Grassroots Bureaucracy: Intergovernmental Relations and Popular Mobilization in Brazil’s AIDS Policy Sector

Jessica A. J. Rich

Article originally published in: Latin American Politics and Society, 55, no. 2 (2013), pp. 1–25

The broader research project that forms the basis for this article examines the political success of the AIDS movement in Brazil. Brazil stands out as an international standard bearer for good governance in AIDS prevention, and civil-society mobilization is generally acknowledged to be a key driver of this continued success. Behind the scenes, civic associations have been central figures in the negotiation, development, and implementation of nearly every AIDS policy decision at both the national and the subnational level. Based on the Brazilian experience, international lending organizations have developed a variety of mechanisms to increase civil society involvement in shaping domestic AIDS policy. Yet, outside of Brazil, the vast amount of global financial and technical support for AIDS NGOs across the developing world has largely failed to achieve the same success.

This particular article project elaborates one of the independent variables that helps to answer one of the questions addressed in my broader project, which is: What factors were key to the expansion of the AIDS movement in Brazil into a broad national constituency that cuts across class, ethnic, and geographic lines? Whereas the explanation for early political organizing around AIDS in the 1980s lies in the socioeconomic resources available to grassroots leaders, I attribute the expansion of Brazil’s AIDS movement into poorer and more rural communities to the active role of government bureaucrats at the federal level. I argue that Brazilian bureaucrats in the national AIDS bureaucracy played a key role both in helping new working-class organizations overcome socioeconomic challenges to mobilization and in providing new opportunities for working-class groups to achieve political influence. This article examines the motivation for national bureaucrats to mobilize new grassroots constituencies as AIDS advocates, as well as the mechanisms they used to accomplish their mobilizational goals.

Initial Research Design

The research design centers on analyzing a crucial case of civic mobilization under the current political and economic regime in Latin America, grassroots mobilization around AIDS policy reform in Brazil, because it modifies the prevailing theories that focus on the state as an obstacle to political mobilization. The prevailing literature argues that decentralization and privatization has fragmented popular interests in the neoliberal era, weakening the influence of civil society vis-à-vis the state. However, while Brazil is highly privatized and the most decentralized country in Latin America, Brazilian AIDS associations are among the most scaled up and politically influential popular nongovernmental organizations in the region. AIDS policy in Brazil is thus a case that goes against prevailing theories of mobilization. In closely analyzing this unexpected case of broad civic engagement, I identify new factors that shape popular organization and mobilization in the era of neoliberal democracies, centering on the resources and channels of access to political power provided by the state.

At the same time, the analysis relies on two types of structured comparisons. The comparison I utilize in this article is change over time within the AIDS policy sector. This within-sectr comparison allows me to isolate the effects of political and economic factors on patterns of popular mobilization while holding constant the influence of issue-specific variables. Other authors have underscored the crucial role of socioeconomic factors in facilitating AIDS advocacy in Brazil, centering on the initial concentration of AIDS in Brazil among urban gay men, who were wealthier and more socially and politically connected than average Brazilians. To be certain, these insights largely explain the strong grassroots response mobilized during the first phase of the AIDS epidemic in the 1980s. Overtime, however, AIDS spread from wealthy urban communities into poorer, more rural areas; and the AIDS associations that emerged in the 1990s and beyond reflect the new demographics of the epidemic, in that they are socioeconomically heterogeneous. While the insights of socioeconomic arguments are relevant for the study of grassroots movements in Brazil, and for the AIDS movement in articular, the change over time in the socioeconomic characteristics of AIDS associations has not led to the expected decline in grassroots mobilization. Paradoxically, the movement grew in some ways stronger and more highly coordinated at the same time as the socioeconomic profile of AIDS associations became more heterogeneous. Thus, comparing patterns of popular mobilization around AIDS over time enables me to argue that socioeconomic attributes of civil society are insufficient for explaining the dynamics of organization and political engagement, and that we must also take into account national political actors—specifically, the role of the state in shaping the incentives and opportunities for civic mobilization.

