The Privatisation of the State from the Inside: Public Health and Assistance Policies in the State of São Paulo

Why study social protection in the South? And why in the Latin American context? Changing the viewpoint from the European context of social protection to a region of the South, such as Latin America, has heuristic virtues. On the one hand, this dislocation makes it possible to denaturalise our own categories of analysis. On the other hand, it makes it possible to predict the future or ongoing developments in national and/or European dynamics, since Latin America has occupied since the 1990s the role of a laboratory for forms of State intervention. In fact, social protection in this region has very different meanings from those in European societies; furthermore, these meanings change over time as well as varying within the different Latin American national contexts. Indeed, these forms of social experimentation, composed of a set of policies, programs and measures, have their own temporality. Their spatio-temporal and territorial inscription reveal what is at stake within the process of construction of the Latin American nation-states. Located at the crossroads of these spatio-temporal and territorial dimensions, these forms of social experimentation are configured according to three distinct periods: the first encompassing the setting up of neo-liberal policies and reduction of social costs, under the aegis of the International Monetary Fund, during the 1990s; the second referring to the operation of the region as a “laboratory of social policies” said to be “more voluntarist” until the middle of the decade of 2010; and c) the current period in which Latin America has become an area of experimentation with multidimensional forms of privatisation, state hybridisation, increased repression and authoritarian drift.

Starting from the stipulate that the forms of social protection make society in order to look at the configurations of the welfare state in the South and its articulation with democracy can reveal keys to apprehend dynamics in progress within North American and European societies. There are keys to understand indirect forms of privatization if we look at the hybridization of State and non-State actors (in the French public health sector for example); or if we change the scope of analysis, looking for transnational relations and forms of financing State pensions in Canada. While the levels of social inequality and the place of work within social protection are radically different in these parts of the world, their links with the radical drift of democratic institutions are particularly salient. In addition, another central feature of the processes under way in Latin America, as in Europe, is the role of the State as one of the main actors of the forms of commodification of different social policies. Therefore, the question of whether the State is more or less present in or even totally absent from the social sphere is no longer relevant, but the question at stake is how the configuration of the State has changed. The study of social protection in the South also makes it possible to question the interweaving between the internationalisation of actors, the national territory and the adjustments of policies at regional and local levels, as well as their interdependencies. Indeed, placing the focal point on this part of the world, with regard to other regions, such as the European context, makes it possible to question the transversality of the processes at work and examine the place of transnational actors.

Work and Social Protection in Brazil: A Historical Approach of Public Action

Historically, the fumbling emergence of social protection in Latin America has been associated exclusively with wage labour, and therefore was limited to a minority of the population. This was the case, for example, in Brazil in the 1940s, during the period of President Getulio Vargas, who created the labour legislation at the time (Carvalho 2001). This Bismarckian conception of social protection has given way to a Beveridgian approach dating back to the post-dictatorship period in Latin America in the 1980s, which saw the introduction of a more “universalist” approach to social protection , linking access to social rights and extended citizenship. In both cases, this access has always been limited, but for different reasons. At the present time, since the political shift that started with the June 2013 protests, the promotion of social rights itself has been questioned, whether allocated through work or citizenship.

In Latin America in general, and in Brazil in particular, access to salaried work has at best been set as the horizon of expectations for the majority of workers. Most of the time this expectation has not materialised. Historically, however, most social rights were associated with the effective exercise of a salaried occupation, understood as “regulated citizenship” (Santos 1979). The level of formalisation of the labour market has rarely exceeded 50% in this region of the world, despite a marked improvement during the first decade of the twenty-first century, thanks to it being one of the stated priorities of the various so-called “left” governments in the region (Georges and Tizziani 2020). A large part of the population has thus only partially, and often temporarily, had access to the social rights conferred by wage labour. In these contexts, the combination of different work situations and forms of multi-activity, such as multiple job-holding, including different forms of work—as a set of heterogeneous strategies and tactics which can be legal as well as illegal, recognized as a salaried activity as well as street dwelling, for example, to ensure the social reproduction of the poor population—has become the norm.

