Table 1 Social-change (“activist”) approach to social accountability: an example from Brazil

The overarching history of the Brazilian experience of social participation in health systems development and reforms exemplifies a long-term approach to social accountability. In the 1970’s a coalition of popular movements, national and international organizations launched and supported a national health movement. In the context of a post-military dictatorshiop redemocratization process, which stretched between the 1980s and 1990s civil society groups fought successfully for the institutionalization of social participation as part of the Brazilian universal health care system (Sistema Único de Saúde, otherwise known as the SUS). From the 1990s to today, this social participation process has resulted in the creation of more than 5000 health councils with nearly 100,000 individual participants, in additiona to related associations. These councils serve as fora in which citizens together with service providers and public officials work together to define public policies and oversee implementation processes [31]. The councils’ planning and monitoring activities inform and are informed by social accountability efforts, in addition to the work of these councils defending access to health care on constitutional grounds. The articulation of a universal ‘right to health’ was a key component in the historical creation and implementation of the SUS, but it has also been central to the increased resourcing of, and expansion of, public health services over the last two decades. The “activist” approach to social accountability of health systems has in this way contributed to the widening of the SUS and concomitantly a reducation of health inequalities on a national scale [32, 33].