Theorizing about Performance Evaluation of Health Systems from the Perspective of Civil Society


One of the slogans that compose managerialism is the participation of civil society in controlling the performance of public administration, thus consolidating itself as a form of accountability. So this article is concerned with theorizing the role of civil society interested in the debate about the performance evaluation of health systems and the limits that the literature presents on this topic. An exploratory, descriptive-reflective, essay was carried out. The scientific literature on the subject presents three controversies on this subject: the first deals with the use of results measurement to evaluate performance in health systems, the second about the health system as an object of performance evaluation and the third deals with evaluation performance as a public policy in health systems, in which we brought the reflection on the case of the Unified Health System and the control of the performance of health policies by civil society. The theoretical reflection brought a wide open view to the complex relationship between society and State, their economic and political implications with performance and the limits of adopting these tools to measure. Finally, we conclude that three dimension of limits were identified (economic, political and technical) in this discussion that we need to overcome. Concerning this fact, we propose an essential research agenda.

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Carnut, L. (2020) Theorizing about Performance Evaluation of Health Systems from the Perspective of Civil Society. Open Journal of Social Sciences, 8, 394-411. doi: 10.4236/jss.2020.86030.

1. Introduction

The role of civil society in controlling contemporary public administration has been reworked with regard to the logic of the managerialist State. Concealed in what is called “flexible bureaucracy”, this type of State tends to deny itself as a form of exercising power. However, this power is strategically exercised through subtle control movements that combine consent and diffusion providing depoliticization and democratic deficit in organized civil society (Paes de Paula, 2005). The very meaning of “civil society”, depending on the author to whom the analysis is affiliated, already leads to academic debates due to its intrinsically abstract content. Even so, there seems to be a consensus that it is in the sphere of civil society that ideological power is formed that characterizes the form and content in which social control, with the meaning of res publica control by the population, will take shape (Bobbio, 1987).

It is in this sphere where the phenomenon of public opinion is usually included, understood as the public expression of consensus and dissent about institutions, transmitted through the press, radio, television (Rothberg, 2008) and contemporaneously, through social networks (Castiel & Vasconcellos-Silva, 2006). It is in this social time when the debate about strongly modern categories, for example, the persistence of conflicts between capital-labor in traditional social structures has to be re-analyzed from the point of view of a subject who, as part of civil society, must have a capacity to judge the decisions and activities carried out by the State in the light of its current reconfiguration.

In this scenario, one of the fundamental questions in the subject’s capacity (and, in other words, in the composition of the criticisms formulated by civil society in this scenario) is the way the subjects deal with information. In the 21st century, information appears in the service of a new order that has subsumed it to economic rationality fundamentally through the excess of information that becomes noise (Castiel & Vasconcellos-Silva, 2006) and the instantaneousness of information as opposed to its historical process (Dias, 2013). Allied to this, the absence of intersubjectivity in the formulation of individual opinions and in the construction of public opinion tends to generate social representations that massify ideas each times less exposed to counter-argument. This makes information a reflection of those who dominate the mass media (Dias, 2013), thus promoting that certain statements become ideologies (Ricouer, 2013).

Added to this is the question of the nature of the contemporary subject and his (dis) interest in the public debate raises the impasse on the adequate control of civil society over the forms of organization of the managerial state. Unlike psychoanalytic bases (Elia, 2004), for Touraine (1998) the “subject” is this effort of the individual to be an actor, that is, to act on his environment and thus create his own individuation. Certainly when it comes to the topic of “civil society control over the State”, especially in light of the need for this social activism required for social control in managerialism (Pires, 2007), it seems that the definition of “subject” proposed by Touraine is not only unsettling but very appropriate. It is questioned about what to expect from the control of civil society over the State where its subjects are mostly in a constant process of hermeticizing themselves.

