF in their
respective regions of the city, and have sought to exercise accountability over the program
(Amâncio et al. 2009).
21. The rationalizing reforms helped earn these regimes the moniker “bureaucratic-
authoritarian regimes” among scholars of Latin America (Collier 1979).
160 LATIN AMERICAN POLITICS AND SOCIETY 56: 3

INTERVIEWS
Hora, Sergio. 2007. Benefits Coordinator, Municipal Secretariat for Social Assistance. São
Paulo, October 11.
Lisboa, William. 2007. Coordinator, Social Assistance Forum. São Paulo, March 19.
Martins Alves Sobrinho, Eduardo Jorge. 2007. Former Health Secretary, City of São Paulo.
São Paulo, June 20.
Paz, Rosangela. 2007. Member, Instituto de Estudos Especiais, Catholic University of São
Paulo. São Paulo, July 25.
Schwengber, Angela. 2007. Coordinator, Departamento de Economia Solidaria, Secretaria
do Desenvolvimento, Trabalho, e Solidaridade. São Paulo, May 31.
Sposati, Aldaíza. 2007. Researcher, Núcleo de Seguridade e Assistência Social, Catholic Uni-
versity of São Paulo. São Paulo, August 14.
Vecina, Gonzalo Neto. 2007. Former Health Secretary, City of São Paulo. São Paulo, Sep-
tember 27.

REFERENCES
Amâncio, Júlia M., Monika Dowbor, and Lizandra Serafim. 2009. Poverty Reduction Pro-
grams and Local Collective Actors: Social Accountability and Public Service Delivery in
São Paulo. Paper presented at the ISA-RC21 Conference, São Paulo, August 23–25.
Avritzer, Leonardo. 2002. Democracy and the Public Space in Latin America. Princeton:
Princeton University Press.
Avritzer, Leonardo, ed. 2004. A participação em São Paulo. São Paulo: Editora UNESP.
Batley, Richard. 2004. The Politics of Service Delivery Reform. Development and Change 35,
1: 31–55.
Bousquat, Aylene, Amélia Cohn, and Paulo Eduardo Elias. 2006. Implantação do Programa
Saúde da Família e exclusão sócio-espacial no Município de São Paulo, Brasil. Cadernos
Saúde Pública 22, 9: 1935–43.
Bresser Pereira, Luis C. 1997. Estratégia e estrutura para um novo estado. Revista de Economia
Política 17, 3: 24–38.
Caetano, Rosângela, and Sulamis Dain. 2002. O Programa de Saúde da Família e a reestru-
ração da atençã básica à saúde nos grandes centros urbanos: velhos problemas, novos
desafios. Physis: Revista Saúde Coletiva 12, 1: 11–21.
Camargo, José Márcio de. 1991. Pobreza e garantia de Renda Mínima. Folha de São Paulo,
December.
Coelho, Vera Schattan P., and Marcel Pedroso. 2002. Distribuição de serviços públicos de
saúde no Município de São Paulo. Novos Estudos 64: 141–52.
Coelho, Vera Schattan P., and Marcos Nobre, eds. 2004. Participação e deliberação: teoria
democrática e experiências institucionais no Brasil contemporâneo. São Paulo: Editora 34.
Coelho, Vera Schattan P., Alexandre Ferraz, Fabiola Fanti, and Meire de Paula Ribeiro.
2010. Mobilização e participação: um jogo de soma zero? Um estudo sobre as dinâmicas
de conselhos de saúde da cidade de São Paulo. Novos Estudos CEBRAP 86: 120–39.
Collier, David, ed. 1979. The New Authoritarianism in Latin America. Princeton: Princeton
University Press.
Dowbor, Monika. 2008. Origins of Successful Health Sector Reform: Public Health Profes-
sionals and Institutional Opportunities in Brazil. IDS Bulletin 38, 6: 73–80.
 DOWBOR AND HOUTZAGER: PROFESSIONALS AND REFORM POLICY 161

