Brazil has historically been notorious for having deep inequalities and relatively low levels of human development—including poor health outcomes—for a middle-income country. However, since the transition to democracy in 1990, the country has made impressive gains in several areas, including health—and especially in reducing infant and child mortality. While a long period of democratic rule in a country is often associated with gains in human development, the precise mechanisms by which literacy rates or population health indicators improve is not always well understood. Christopher Gibson's Movement-Driven Development: The Politics of Health and Democracy in Brazil is, in this respect, a fascinating, important and insightful account of how infant and child mortality rates fell significantly across several Brazilian cities after the transition to democracy. It is a different matter that some, or even many, of these gains may be reversing under the current government led by President Jair Bolsonaro.

The foundation for Brazil's advances in public health was laid by the sanitaristas—health professionals and experts from academia, research institutes and think tanks who formed an influential public health movement, Movimento Sanitario (Sanitary Movement), that emerged in the 1970s when the country was still under military rule. Although the group initially organized as a social movement, many of its members subsequently came to occupy key positions at various levels of the Brazilian government during the 1980s, as the country progressed toward democratic rule. Through their induction into the government as bureaucrats and consultants, the sanitaristas secured the recognition of health as a fundamental right of every citizen—and a corresponding duty of the state—in Brazil's 1988 Constitution and in the establishment of the Sistema Único de Saúde (Unified System of Health).

Remarkably, there is very little published scholarship in English on Brazil's Sanitary Movement; what we know about the movement and its achievements is drawn almost entirely from the work of Brazilians and accessible only to those with knowledge of Portuguese. Furthermore, writings on the sanitaristas routinely stop with Brazil's transition to democracy and the promulgation of the new constitution, almost as if they became irrelevant after. Given this context, Gibson's book fills a void by examining the role played by sanitaristas in improving population health over a period of three decades after the transition to democracy, and it does so by focusing on the health gains made in Brazil's largest cities.

The central argument of Gibson's book is that Brazil's advances in health were driven from below by the sanitaristas, who constituted the backbone of what Gibson terms “movement-driven development.” For Gibson, the sanitaristas and other like-minded civil society actors, notably popular movements in some cities, constituted “pragmatic publics” who pushed for the realization of health rights provided in the new constitution by improving public delivery of key social services. Of course, not all cities came to witness the emergence of pragmatic publics: health performance varied based on the inroads made by sanitaristas in securing key positions in the bureaucracy, on the extent and nature of popular support for their program, and on the distribution of power between left and centre parties, on the one hand, and conservative groups and parties, on the other. Thus, cities such as Salvador and Rio de Janeiro, where opposition forces were powerful and obstructed the sanitaristas, experienced only a “minimalist” version of health democratization. In contrast, cities such as Belo Horizonte, Porto Alegre and Recife, where pragmatic publics were robust in terms of the presence of sanitaristas in key positions and popular participation, witnessed impressive gains in health via what Gibson terms a “participatory-programmatic” trajectory. Other cities such as Curitiba and Fortaleza made health gains via a “programmatic” trajectory, since sanitaristas occupied key positions in the government even though popular participation around health issues was insignificant or even absent.

Building on prior research on social movements and civil society, Gibson theorizes at length on pragmatic publics (chap. 2). In brief, he sees the Sanitary Movement as combining an outward public orientation with a focus on democratic office and a deep-seated commitment to the solidary ideology of a universal right to health, which enabled the group to adapt to changing political-opportunity structures and thereby become key protagonists in Brazil's success story in the health sector. As is the case with much of the new generation of scholarship in comparative politics, Gibson's book uses a multi-methods approach to make his argument on the role of pragmatic publics represented by the Sanitary Movement. In addition to an empirical chapter with statistical analysis, there are well-researched and fascinating case studies of Belo Horizonte, Porto Alegre, Curitiba and Fortaleza, all of which are nuanced and convincing and which will be of great interest to scholars working on Brazil and on cities.

Gibson's book tells a significant story for those engaged in debates over the role of top-down interventions and bottom-up pressures in the expansion and improvement of public services such as health. Norman Uphoff once noted that although we are commonly constrained by thinking in either/or terms for top-down interventions and bottom-up pressures, both are needed in a positive-sum way to achieve development. Gibson's book, beginning with the title, conveys the idea that bottom-up pressures played the key role in improving health outcomes in Brazil, but both his theory and research admits the equally important role of top-down interventions. In a more conventional scenario, elected politicians are expected to respond to bottom-up pressures for welfare goods by improving the provision of public services. In the case of Brazil and the sanitaristas, there is a twist to the story: what started as a movement from below to demand improvements in population health became, over time, part of top-down interventions when the sanitaristas occupied key positions in the bureaucracy. Indeed, this was the key to success in both the “programmatic-participatory” and “programmatic” trajectories described above. To that extent, Gibson's insistence that the book provides a “civil-society-based explanation” for Brazil's social development is not entirely true.

There is a lesser complaint about the book too. Gibson measures Brazil's health progress primarily in terms of infant and child mortality even though the country's population and health profile changed over time despite high levels of income inequality and poverty. Fairly large parts of the country underwent an epidemiological transition, and the country's main health challenges by the 1990s were not limited to infant and child mortality; they also included, among other things, an increase in so-called “affluent diseases” and a growing number of deaths from road accidents and violence, both of which were recognized as “new” public health problems. The book's arguments would surely become even more convincing if it could also show that the sanitaristas helped Brazil make progress in addressing its newer health challenges.

Overall, Gibson's Movement-Driven Development represents the best of the new comparative politics scholarship and deserves to be read by social scientists across disciplines interested in civil society, health and public goods provision.