In the current conjuncture, the subject appears individualized and hostage to the acute complexification of modern social structures (Beck, 2010), which makes decoding the social scenario somewhat unattractive (Berger, 2007). The conflict inherent in the abuse of economic power over the State is one of those quarrels in which civil society suffers from the low politicization necessary for the exercise of “accountability” that challenges the State in matters of public interest (Arato, 2002). This aspect is especially strategic when it comes to building the State at the expense of new public management.

As a material expression of management tools in managerialism, management processes such as: contracting results, public-private partnerships and variable remuneration for performance evaluations have been constituting one of the pillars of ongoing reforms in several countries in the last two or three decades. The controversies surrounding the application of these management tools in the public sector are intense, both among supporters and among critics and defenders (Pacheco, 2009). In the health sector, this proposal would not go unnoticed, and in 2012, with the advent of the Unified Health System Development Index (IDSUS) (Brasil, 2011a), this tool gains its materiality within the scope of the Brazilian health system. Concerning managers, provoking academics, this instrument is based on the slogan of two-sided control (either by management—by measuring performance for awards; or by the population—through social control of activities carried out in their local systems).

In the practice, the paths taken to formulate these management tools run through another latent ideology: that one linked on business logic with a market orientation. This can be seen from the development of evaluation models to their application on the target objects (often without much thought about their object of evaluation). Under the light of managerialism, these evaluation models become instruments of evaluation of contemporary public policies whose little dialogue with stakeholders (in general) makes them managerial tools that tend not to capture the measurement objects in their singularities and make it difficult external control by civil society.

Based on these arguments, this article aims to theorize the role of civil society interested in a debate about the performance evaluation of health systems and the limits that the literature presents on this topic. Thus, an exploratory descriptive-reflective essay was carried out. The scientific literature on the subject presents three main controversies: the first deals with the use of results measurement to evaluate performance in health systems, the second about the health system as an object of performance evaluation and the third deals with evaluation performance as a public policy in health systems, in which we brought the reflection on the case of the Unified Health System and the control of the performance of health policies by civil society.

2. Health Sector: Measuring Results and Evaluating Performance to Control

The results achieved by organizations have become, for the past 20 years, the main input used for performance arbitrage. For this reason, to capture what has been called “performance” in these organizations has become the ultimate goal of those who believe in these mechanisms to assess the fulfillment of their missions. So, these organizations have resorted to performance measurement systems trying to characterize their performance in the circumstances in which they operate (Motta, 2007).

For theorists in the field of administration, an organizational performance measurement system, as it aligns organizational strategies (Kaplan & Norton, 1997) seems to be a growing trend in public administration (Júnior, Ruiz, & Corrêa, 2005). Therefore, the formulation of indicators and their powers in describing what is essential to performance must be a task to be carried out with great caution.

Lohman, Fourtuin and Wouters (2004) refer that a performance indicator is a variable that quantitatively demonstrates the effectiveness or efficiency or both, of part or the whole of a process or system, against a standard or objective. Also, there are times when the indicator is called “performance metric”. An “indicator” or “metric” allows you to monitor the performance of actions aimed at materializing strategies, thus creating a “link” between planned and accomplished, a relationship that involves strategy, action and measurement. From the perspective of a measurement system, a Performance Measurement System (or “Performance Measurement System”—PMS) can be understood as a “set” of these metrics when applied to quantify the efficiency and effectiveness of organizational actions (Neely, Gregory, & Platts, 2005).

Performance measurement has some advantages. According to Atkinson, Waterhouse and Wells (1997), with these performance measurements we can monitor the implementation of organizational plans and determine when they are not being successful and how to improve them. Bititci, Turner and Begermann (2000) state that performance measures need to be aligned with the organization’s strategic priorities, under the prism of strategic control. In general, the evolution of Performance Measurement Systems has been outlined in order to follow the way of operating of organizations that have concentrated their processes in the form of chains or networks (Busanello, 2011).