———. 2009. Sujeitos da assistência social: estado, entidades assistenciais, assistentes sociais e
usuários na trajetória da assistência social, 1974–2005. Mimeograph.
———. 2012. A arte da institucionalização: estratégias de mobilização dos sanitaristas (1974 a
2006). Ph.D. diss., Departmaneto de Ciência Política, Universidade de São Paulo.
Eaton, Kent. 2004. Politics Beyond the Capital: The Design of Subnational Institutions in South
America. Stanford: Stanford University Press.
Escorel, Sarah. 1998. Reviravolta na saúde: origem e articulação do movimento sanitário. Rio de
Janeiro: FIOCRUZ.
Falleti, Tulia G. 2010a. Decentralization and Subnational Politics in Latin America. Cam-
bridge: Cambridge University Press.
———. 2010b. Infiltrating the State: The Evolution of Health Care Reforms in Brazil, 1964–
1988. In Explaining Institutional Change: Ambiguity, Agency, and Power, ed. Kathleen
Thelen and James Mahoney. Cambridge: Cambridge University Press. 38–62.
Fonseca, Ana Maria M. 2001. Família e política de Renda Mínima. São Paulo: Cortez.
Fundação do Desenvolvimento Administrativo (FUNDAP). 2009. Políticas publicas em
foco. Sistema privado e público de saúde. www.boletim-fundap.cebrap.org.br. Accessed
May 12, 2009.
Fung, Archon, and Erik O. Wright, eds. 2003. Deepening Democracy: Institutional Innova-
tions in Empowered Participatory Governance. London: Verso.
Governo do Município de São Paulo, Departamento de Atenção Básica (DAB). 2009.
Números. http://200.214.130.35/dab/abnumeros.php#numeros. Accessed September
30, 2009.
Grindle, Merilee. 2000. Audacious Reforms: Institutional Invention and Democracy in Latin
America. Baltimore: Johns Hopkins University Press.
Gurza Lavalle, Adrian, Arnab Acharya, and Peter Houtzager. 2005. Beyond Comparative
Anecdotalism: Lessons on Civil Society and Participation from São Paulo, Brazil. World
Development 33, 6: 951–64.
Haggard, Stephen, and Robert R. Kaufman. 2008. Development, Democracy, and Welfare States:
Latin America, East Asia, and Eastern Europe. Princeton: Princeton University Press.
Heller, Patrick. 2001. Moving the State: The Politics of Decentralization in Kerala, South
Africa, and Porto Alegre. Politics & Society 29, 1: 131–63.
Houtzager, Peter P., and Adrian Gurza Lavalle. 2010. Civil Society’s Claims to Political Rep-
resentation in Brazil. Studies in Comparative International Development 45, 1: 1–29.
Instituto Brasileiro de Geografia e Estatística (IBGE). 2000. Censo demográfico. Rio de
Janeiro: IBGE.
Instituto Florestan Fernandes (IFF). 2007. Pela construção de um sistema único de saúde
universal e integral no Município de São Paulo. Mimeograph.
Kaufman, Robert, and Joan Nelson. 2004a. Conclusion: The Political Dynamics of Reform.
In Kaufman and Nelson 2004b. 473–519.
Kaufman, Robert, and Joan Nelson, eds. 2004b. Crucial Needs, Weak Incentives: Social Sector
Reform, Democratization, and Globalization in Latin America. Washington, DC/Balti-
more: Woodrow Wilson Center Press/Johns Hopkins University Press.
Kay, Stephen. 1999. Unexpected Privatizations: Politics and Social Security Reform in the
Southern Cone. Comparative Politics 31, 4: 403–22.
Keck, Margaret, and Rebecca N. Abers. 2006. Civil Society and State-Building in Latin
America. LASA Forum 37, 1: 30–32.
Madrid, Raúl L. 2003. Retiring the State: The Politics of Pension Privatization in Latin America
and Beyond. Stanford: Stanford University Press.
162 LATIN AMERICAN POLITICS AND SOCIETY 56: 3

Martins Alves Sobrinho, Eduardo J., and Paulo F. Capucci. 2003. Saúde em São Paulo:
aspectos da implantação do SUS no período de 2001–2002. Estudos Avançados 17, 48:
209–27.
Melo, Marcus A. 2008. Unexpected Successes, Unanticipated Failures: Social Policy from
Cardoso to Lula. In Democratic Brazil Revisited, ed. Peter R. Kingstone and Timothy J.
Power. Pittsburgh: University of Pittsburgh Press. 161–84.
Ministério da Saúde-Departamento de Atenção Básica (MS-DAB) 2002. Dez grandes centros
urbanos. Síntese dos principais resultados. Série C. Projetos, Programas e Relatórios.
Brasília: MS-DAB.
Nelson, Joan. 2004. The Politics of Health Sector Reform: Cross-National Comparison. In
Kaufman and Nelson 2004b. 23–63.
Pochmann, Marcio, ed. 2002. Desenvolvimento, trabalho e solidaridade: novos caminhos para a
inclusão social. São Paulo: Fundação Persei Abramo/Cortez.
———. 2004. Políticas de inclusão social: resultados e avaliação. São Paulo: Cortez.
Pólis. 2007. Assistência social: controle social e política pública. Série Observatório dos Direitos
do Cidadão no. 30. São Paulo: Instituto Pólis/PUC-SP.
Roberts, Kenneth M. 2002. Party-Society Linkages and Democratic Representation in Latin
America. Canadian Journal of Latin American and Caribbean Studies 27, 53: 9–34.
Samuels, David. 2000. Reinventing Local Government? Municipalities and Intergovernmen-
tal Relations in Democratic Brazil. In Democratic Brazil: Actors, Institutions, and
Processes, ed. Peter R. Kingstone and Timothy J. Power. Pittsburgh: University of Pitts-
burgh Press. 77–100.
Santos, Boaventura de Sousa. 1998. Participatory Budgeting in Porto Alegre: Toward a
Redistributive Democracy. Politics & Society 26, 4: 461–510.
Saúde e Sociedade. 1992. Debate, Municipalização em São Paulo: no peito e na raça. Special
edition. Saúde e Sociedade 1, 2: 3–28.
Serafim, Lizandra. 2007. Controle social nos conselhos municipais de assistência social e
saúde de São Paulo. Unpublished mss.
Silveira, Antonio Maria da. 1975. Redistribuição da renda. Revista Brasileira de Economia 29,
2 (April–June): 3–15.
Sposati, Aldaíza, ed. 1997. Renda Miníma e crise mundial: saída ou agravamento? São Paulo:
Cortez.
Sugiyama, Natasha Borges. 2008. Ideology and Networks: The Politics of Social Policy Dif-
fusion in Brazil. Latin American Research Review 43, 3: 82–108.
Suplicy, Eduardo M. 1992. Programa de garantia de renda mínima. Brasília: Federal Senate.
———. 2006. Renda de cidadania: a saída é pela porta. 4th edition. São Paulo: Cortez/Editoro
Fundação Perseu Abramo.
Tatagiba, Luciana. 2004. A institucionalização da participação: os conselhos municipais de
políticas publicas na cidade de São Paulo. In Avritzer 2004. 323–408.
Tendler, Judith. 1997. Good Government in the Tropics. Baltimore: Johns Hopkins University
Press.
Wampler, Brian. 2010. Participatory Budgeting in Brazil: Contestation, Cooperation, and
Accountability. University Park: Penn State University Press.
Weyland, Kurt. 1995. Social Movements and the State: The Politics of Health Reform in
Brazil. World Development 23, 10: 1699–1712.