[Local governance in the decentralized health care system in Brazil]

To analyze the changes in local health care governance resulting from the decentralization process associated with the Unified Health System (SUS) in Brazil between 1996 and 2006.

A questionnaire was answered in 1996 and again in 2006 by all city officials involved in health care management in Brazil. Information was collected on the innovative characteristics of administrative practices in terms of three dimensions: social, management, and care. The present article analyzes the results relating to the social dimension (relationship between municipal officials and the various community actors) according to four attributes: preparing the budget (degree of influence of various actors), establishing priorities, accountability, and flow of information to the community.

The influence of municipal secretaries of health and health councils on budget preparation has increased, with a decrease of local politician influence. In prioritizing health issues, local politicians and spontaneous demands have also become less influential, with strengthening of the influence of technical opinions and proposals by health councils and conferences. Public disclosure of results has become institutionalized as a result of the diversification of stakeholders (especially municipal secretaries and health councils) and of the methods available for disclosure, even though balance sheets are still the most common type of information disclosed (which imply technical knowledge for interpretation of results). Finally, the information conveyed to the community still mainly refers to health actions and campaigns and functioning of health services, even though a larger amount of innovative information is being communicated. This was observed in all regions and in cities of all sizes, with a more progressive trend in the South of Brazil.

The relationship between government and society has changed toward a more democratic standard of local governance, despite the maintenance of centralized government decision-making practices. The process of decentralization still faces important obstacles to the establishment of a more participative model, with enhanced social control, accountability and interaction between government and society.