However, there are some disadvantages associated with performance measures. A latent concern among scholars of these measures is related to the “definition of coherent indicators for this practice”, that is, that they translate the dimensions to be considered in the evaluation process (Busanello, 2011). Another aspect, very common in companies with a focus on the market, is the abuse in the use of financial indicators as measures that summarize the performance of a certain organization. In view of this aspect, non-financial measures are increasingly being used to provide performance information of a non-monetary nature such as market share, customer satisfaction, innovation and development of new products and employee turnover (Verbeeten & Boons, 2009).

In the field of services, Fitzgerald et al. (1991) emphasize the existence of two basic types of performance measures in organizations: 1) measures that report results (competitiveness, financial performance); and, 2) measures that focus on the determinants of results (quality, flexibility, use of resources and innovation). The emphasis on considering financial and non-financial indicators as defining measured performance is evident. Health, understood economically as a service (Meirelles, 2006), would also start to take into account indicators related to the measurement of the determinants of its results.

Neely (1999) presents another set of principles for the development of indicators to be used in Performance Measurement Systems: 1) the metrics or indicators should be directly related to the company’s production strategies; 2) non-financial indicators must be adopted; 3) it must be recognized that indicators vary depending on the location as a measure may not be suitable for all departments or locations; 4) it should be recognized that indicators change as well as circumstances; 5) indicators must be simple and easy to use; 6) indicators must offer rapid “feedback”; and, 7) indicators must be designed to encourage continuous improvement and not just as monitors (Tanaka & Tamaki, 2012). Thus, it is possible to apply mathematical optimization techniques to maximize or minimize a function previously defined as Performance Indexes (IP), in order to find an “optimal solution” of the problem, that is, that results in the best possible IP.

In effect, the measurement of a given process is only justified if it proposes to be subject to evaluation. Evaluation is an essential tool to support management because of its ability to improve the quality of decision making. An obstacle to a broader use of evaluation in decision-making in health services is that its implementation requires resources and time, which makes it difficult to use it for problems that need immediate solutions. In these situations, very common when it comes to the health of groups and populations, only the existence of accumulated knowledge, resulting from past or previously planned evaluations, can contribute to this decision making.

The word “evaluation”, in its broad sense, consists of assigning value to something (Aguilar & Anger-Egg, 1994). For Arnold (1971) evaluation “it is the planned and systematic feedback of information needed to guide future action”. Evaluation is a way to judge the performance of programs, and it is necessary to define ways to measure the result obtained. Thus, outcome measures are the most required evaluation criteria nowadays (Oliveira, Silva, & Bruni, 2012) and it is fact that without evaluating, it is not possible to exercise the administrative function of controlling.

In the next section, we explore with more details the relationship between these performance evaluation measures applied to health system as a target to control function exercises.

3. Health System as an Object of Performance Evaluation in the Exercise of the Control Function

As seen, one aspect of the performance evaluation debate refers to the precise definition of the object of the evaluation so that it is possible to choose the best indicators. The diversity of concepts highlights the wide variety of ways in which “evaluating performance” is perceived by different authors and models. This also occurs when it comes to the perception of “health systems” because, in addition to presenting differences between authors and disciplines, they have also been defined differently over time (Hoffman et al., 2012).

For Roemer (1991), “health systems” are service structures based on a combination of resources, organization, financing and management that culminates in the provision of health services to the population. In Mendes (2002), these structures are social responses organized deliberately to respond to the needs, demands and representations [“health”] of populations, in a given society and at a certain time. For Lobato and Giovanella (2012), it is the set of political, economic and institutional relationships responsible for conducting the processes related to the health of a given population, whose set is embodied in organizations, rules and services that aim to achieve the results consistent with a prevailing concept of health in a given society.

