Engaging citizens: Lessons from building Brazil’s national health system Andrea Cornwall * , Alex Shankland Institute of Development Studies, University of Sussex, Brighton, United Kingdom Available online 11 March 2008 Abstract Brazil’s Sistema U ´ nico de Sau ´de (SUS), a universal, publicly-funded, rights-based health system, designed and put in place in an era where neo-liberal reforms elsewhere in the world have driven the marketization of health services, offers important lessons for future health systems. In this article, we focus on the innovative institutional mechanisms for popular involvement and accountabil- ity that are part of the architecture for governance of the SUS. We argue that these mechanisms of public involvement hold the potential to sustain a compact between state and citizens and ensure the political momentum required to broaden access to basic health services, while at the same time providing a framework for the emergence of ‘‘regulatory partnerships’’ capable of managing the complex reality of pluralistic provision and multiplying sources of health expertise in a way which ensures that the needs and rights of poor and marginalised citizens are not relegated to the periphery of a segmented health system. Ó 2008 Elsevier Ltd. All rights reserved. Keywords: Participation; Brazil; Health systems; Accountability; Rights; Public sector Introduction Brazil’s Sistema U ´ nico de Sau ´de (SUS) is a univer- sal, publicly-funded, rights-based health system. Designed and put into place during an era in which neo-liberal health reforms elsewhere in the world e and especially in Latin America e have driven the marketization of health, Brazil’s SUS holds a number of important lessons for the development of future health systems. Health systems, Bloom and Standing (2008) argue to this Special Issue are based on two kinds of compact: between states and professions, to restrict access to expertise through professionalisation in return for the power to regulate access to goods and services through bureaucratic means; and between states and the market, through the use of market mech- anisms to manage risk by limiting access. They argue that these means of ‘socialising’ health systems have, in recent decades, come to confront a number of chal- lenges. Health expertise is increasingly pluralised, rede- fining what it means to be an ‘expert’ and redrawing the boundaries of what counts as ‘knowledge’. Other boundaries come to be reconfigured in the process: be- tween the public and the private, between the roles of the state and the market, and between systems of medicine. This article addresses a further dimension of these changes: that of the involvement of citizens in deliber- ation over health policy, in mechanisms for ensuring * Corresponding author. Institute of Development Studies, Univer- sity of Sussex, Falmer, Brighton BN1 9RE, United Kingdom. E-mail addresses: a.cornwall@ids.ac.uk (A. Cornwall), a.shankland@ids.ac.uk (A. Shankland). 0277-9536/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2008.01.038 Social Science & Medicine 66 (2008) 2173e2184 www.elsevier.com/locate/socscimed