In the context of the struggle against the various Latin American dictatorial regimes of the 1960s and 1970s, civil societies organised to place social rights on the political agenda (Monteleone et al. 2016). During the 1980s, in Brazil “new actors” entered the scene with the mobilisation of civil society, such as groups of mothers, ecclesiastical basic communities and unions of the metallurgical industry, especially in the region of São Paulo (Sader 1988). In the context of a (re-)democratic opening Brazilian social movements that had fought the dictatorship (1964–1985) demanded access to a set of social rights, such as public health services, transport, education, housing, etc., guaranteeing basic conditions of social reproduction to the poor population. These claims led to an ambiguous process during the 1990s, called a “perverse confluence” (Dagnino et al. 2006) that implied a truncated implementation of a number of public services simultaneously with neo-liberal policies of cost reduction, under the auspices of international institutions such as the International Monetary Fund, which imposed conditionalities to repay the country’s external debt. This movement of shifting the attention of public action towards the question of governance (instead of work) thus followed an international trend as it responded to political demands from the population. Forms of institutionalisation of access to social rights are at the same time a demand for political participation. The form of operationalisation of services that results from this dual contradictory injunction both responds to the demands of social movements and reduces the cost of policies by involving the participation of the population. The modalities of participation vary from one national context to another, and contribute to define the meaning of public policies in the eyes of the population, including the case of policies with similar architectures between the different Latin American countries, such as Conditional Cash Transfer Programs (CCTP) (Destremau and Georges 2017).

Multidimensional Forms of Privatisation: The Case of São Paulo (Public Health and Social Assistance Policies)

The contemporary period is characterised by a great continuity of structural inequalities in most Latin American countries, despite a temporary improvement in the living conditions of the working classes during the first decade of the twenty-first century, which is associated with the emergence of innovative forms of recognition in the context of “new” social policies. The reflection on inequalities has become a key not only to reading the social, economic and political dynamics that have characterised Latin American countries since the beginning of the century (Kessler 2014), but also to evaluating these policies (Georges and Tizziani 2020). On the one hand, the arenas of public action have become internationalised, and on the other, the different national conjunctures are experiencing a strong degradation of the social, economic and political order. Despite the differences between the national conjunctures, some common trends can be observed in the region: besides the degradation of the economic context, partly due to the competition of the Chinese market, the social and political compromises that sustained the so-called more progressive Latin-American governments came to an end during the second decade of the twenty-first century.

In Brazil, the State of São Paulo, and through its different imbrications, the municipality of São Paulo, the economic centre of the country, are very expressive examples of multidimensional forms of privatisation of the State from the inside, on the long term. First, there has been a historical tendency towards privatisation within the operationalisation of social assistance since the 1950s, at least at the municipal level (Sposati 1988). This can be seen in the public health sector, which is segregated between more lucrative, private areas of health care, and less lucrative areas, such as long-term care and chronic illness. This dualist tendency has been present since the period of the dictatorship (1964–1985) (Veras 2008). It can also be seen in the sector of education, where secondary education is undergoing a violent process of privatisation, in line with the right-wing political orientation of the State. Second, more recently, during the period of the more “voluntaristic” or “developmentist” social policies, since the beginning of the twenty-first century, the operationalisation of social policies, which has been delegated to the municipalities since the 1990s during the process of internal reform of the State as well as of political decentralisation, has shown different forms of State privatisation from the inside. These include a) the delegation or outsourcing of social assistance as well as of public health policies to NGOs (nearly 1,000 in the municipality of São Paulo, in the social assistance sector), as well as Social Organizations (OS) or OSCIPs , in the public health sector, creating different forms of merchandising of the social, maintaining forms of clientelism and the implementation of “political merchandise” (Misse 1997); and b) crossed forms of privatisation between different sectors of public policies, on the level of capturing financialisation (law Rouanet) , as well as with regard to conditionalities of access: the right of health or education is also the conditionality for the access to social assistance policies, such as the Bolsa família, the Brazilian CCTP. More generally, the crossing of forms of constraint and consent of the poor women, the main beneficiaries of these policies, through their implementation, lead to a privatization of the general interest, emptying the sense of the notion of social right before introducing private services to substitute them, starting with the health sector, even for the poor.

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Cover image: Sao Paulo, Brazil, Photo by ESP Professional for Shutterstock