Brazil's Public Option

What Obama can learn from Lula about universal health care.

Brazil's place as one of the "BRIC" emerging powers has never been in question since the term came into use in 2001. Under the leadership of President Luiz Inácio Lula da Silva, the country has emerged as a diplomatic power and the region's clear economic leader. It also happens to be one of the few countries in the Western Hemisphere with universal health care. As U.S. President Barack Obama strives to pass health-care reform in the coming weeks, he would do well to examine the praiseworthy successes -- and the worrying failures -- of a decades-old universal system in the region's second-largest democracy, one that has brought real improvements in access for the poor, tempered by financial shortfalls, declining infrastructure, government inefficiency, and new, unanticipated forms of health-care inequality. Brazil's case illustrates that if you go public, you'd better be committed to maintaining your creation.

Brazil passed its reforms more than 20 years ago during an economic phase surprisingly similar to the United States' today: fiscal deficits, recession, inequality in access to health care, and loud demands for change. If recent town-hall bickerings across the United States look bad, look back at the unrest surrounding Brazil's implementation of universal health care in the early 1980s. Massive civic protests demanded an end to health-care inequality -- an ambition that dovetailed nicely with the broader democratization movement.

Like the United States today, Brazil also had a pre-existing health-care system that linked coverage to employment. A 1923 Brazilian law granted access to government-paid health care only to workers and those government officials contributing to the social security system. Informal or agricultural workers were left to pick at whatever services they could find from city officials and charities. The gaps left more than 90 percent of Brazilians without coverage by 1930.

The universal health-care system begun in 1988 was meant to change all this, enshrining access to care as a human right. The plan has two components: one public and one private, much like the plan that the Obama administration started out pushing for. Government-funded services are dished out through the decentralized Sistema Único de Saúde (Unified Health System, known as SUS), which relies on financing and management from federal, state, and municipal governments. SUS funds everything from annual checkups and free drugs to complex surgeries and health prevention education. On top of this government protection, businesses and individuals can purchase health care through private insurers, regulated by the Agência Nacional de Saúde Suplementar (National Supplementary Health Agency). Those who opt in to such a system receive a tax rebate for these expenses, though they do still contribute to SUS through their income taxes. And of course, anyone is still welcome to pay out of pocket at hospitals and clinics for service.

Financing for the public plan has always been a concern, in the same way it is in the United States. Brazil's federal, state, and local governments all raise revenue to help pay for health care. Taxes on such things as individual income, property, goods and services, banking transactions, and social security (at the federal level) help fill the pot. Yet even as Brazil has secured multiple sources of funding (something that will be very difficult to achieve under Obama), the cost of universal health care is quickly outpacing the revenue needed to sustain it. The World Health Organization estimates that health expenditures in Brazil have risen from 6.7 percent of GDP in 1995 to 7.5 percent in 2006. Although these figures are still far lower than the 15.3 percent of U.S. GDP that Americans spent on health care in 2006, Brazil's costs are growing faster. Lula does not seem committed to increasing the SUS budget because this could starve his other anti-poverty programs and make international creditors nervous about Brazil's economic stability. They are right to worry: Brazil will either have to spend more itself or end up borrowing from those same creditors to keep the program funded. As a core aspect of the 1988 democratic Constitution, SUS is unlikely to be shut down, no matter the cost.

Funding concerns aside, putting coverage policies in place has proven even harder. SUS does do an excellent job of providing primary care through its Programa de Saúde da Família (Family Health Program), staffed by about 28,300 teams of well-paid health-care workers who venture into poor and remote areas. But beyond the basics, there are alarming gaps. Brazil simply does not have the capacity to offer high-quality care to all. Hospitals lack basic infrastructure and personnel. Corruption peppers the local bureaucracy, and funds are often poorly allocated; politicians often fill budgetary committees with their friends, who neither know nor care much about public health. The mismanagement goes unpenalized because municipal health departments operate without federal oversight.

As a result of missing funding and poor management, the overall quality of Brazil's health-care system has gradually declined. So it's no surprise that those who can afford it opt for the private sector. The percentage of subscribers to private insurance saw an increase of about 38 percent between 1987 and 1995. By 2009, more than a fifth of the population had purchased private health insurance. The middle and upper classes are beginning to rely more on private insurers, while the poor rely more on the public sector.

