The Accountability Politics of Reducing Health Inequities: Learning from Brazil and Mozambique.

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Health inequities - that is, inequalities in health which result from social, economic or political factors and unfairly disadvantage the poor and marginalised - are trapping millions of people in poverty. Unless they are tackled, the effort to fulfill the promise of universal health coverage as part of the fairer world envisaged in the post-2015 Sustainable Development Goals may lead to more waste and unfairness, because new health services and resources will fail to reach the people who need them most. In Mozambique, for example, the gap in infant mortality between the best-performing and worst-performing areas actually increased between 1997 and 2008, despite improvements in health indicators for the country as a whole. However, while many low- and middle-income countries are failing to translate economic growth into better health services for the poorest, some - including Brazil - stand out as having taken determined and effective action. One key factor that differentiates a strong performer like Brazil from a relatively weak performer like Mozambique is accountability politics: the formal and informal relationships of oversight and control that ensure that health system managers and service providers deliver for the poorest rather than excluding them. Since the mid-1990s, Brazil has transformed health policy to try to ensure that the poorest people and places are covered by basic services. This shift was driven by many factors: by a strong social movement calling for the right to health; by political competition as politicians realised that improving health care for the poor won them votes; by changes to health service contracting that changed the incentives for local governments and other providers to ensure that services reached the poor; and by mass participation that ensured citizen voice in decisions on health priority-setting and citizen oversight of services. However, these factors did not work equally well for all groups of citizens, and some - notably the country's indigenous peoples - continue to lag behind the population as a whole in terms of improved health outcomes.This project is designed to address the ESRC-DFID call's key cross-cutting issue of structural inequalities, and its core research question "what political and institutional conditions are associated with effective poverty reduction and development, and what can domestic and external actors do to promote these conditions?", by comparing the dimensions of accountability politics across Brazil and Mozambique and between different areas within each country. As Mozambique and Brazil seek to implement similar policies to improve service delivery, in each country the research team will examine one urban location with competitive politics and a high level of economic inequality and one rural location where the population as a whole has been politically marginalised and under-provided with services, looking at changes in power relationships among managers, providers and citizens and at changes in health system performance, in order to arrive at a better understanding of what works for different poor and marginalised groups in different contexts.As two Portuguese-speaking countries that have increasingly close economic, political and policy links, Brazil and Mozambique are also well-placed to benefit from exchanges of experience and mutual learning of the kind that Brazil is seeking to promote through its South-South Cooperation programmes. The project will support this mutual learning process by working closely with Brazilian and Mozambican organisations that are engaged in efforts to promote social accountability through the use of community scorecards and through strengthening health oversight committees, and link these efforts with wider networks working on participation and health equity across Southern Africa and beyond.