Unequal Voices: The Politics of Accountability for Equity in Health Systems


Health inequities – that is, unfair and avoidable difference in health arising from social, economic or political factors, and which disadvantage the poor and marginalised – are trapping millions of people in poverty. Unless they are tackled, the effort to achieve Universal Health Coverage as part of the fairer world envisaged in the UN’s 2030 Agenda for Sustainable Development may lead to more waste and unfairness, because new health services and resources will fail to reach the people who need them most.

Logo for Vozes Desiguais (Unequal Voices) project

The Unequal Voices project – Vozes Desiguais in Portuguese – aims to strengthen the evidence base on the politics of accountability via multi-level case studies in health systems in Brazil and Mozambique, exploring how accountability can be strengthened to deliver better health services for citizens everywhere.

Led by Alex Shankland (Principle Investigator), with Gerry Bloom (IDS), Denise Namburete (N’weti Comunicação e Saúde), and Vera Schattan Coelho (CEBRAP), this project will compare the dimensions of accountability politics across Brazil and Mozambique and between different areas within each country. In the first phase, background studies of the trajectories of change in the political context and in patterns of health inequalities in the two coutries will inform the design of the case studies. 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 competitve 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. We will look 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.

Rethinking the role of the citizen-user in the national health service in Mozambique

The state of health equity in Mozambique and Brazil

In Mozambique, despite improvements in health indicators for the country as a whole, the gap in infant mortality between the best-performing and worst-performing areas actually increased between 1997 and 2008, as research from EQUINET shows. Now, with government revenue falling and the threat of armed conflict, the country faces a series of challenges in maintaining improvements and broadening inclusion.

While Mozambique, along with many other low- and middle-income countries, has struggled to translate economic growth into better health services for the poorest, some countries – including Brazil – stand out as having taken determined and effective action.

One key factor that differentiates a strong performer like Brazil from other countries that have made less progress in reducing health inequalities 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 people 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:

  • A strong social movement calling for the right to health
  • Political competition, as politicians realised that improving health care for the poor won them votes
  • Changes to health service contracting that changed the incentives for local governments and other providers to ensure that services reached the poor
  • 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 – have continued to lag behind the population as a whole in terms of improved health outcomes. And despite its strong performance in recent years, the Brazilian health system is now facing fresh challenges as demographic changes and rising costs increase the pressure on services that are already suffering the effects of an ongoing economic crisis.

Poor citizens at the heart of the health system in Brazil – Watch video below

Indigenous leaders engaging with the government health system in Brazil

Engagement and Impact

The main impact goal of the Unequal Voices project is to help ensure that better-quality health services reach the poorest and most marginalised people in Brazil and Mozambique, by making use of strong existing links with key policymakers and practitioners in both countries. It also includes a commitment to engagement with academic, policy and practitioner audiences in other fields. At a time of rapid change and complex global challenges, lessons learnt on the implementation of accountability mechanisms in health can inform work in other sectors and vice-versa, leading to improved service delivery for citizens as well as value for money for governments.

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 is promoted through South-South Cooperation programmes such as those led by the Brazilian public health research and training institute, Fiocruz.

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 tools such as community scorecards, and through strengthening health oversight committees. We will also link these efforts with work being done by partners in the Future Health Systems consortium, and with wider networks working on participation, governance for health and health equity across Southern Africa and beyond, supported by the project’s Reference Groups.

As the project develops, emerging findings will be shared on our project blog Vozes Desiguais (Unequal Voices) – in English and Portuguese. Join the discussion via the blog, and on Twitter via #VozesDesiguais #UnequalVoices.

International Reference Group members

  • Walter Flores, Executive Director, Center for the Study of Equity in Governance in Health Systems (CESGS), Guatemala
  • Luiz Eduardo Fonseca, Centre for International Relations, Oswaldo Cruz Foundation (FIOCRUZ), Brazil
  • John Gaventa, Director of Research, Institute of Development Studies, UK
  • Asha George, South African Research Chair in Health Systems, Complexity and Social Change at University of the Western Cape, South Africa
  • Rene Loewenson, Director, Training and Research Support Centre (TARSC), and Regional Network on Equity in Health in East and Southern Africa (EQUINET), Zimbabwe
  • Leslie London, Professor, School of Family and Public Health, University of Cape Town, and Regional Network on Equity in Health in East and Soutern Africa (EQUINET), South Africa
  • Rômulo Paes de Sousa, Director, RIO+ World Centre for Sustainable Development, Brazil

Mozambique Reference Group members

Brazil Reference Group members

  • Ana Luiza d’Ávila Viana, University of São Paulo, Faculty of Economics
  • Douglas A. Rodrigues, Federal University of São Paulo, Faculty of Collective Health
  • Gabriela S Lotta, Federal University of ABC, Public Policies Program and the Public Administration National School
  • Rômulo Paes de Sousa, Director, RIO+ World Centre for Sustainable Development, Brazil
  • Vanessa E Oliveira, Federal University of ABC, Public Policies Program






Project details

start date
5 July 2016
end date
30 September 2018


Supported by

About this project

Programmes and centres
Brazil IDS Initiative


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