Of course, the irony here is clear: Brazil's perceived solution to inequality in access to health care has bred even more inequality. The private sector has better infrastructure and technology, and treatment is immediate -- an appealing quality for those hoping to escape the long waiting lists for services in the public sector. What's more, those who have private care can still, at any time, sign up for public services, such as complex, costly surgeries or medicines that private insurance does not cover. Obviously, the poor cannot afford to stick their hands in both cookie jars.

Brazil's case spells out a clear message for the United States and the Obama administration: Halfway is no way at all. Without the money and institutional capacity to keep a public option working at the level of the private options, universal health care can simply create even more inequalities. And you'll be back to square one.



Can Mosquito Nets Stop Terrorists?

A previously unreported program sheds light on the battle for Africa's hearts and minds -- and the battle between the State Department and the Department of Defense.

A little-noticed discussion in Washington has recently hit fever pitch as members of the U.S. government debate how to turn their ambition -- to win the hearts and minds of the global public -- into action. At issue is how best the United States, now led by an administration promising to re-engage with the world through initiatives like Barack Obama's high-profile speech to Muslims in Cairo, can get its message across to enemies, skeptics, would-be allies, and even close friends.

A previously undisclosed program intended to counter extremist ideology in West Africa's predominantly Muslim Sahel region, details of which have been described to Foreign Policy, offers a window into how this Washington debate is playing out inside the beltway and on the ground. The quarter-million-dollar "Regional Marketing Campaign," as laid out in a draft Performance Work Statement (PWS) --  a document outlining the government's requirements and expectations for a given project -- will enlist a private contractor under the auspices of the U.S. Africa Command (Africom), the public-diplomacy shop in the State Department's Africa Bureau, and individual embassies in four West African countries. Among its strategies will be using certain "advertising vehicles," such as mosquito nets and water bottles, without explicitly disclosing that they are coming from the U.S. government. The aim of the program is to encourage a local national identity of peace, thereby portraying extremism as a trait "inconsistent" with "the character of the population," according to the document.

The broad debate about such programs puts three hot issues on the table: how the message should be carried (whether clandestine or not), who can and should do the work (civilians or the military), and how to fund those activities (explicitly from Congress, or discretionally through broader programs). Adm. Michael G. Mullen, chairman of the Joint Chiefs of Staff, joined the debate last week as he delivered an unusually blunt critique of the U.S. government's "strategic communication" efforts in Joint Force Quarterly, a government publication.

"Frankly, I don't care for the term," he writes. Mullen argues that the most powerful communication tools are not words or ad campaigns but deeds. "We've come to believe that messages are something we can launch downrange like a rocket, something we can fire for effect. They are not."

Meanwhile, the House Committee on Appropriations' subcommittee on defense has upped the ante further by slashing in half the Department of Defense's requested budget for information operations, a major military component of strategic communication.

But strategic communication, a blanket term for a plethora of efforts to engage audiences and promote U.S. interests, including through public diplomacy, are unlikely to go anywhere soon. "Actions speak louder than words, but words are still necessary to explain those actions and our reasons for them," a spokesperson for Africom told FP. The start date for the Sahel contract is indicated as Sept. 1, 2009, with January 2010 named as the campaign's operational launch. On Sept. 1, a spokesman for Africom confirmed the existence of the project.

Under the early years of George W. Bush, critics of the former president's administration say, overtly pro-American messages delivered by U.S. officials had little effect, or even backfired. By contrast, this campaign is meant to place "the emphasis of message delivery on internal voices," the PWS states. A source familiar with the project told FP that the project may work with local governments to frame the campaign, representing the local government as the origin of the message, rather than the U.S. government. "An internally produced message, synchronized with a parallel U.S.-faced influencing effort, is an encompassing strategy aimed at reaching a wide spectrum of the population," according to the PWS.

That will mean the use of "novelty items, events, public statements, and more" to convey the message. Television, radio, and billboards are all cited as primary mediums. Other "country-specific advertising vehicles," including mosquito bed nets and water bottles, are mentioned in the draft PWS, as well. Another source within the State Department told FP that such items might not be disclosed as coming from the U.S. government. (Asked about that, Africom replied: "Although we do not highlight our support, we disclose our involvement freely.")