As for the purpose, according to Starfield (2002), every health system has two main objectives that must be pursued. The first corresponds to the optimization of the population’s health through the application of the most advanced knowledge about the causes of illnesses. The second aims to minimize inequity between population subgroups, so that certain groups are not at a systematic disadvantage in relation to access to health services. For the World Health Organization, health systems aim to: “all activities which were primarily proposed: promoting, restoring or maintaining health”. These activities can be grouped into six categories: 1) provision of services; 2) health professionals; 3) health information systems; 4) medical supplies, vaccines and technologies; 5) health financing system; and, 6) leadership and governance (WHO, 2007). The growing contribution of the method of comparative analysis to the study of health systems coincides with the growth and expansion of these services, since government action in social and health policies has increased considerably over the 20th century (Conill, 2006).

For Conill (2006) health systems can be divided into three major groups: 1) national health systems (with the perspective of being constituted in universal health systems, financed from fiscal resources, such as the British system); 2) public health insurance (under state control, but financed by the insured, even if they receive some public resource, such as the German system); and, 3) business-permissive systems (financed directly by beneficiaries and under state regulation only, such as that of the United States). An ideal health system should basically have three major functions: 1) regulation; 2) financing (universal or segmented); and, 3) the provision of services (integrated or fragmented services, with state monopoly, public contracts, managed or free market competition). As for its components, Kleczkowski, Roemer and Werff (1984) state that health systems are made up of the following components: 1) model of care; 2) financing; 3) infrastructure; 4) organization; and management. In a more comprehensive proposition, Lobato and Giovanella (2012) identify that health systems depend on “components” that interact through their “functions”. For these authors, among the components of health systems are: 1) coverage and benefits catalog; 2) resources (human, financial, service network, technology and knowledge, inputs); and, 3) organizations. As for the functions, these would be four mainly: 1) the financing; 2) the provision of services; 3) management; and, 4) regulation.

For these reasons, when comparing systems, it is necessary to clearly establish the difference between “health systems” and “health care and service systems” (Mendes, 2011). The former are much more comprehensive and refer to health in a broader sense which is the result of a complex interaction of a set of factors and actions of different social systems. Health systems include the set of interventions that target specific, social or health problems; cover the entire range of interventions, from preventive services to palliative services, to diagnostic and curative services. They comprise the major functions of public health (surveillance, health protection and promotion, disease prevention, evaluation of the health services system, development of public health skills) (Lévesque & Bergeron, 2003), but health systems have no direct responsibilities, or governance, on the set of social, economic, cultural, demographic conditions that affect people’s ability to live well and for a long time.

In fact, when looking to comparatively analyze health systems, the focus tends to fall on “service and care systems” (Conill, 2006). Health systems studies are very close to policy analyzes and health services studies. This is because these studies use close disciplinary resources, such as epidemiology, economics, social and human sciences and administration. This interaction is positive and should be encouraged because it helps a lot in the knowledge of health systems. However, there is a need to distinguish them. The analysis of health policies prioritizes political and institutional relations between health actors, while health services studies prioritize knowledge of the effects of the actions of institutions providing health services on the living and health conditions of populations (Lobato & Giovanella, 2012).

These aspects correspond to the conditionalities of the studies, analyzes and evaluations that have implications for the design and execution of the research that takes as its object the “health systems”, since it is an elementary prerequisite to understand this field of research as necessarily multidisciplinary and comprehensive (insofar as it requires considering factors related to governance, financing and organization of public health service delivery, implementation considerations to reform or strengthen this form of service organization and more broadly the economic context, legal, political and social in which these services are negotiated and operated. The purpose of health systems research is to improve the understanding and performance of health systems. Health systems research includes all health service research, most health policy research and some clinical-epidemiological research, but does not include biomedical research (Hoffman et al., 2012). Therefore, it is suggested that studies on health systems have as their frontier the analysis of the dynamics of one or more of its components. In other words, studies must be comprehensive to the point of considering the social, political and economic aspects that interfere in health systems, but always with a focus on at least one of its components and its dynamics, or compared to the other systems (Lobato & Giovanella, 2012).