By the same token, examining variation in patterns of mobilization within the area of AIDS policy in Brazil enables me to hold factors related to the nature of demands largely constant and to argue, therefore, that issue-specific factors are not sufficient to explain the broad range of popular mobilization around AIDS issues in Brazil—and that, rather, we must also examine the effects of resources and institutions on patterns of demand-making. More specifically, civic mobilization around AIDS, as around any policy, is shaped in part by the nature of the demands inherent to the issue. In the case of AIDS, access to ARV (anti-retroviral) drugs is a matter of life and death to the grassroots protagonists who are affected by the virus. Access to these medications must also be renegotiated constantly, as new drugs are developed by pharmaceutical research companies and as each generation of ARVs produces its own side-effects, which, in turn, require further treatments. In other words, AIDS advocacy centers on demands that are discrete and recurring, which facilitate s sustained collective action and organizational coordination. Comparing temporal differences in patterns of mobilization within the area of AIDS policy allows me to hold constant the influence of issue-specific variables.

Research Trajectory

My initial research design focused on examining subnational variation in patterns of grassroots mobilization around AIDS. However, an unexpected finding that came out of my fieldwork was that the degree of subnational variation was much less than I had expected. Whereas AIDS movements were generally weaker in the poor Northeast, North, and Center-west regions of Brazil than in the highly developed Southeast and South regions, the fact that there were autonomous AIDS movements at all in these poorer regions was quite surprising given the challenging local political and economic contexts in which they were operating. Based on this unexpected finding, I tweaked the project to focus on explaining why grassroots mobilization in Brazil expanded to poor and rural states—which is distincy from my original focus on explaining variation among strong versus weak local AIDS movements and among different types of strategic repertoires employed by local AIDS movements.

I summarized this unexpected finding in the following memo to my dissertation advisors, written on November 17, 2007. This memo constitutes the base of the published article in LAPS that is linked to this TRAX.

Memo excerpt, beginning on p.6:

Centralized Control

In contrast to the centralized organizational structure that characterized the initial policymaking model in Brazil, AIDS policy underwent a gradual process of decentralization beginning in 1998. Regarding the impact of decentralization, I made two key observations during my time in Brazil. On the one hand, there are significant state-by-state differences in models of intermediation between the state and AIDS associations, which seemingly correspond to two factors: (1) the character of the government, and (2) the presence of a well-entrenched gay movement.

But more surprisingly, the degree of difference between states was weaker than I had expected. In explaining this surprising lack of discrepancy between AIDS policymaking models at the state level, I suggest that while authority over AIDS policy has been formally decentralized to the state level, the national government retains strong elements of informal control over the AIDS policymaking process. Moreover, it seems that these elements of central control are critical to maintaining the success of the AIDS policy model in Brazil. Specifically, I argue that central control over AIDS policy persists in three primary forms. 

First, the national AIDS program still retains a degree of financial control over state-level AIDS bureaucracies. The national government transfers funding for AIDS control to the state-level government through what is known in Brazil as the “fund-to-fund” system. In order for states to receive funding, they must adhere to a list of requirements. The national AIDS program monitors their compliance with these conditions, and it collaborates closely with state and local AIDS bureaucracies to guide the institutional development of their programs.

Second, the national AIDS program maintains direct contact with local AIDS associations. The Sector for Articulation with Civil Society within the national AIDS program not only still exists, but it has become one of the [five] principle subunits of the national AIDS bureaucracy. Despite Brazil’s decentralizing reforms, the national program has maintained its strong communication with local activists through two principle avenues. One mechanism is through pure shoe leather. The X bureaucrats who run the Civil Society subunit travel regularly to each of the twenty six states in the Brazilian federation, either conducting training sessions or attending events at the behest of local AIDS groups. (Several members of the national AIDS bureaucracy mentioned to me that their unofficial policy is to never refuse an invitation to any event organized by local AIDS associations.) The other mechanism for maintaining their close connections with AIDS associations is to fly associational leaders to Brasília on a regular basis for national-government sponsored events such as conferences, rallies, and “capacity-building” training sessions.

Through these two channels, the central government seems in part to be bolstering political mobilization among local AIDS associations, with the explicit purpose of increasing outside pressure on state health secretariats to improve their policy management.

