Politics, class actors, and health sector reform in Brazil and Venezuela.

Universal access to healthcare has assumed renewed importance in global health discourse, along with a focus on strengthening health systems. These developments are taking place in the backdrop of concerted efforts to advocate moving away from vertical, disease-based approaches to tackling health problems. While this approach to addressing public health problems is a step in the right direction, there is still insufficient emphasis on understanding the socio-political context of health systems. Reforms to strengthen health systems and achieve universal access to healthcare should be cognizant of the importance of the socio-political context, especially state-society relations. That context determines the nature and trajectory of reforms promoting universality or any pro-equity change. Brazil and Venezuela in recent years have made progress in developing healthcare systems that aim to achieve universal access. These achievements are noteworthy given that, historically, both countries had a long tradition of healthcare systems which were highly privatized and geared towards access to healthcare for a small segment of the population while the majority was excluded. These achievements are also remarkable since they took place in an era of neoliberalism when many states, even those with universally-based healthcare systems, were moving in the opposite direction. We analyze the socio-political context in each of these countries and look specifically at how the changing state-society relations resulted in health being constitutionally recognized as a social right. We describe the challenges that each faced in developing and implementing healthcare systems embracing universality. Our contention is that achieving the principle of universality in healthcare systems is less of a technical matter and more a political project. It involves opposition from the socially conservative elements in the society. Navigation to achieve this goal requires a political strategy that involves various actors within the state, the political society and civil society.