According to these elements, it is quite important to illustrate the role of public policies in promoting/developing performance evaluation with a concrete example. So, in the next section, we brought up the case of performance evaluation policy of health system in Brazil and the public control of civil society mediated by its mainly tool called IDSUS (Índice de Desempenho do Sistema Único de Saúde—Performance Index of Unified Health System).

4. Performance Evaluation as a Public Policy in the Brazilian Unified Health System and Its Control by Civil Society

The problems faced by the Unified Health System (SUS) in the development of health management have led to the search for “more objective” decision-making alternatives to implement the principles of universality, integrality and equity (Tanaka, Tamaki, & Felisberto, 2012), especially in the historical context in which it is sought a new public administration focused on results (Garces & Silveira, 2002).

As a result, performance has become a central concern for public policy makers and managers in the historic period of the late 20th century and early decades of the 21st century. The logic of performance has been crucial in the wave of public service management approaches (especially in health services) that has been called “the new public management” (Exworthy, 2010).

For that, the identification of performance measures has been the target of researchers in the area with the purpose of implementing decision making under this new form of management. When it comes to health systems, there is a reasonable consensus that the objectives can be summarized in four topics: 1) giving health to citizens through the health system; 2) ability to respond to individual needs and user preferences; 3) financial protection offered by the health system; and, 4) productivity in the use of health resources (Smith, Mossialos, Papanicolas, & Leatherman, 2012).

Pioneering experiences in Brazil in this area come from research by the Institute of Communication and Information in Science and Technology—ICICT of the Oswaldo Cruz Foundation, through the creation of PRO-ADESS (Performance Evaluation Program for Health Systems) (Brasil, 2011a; Viacava et al., 2012). PRO-ADESS is within the scope of which a performance evaluation model for the Brazilian health system was proposed, using the theoretical framework of health inequalities.

In terms of management, the SUS performance evaluation experience, with national coverage, gained prominence with the creation of the Performance Index of the Unified Health System (IDSUS) and with the implementation of the Quality Assessment Improvement Program in Primary Care (PMAQ-AB). IDSUS analyzes performance based on the crossing of simple and composite indicators applied to federative entities: municipalities (whether or not organized in health regions), states (provinces) and the Union. Focusing on “performance” is the question of “efficiency” and “access to services health” it has indicators of various healthcare levels (primary, secondary and terciary) and works with some elements of social determination of health (Andrade, 2012). The second performance index (PMAQ-AB) focuses its evaluation process at the “micro” level (health teams) on only one level of care (primary health care) and with a Donabedian-inspired methodology, uses indicators of structure, process and user satisfaction (Brasil, 2011b).

Notwithstanding the value that can be attributed to these evaluation initiatives originating from the national management of SUS, the crucial fact regarding these mentioned evaluation processes is that the essence of what is taken for “performance” is questionable, especially if the questioning is not restricted to the methods and techniques used, but is directed, epistemologically, to the object (what) these evaluative processes, with the instruments employed, are proposing to measure. It is worth emphasizing that the basic characteristics of the performance evaluation processes are not explained in the formulations of these evaluation processes, deducing that their meaning is tacit, requiring no explanation. However, the sense of performance itself is not sufficiently clarified as an expression of the indicators used in both processes. The main consequence of this lack of definition is the possibility of “biases” of various types in studies and analyzes of performance, based on these evaluation processes. Another aspect that adds to this type of evaluation as a public policy is the polysemy of the word “result”. The tendency in “management by results” is to understand the “processes” of service production as “results”, not the actual results that are expected of a health system that is about improving the health conditions of a population.

A repeated argument for the relentless search for results (and consequently for performance evaluation) comes from the principle of citizen participation in the (external) control of the State through the appreciation of the performance of public administration (Guedes & Fonseca, 2007). Also called vertical accountability (O’Donnell, 1998), the incorporation of this type of social control and accountability of the public administration for performance appears as a promise to replace a model in which bureaucratic control based on compliance with rules and procedures prevails, without the participation of citizens, to another in which the a posteriori control of the results of government action is established, and in which society would participate in the definition of its goals and performance indicators, as well as in the direct evaluation of public goods and services (Ceneviva & Farah, 2007).