Finally, the central government plays an important role in supporting the national political network of AIDS associations that developed in response to the initial creation of Brazil’s AIDS program. All of the NGO leaders whom I interviewed emphasized the central significance of cross-regional associational networks to their ultimate political success. The decentralization of AIDS policy has posed challenges to national mobilization by fragmenting associational interests. However, the National AIDS Program plays a key role in maintaining national associational networks by both financing their meetings and by offsetting travel expenses so that locally-elected delegates can afford to attend them.

Data Collection

The evidence presented in this project draws on original data collected during nineteen months of fieldwork in Rio de Janeiro, Sao Paulo, and Brasilia, combining qualitative and quantitative methods of data collection. Archival research: I used the Center for Documentation and Resources (CEDOC), an archive housed in ABIA (The Brazilian Inter-Disciplinary AIDS Association) to collect policy analyses and monographs. I also collected unpublished government documents from the national AIDS bureaucracy, by making requests of my government informants. Finally, I collected media reports about AIDS in Brazil using the Factiva search tool on the internet.

Compilation of existing material: I constructed a national database of civic AIDS organizations in the years 2001 and 2002, using information from The National Catalog of HIV/AIDS Civil Society Organizations. This catalog of organizations is the product of an effort by the Ministry of Health to construct a comprehensive registry of AIDS associations in Brazil. The end result of this national questionnaire was a hardcover book that contained two-pages of information on every organization in their national sample. The responses of each organization were printed word-for-word, some of which were open-ended, and some of which were answers to multiple-choice questions. The focus of the questions was on their missions, activities, leadership, and organizational attributes. No electronic version of the catalog was available. I constructed the database by hiring a data entry company, Digital Divide, to enter all the information contained with the catalog into a spreadsheet that I could use to perform quantitative analyses of the survey responses.

Interviews: I conducted over 100 in-depth, open-ended interviews with civil-society leaders, bureaucrats, politicians, and World Bank officials directly involved in AIDS policy in Brazil. I selected the interview informants based on two methods. I used snowball-sampling procedures toidentify and gain access to AIDS activists and bureaucrats. For each of my four cases (two country-time cases and two subnational cases), I also attempted to distribute the interviews somewhat equally across six categories: AIDS activists, AIDS-movement representatives on government policy councils, leaders of AIDS networks, LGBT activists, tuberculosis activists, and AIDS-sector bureaucrats.

Observation: I also observed over 40 events and meetings. This included attending AIDS policy conferences and observing AIDS-policy protests. My observations also included sitting in on closed-door meetings among activists, and between activists and government bureaucrats. I attended as many of these events and meetings as possible given time and budgetary constraints, making a special effort to attend meetings involving political challenges or issues.

Survey: The Brazilian survey of AIDS NGOs was carried out between February and May 2010 via the internet in the states of Rio de Janeiro and São Paulo. Two hundred thirty-one organizations were included in the sample, and one hundred twenty-three organizations responded—yielding a response of fifty-three percent. I drew the sample from three registries of AIDS-related organizations in each state: the list of member organizations in the state-level umbrella network of AIDS NGOs, the list of organizations that received state funding at any point over the four years prior to the survey, and the list of government-funded AIDS hospices. My sampling procedure likely produced a selection of organizations that was more politically active than a random sample would have produced. Drawing such a sample was not possible, since no reliable registries existed from which to determine a population. At the same time, my analytic goal was not to make generalizations about the population of NGOs in Brazil but, rather, about the population of civic groups that are involved in political demand making. I conducted the survey via the internet. My response rate was fifty-three percent.

Logic of Activation

I activated citations using the four criteria for assessment suggested in the current version of the Guide to Active Citation: centrality of the (evidence-based) claim, importance of the data source, contested or controversial nature of the (evidence-based) claim, and contested or controversial nature of the data source. I also activated (or attempted to activate, given that this is a pilot project and I do not yet know whether ACE will support this action) some sentences that did not include citations in the published article. I chose to activate these sentences, despite the fact that they lacked citations, using the same logic in the Guide to Active Citation. In other words, I determined that these sentences should have included citations in the published version of the article.

Logic of Annotation

When I activated citations but did not annotate them, it was because the meaning of the source and how it supports the evidence-based claim in the text was unambiguous and uncontestable