It is from this process that managerialism intends to fill a theoretical and practical vacuum, capturing the main trends present in public opinion, among which stand out the control of public spending and the demand for better quality of public services, as well as promoting the exercise of social learning with the public sphere creating a “new civic culture”, which brings together politicians, officials and citizens (Abrucio, 1997; Reis, 2015). However, the questioning about the power of this public opinion of the actors in controlling the State’s actions remains latent, since the asymmetry between the power of economic agents and community organizations is notorious, to stand in just one example on the difficulties and challenges to those interested in radicalizing the experiences of deepening democracy in the contemporary State.

In the historical period that we live, the constitution of subjects with rights postulates difference as compatible with equality, as well as its more immediate implications that relate to how to reconcile the individualism that underlies the modern notion of citizenship with the growing demands for rights of minorities, or collective rights, such as health (Reis, 2015). In the logic of managerialism, citizenship is related to the value of “accountability”. This requires an active participation of civil society from the choice of leaders to the moment of policy making and the evaluation of public services. However, the act of controlling public policies seems to be carried out by a type of “consumer” subject who is, more often than not, a passive citizen (Abrucio, 1997).

These concerns are pertinent, as there seems to be a convergence of the literature on the objectives of the evaluation and its relationship with the creation and strengthening of mechanisms of accountability in public administration. The general idea is that how closer the decision-making power in relation to public policies is, the better the quality of service provision will be (Abrucio, 1997). However, there is a lack of empirical analysis or systematic research about these causal relationships and the conditions that structure this supposed relationship between the evaluation of public policy performance and the promotion of greater transparency and the creation of accountability mechanisms (Ceneviva & Farah, 2007).

Admitting the contemporary subject like this person who seems more distant from his integration with his own or his capacity to generate change that we think the issue of social control of the State by the subjects of civil society becomes critical. When one speaks of “subject”, an enlightenment image of an individual identified with reason whose conscience is the presence in the individual (or in a group of individuals), some images of self-representations with moral value judgments about the conduct of these individuals is evoked (Touraine, 2007). However, under the label of individuation, the importance of the idea of subject for collective action has been reconfiguring, with profound implications for what is meant by accountability. Being a subject in contemporaneity is this call from oneself to oneself, this word addressed to oneself that only appears when human action is capable of creating an entirely artificial world, such as communication networks, for example, which make subjects disappear in the works of collective activity (Scherer-Warren, 2015).

In this situation, the interface between subjects and political institutions, which some authors call “new citizenship” or “citizenship of subjects in networks”, is a growing reality in the Society of Information, with emphasis on participation, predominantly opinionated, stimulated by networks (Twitter, Facebook and others). This type of participation has increased the public visibility of political events, with great repercussions through the media, but without guarantee of continuity of mobilizing engagement, due to the ephemerality of their political commitment (Scherer-Warren, 2015).

With all these elements to widen the debate, we follow to the next section where we could elaborate some theoretical reflections on the performance evaluation of health systems from the perspective of civil society and its limits.

5. Rethinking the Limits of Performance Evaluation of Health Systems from the Perspective of Civil Society

The elaboration of a “performance evaluation model” to measure (and compare) the results from the work done in health systems is not an easy task and requires caution due to all the theoretical and methodological limits identified.

The discourse of efficiency and effectiveness has become a widely used instrument in public management and also in the ideas of the research agenda on State reform. It is in this scenario in which performance appears as a keyword in the new order of managing services. Therefore, maintaining the public ethos of health systems without incurring the entrepreneurial heritage from which the assessment models are derived is a current challenge for public health management. If this element is not considered, it is very likely that the performance evaluation will help in the social mischaracterization of social policies and, still, make social protection unfeasible in the logic of a Social Welfare State (even this one in “crisis” in neoliberal times).

It is important to remember that there are several interpretations about the crisis of the Welfare State that, generally, conceive it with a crisis in particular. We rely on that in which it demonstrates that the crisis is associated with the capitalist crisis of overproduction and overaccumulation. Thus, the crisis of the Welfare State can only be understood as an unfolding of the structural capitalist crisis. In fact, it is the reduction of economic activities (and the resulting decrease in States revenues) and the tendency of the rate of profit to fall (causing fiscal deficit and public indebtedness) that provide the resistance for the maintenance and/or expansion of the supply network in social protection (Montaño & Duriguetto, 2011) and as a result of public services in general, as in the case of health.

The debate on the managerial model cannot only be limited to this context. On the contrary, the whole discussion about the use of managerialism in public administration is part of a larger context, characterized by the priority given to the theme of administrative reform. Models of performance evaluation, new ways of controlling the budget and public services directed to the preferences of “consumers”, typical methods of managerialism, are fundamental parameters today in different countries, according to local conditions. In fact, these models are forms of modify the old structures (Abrucio, 1997), in a movement to “modernize” conserving the hard core of power.

It is in this context that mechanisms for evaluating individual performance and organizational results have been widely introduced. Performance would be ideologically associated with that advocated by the pure managerial model and consumerism (Abrucio, 1997). Thus, pure managers did not consider that the specificity of the public sector makes it difficult to measure efficiency and evaluate performance. In public management, values such as equity and justice are at stake, and these cannot be measured or evaluated through the concepts of pure managerialism. In the first moment of this implantation, the instruments of budgetary rationalization were more used for allowing the incorporation of a greater “cost awareness” (cost-consciousness) in the public service. The problem now lies in the fact that performance evaluation techniques are being used to achieve this end (Montaño & Duriguetto, 2011) and nothing more.

Even with the use of public administration control by measuring their performance, studies indicate that there has been a huge increase in proceduralism and in exhaustive forms of performance monitoring, without, however, increasing transparency. On the contrary, now, these measures are hidden behind the rhetoric of “business secrets”, avoiding the judgment of both employees and the general public.

With the increase in political control, it is inevitable that weaknesses in internal and external controls over the performance of public administration will occur. For defenders of managerialism, a point that deserves consideration is the fact that such inspection/control instruments are guided by guidelines that should have the potential to “improve public debate”, and in this sense, provide not only as a form of control, more equally as a civic learning (Ceneviva & Farah, 2007).

The problem is that the subjects are not interested in the public debate for two reasons: 1) the first refers to the individuation processes in which these subjects are immersed. More and more they are concerned with “entrepreneurship themselves”, looking for elements to survive alone in the face of the massive inculcation of the “deprotection-loneliness-consumption” ideology and, 2) those who are interested (stakeholders) in the public debate, in their greatest part do not present qualified arguments to generate interpretation/criticism of the performance of public administration in the specific area, nor sufficient political strength. This effect is intensified when it comes to sectors whose products are eminently intangible (such as health and education, just to be seen in these two examples). In these circumstances, admitting the possibility that the community may deliberate on performance is, at least, naive.

Defending the idea of accountability in this scenario cannot be disconnected from the question about the conditions in which the contemporary subject presents itself for this challenge, knowing, however, that the owners of the State, the economy, as well as those of the ideological world are opposed and the subject’s conscience was strongly affected (Touraine, 1998).

Therefore, the redefinition of the notion of Society to “civil society” designates perhaps the most visible shift produced within the scope of the hegemony of the neoliberal project. Accelerated growth and the new role played by Non-Governmental Organizations (NGOs); the emergence of the so-called Third Sector and Corporate Foundations, with a strong emphasis on a redefined philanthropy and marginalization (which some authors refer to as the “criminalization” of social movements), evidence this redefinition movement. The result has been a growing identification between “civil society” and “NGO”, where the meaning of the term “civil society” is increasingly restricted to designating only these organizations, if not in a mere synonym for “Third Sector” (Dagnino, 2004).

The debates on this “third sector” clearly expose some of the new issues raised on the ground of National States. Thus, for example, for some, the acceptance of NGOs as partners in the conduct of social policies signals that authority is omitting, giving up what should be a legitimate governmental obligation. Furthermore, it should be noted that market interests, eager to cut taxes, are imposing the shrinkage of the meager advances instilled by the “Social State”. For them, the new dynamism of civil society would be the result of the neoliberal wave. For others, on the contrary, the effervescence of “civil society”, the growing importance of non-governmental organizations would be indications that democracy would be making progress in National States. In their view, the expansion of these new organizations would indicate that the civic component of citizenship is expanding (Scherer-Warren, 2015).

However, we defend the radical idea of civil society in addition to that which is formally organized or institutionalized along the neoliberal lines. We insist on: Society is inseparable from the State. More precisely, we refer to participation in/from virtual networks and modes of individualized, non-institutionalized participation, which lack reference to broader and more politically defined political collectives in terms of their public demands (Reis, 2015). In these exhibitions of individualized “opinions”, both civilians and representatives of the government express themselves to the point of reinforcing the thesis of “inseparable State-Society”.

No one better than users and beneficiaries of social services to assess the quality and relevance of these services. They usually contribute to the assessment of the effectiveness and the economy of governmental actions and, ultimately, the performance of government agencies and agents. Therefore, your satisfaction/dissatisfaction with the performance of public services should be welcomed in the most viable way possible. That is why virtual spaces are today public spaces par excellence where the most expanded idea of the term of civil society can be found.

However, democratizing these wiretaps does not eliminate the quality problem inherent in the opinion possibility. What is perceived in the virtual space is the most genuine capacity for expression, but with little critical-reflexive charge. The risk arises when the participation of society in decision-making bodies ends up serving the objectives of the project that is antagonistic to it, that is, the lack of understanding of the historical processes that are situated in the construction of the State (Dagnino, 2004) or, also, for not understanding the technical elements related to the conduct of each service operated by the public administration.

6. Final Remarks

Finally, we conclude that, by theorizing about the performance evaluation of health systems by civil society and its limits, it is possible to synthesize the problems in the economic dimension (capital crisis and mischaracterization of Social Welfare States), in political dimension (counter-reforms of the State, managerialism, individualized subjects and low capacity to control performance) and in technical dimension (theoretical-methodological problems of performance measures and little capacity of civil society to analyze these measures).

This reflection has relevant implications for public health and for the debate on the democratization of public services. The main one, undoubtedly, is the contribution brought by the criticism to the evaluation processes undertaken in the light of managerialism. Two other implications, which I consider to be subsidiary to that previously reported, are the necessary reflection for the repoliticization of social movements that defend public health. This refers to the clarity that these movements must hold on the rigging of the State under the neoliberal aegis. Yet, another important implication is related to researchers. They must produce knowledge that dialogs with the empirical reality of their health systems, taking as a starting point the defense of health as a social right.

According to the findings of this research, we suggest a research agenda in this area of study for those who might be interested in this discussion.

1) Studies on the reflection of the State Reform in the evaluation processes carried out in the different management modalities that provide health services in the countries;

2) Studies on the implication of the managerial logic in the format of evaluation of microprocesses of work in the health systems;

3) Studies on communities’ involvement, workers and management in the construction of plural evaluation methods, as well as the effectiveness of community participation in the “accountability” process of these organizations;

4) Studies on assessment instruments with a qualitative approach, especially on the daily life of health services, as well as on the weaknesses of the communication relationships between services;

5) Studies on ways of using evaluation as “trajectory correction” in the search for formulating instruments based on “formative” logic as well as using multiple associated methods to capture the nature of complex objects.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.


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