The Sahel program is reminiscent of a controversy first brought to light when the Lincoln Group, a private public relations firm, was reported in late 2005 to have been producing pro-American press coverage in the Iraqi media on behalf of the U.S. military. Many in the defense community argued that these sorts of information operations, carried out through local "voices" rather than explicitly foreign ones, were precisely what was needed to marginalize extremists. "This project is not about the U.S. government, it is about sending a message of peace and tolerance to the people of these nations that our U.S. ambassadors and Department of State believe is important," the Africom spokesman told FP, referring to the Sahel project.

"The substantive message carried by this campaign is for the population to adopt and reflect an existence that involves peace, tolerance, and understanding, thereby turning against violent extremist ideology," the draft PWS reads. "[T]his campaign provides the host nation governments a platform from which they are able to condemn acts of violent extremists as inconsistent with these themes and the character of the population."

Any prospective contractor might find itself in a different position than the Lincoln Group faced in Iraq -- namely, being outside a war zone and without the same freedom not to attribute their actions to the U.S. government. In Iraq, the Defense Department umbrella of psychological operations ("psyops"), defined as Defense Department activities meant to influence foreign opinion abroad, allow for nonattribution of the source. Such products would qualify as either gray or black propaganda -- defined in a 2005 Army Field Manual pertaining to psyops as "products that conceal and/or do not identify a source" and "products that purport to emanate from a source other than the true one," respectively.

But the Sahel region, which is neither a war zone nor host to a combat troop presence, might not benefit from such leeway without specific congressional authorization. According to the PWS, this particular Africom operation is funded through from Operation Enduring Freedom-Trans-Sahara, a Department of Defense initiative begun in 2001 (and described here on Africom's Web site) as part of Operation Enduring Freedom, which includes the war in Afghanistan. The program falls under Africom's $7.8 million Operation Objective Voice program, which "strikes at the heart of violent extremist ideology," according to Africom. Asked if the program were designated as psychological operations (thus allowing nondisclosure of U.S. funding), Africom replied that it was considered information operations, a broader category.

In a summer 2009 paper for the U.S. Army War College, Daniel Silverberg and Joseph Heimann, counsel to the House Committee on Foreign Affairs and former deputy counsel to the chairman of the Joint Chiefs of Staff, respectively, explain the legal ambiguity about what can and cannot be done. All of Defense Department's strategic communication efforts are restricted by the "publicity and propaganda rider" clause, which the authors say is "inserted annually in the defense appropriation act that prohibits use of funds for publicity or propaganda purposes that are not authorized by congress." Legal experts debate whether and how much authorization is needed from Congress for information campaigns abroad.

As recently as June, the Government Accountability Office noted, regarding a separate Defense Department program, that the prohibition on propaganda and publicity "restricts agency communications that are covert as to their source," but when this clause applies is a judgment call, weighed against an agency's responsibilities and need to explain its mission.

Aside from the legal questions, the Sahel marketing program raises long-standing bureaucratic fears. After the United States Information Agency was folded into the State Department in 1999, Foggy Bottom has taken the lead on public diplomacy. Increasingly, however, such tasks are moving into the Department of Defense, to the concern of some observers -- many of them, naturally, in the State Department.

In the Africa case, differences in funding levels for public diplomacy and other sectors -- with Africom having vastly more funds at its disposal than the Department of State -- have led to some tensions in the relationship between military and civilian colleagues working on the continent. Speaking to FP about the State Department's Office of the Inspector General report earlier this month, acting Inspector General Harold W. Geisel explained, "The military deals in resources that the State Department can only dream about, either in a pleasant dream or a nightmare." Those differences have fueled concerns within the State Department that foreign policy has become increasingly "militarized," with a great deal of responsibility, funding, and coordination shifting to the Pentagon. Indeed, in one example mentioned in that report, military teams operating in Somalia had 20 times more money to conduct information campaigns than their State Department counterparts.

(Queried generally about the relationship between the State Department and Africom with regards to public diplomacy, Undersecretary Judith McHale replied to FP, "The Department of State and Africom enjoy a strong relationship. Our shared goal is to help African nations create a more stable environment on the continent and to enable political and economic growth that benefits the people of Africa. Our relationship with Africom is similar to the relationships the Department has with other regional commands.")

One former State Department official says it's a good thing that the Defense Department is taking a more proactive role in strategic communications. "The fact is that this is work that really needs to be done," he said. "You can argue that it needs to be done by State [and not Defense Department]. But it is not going to be done by State -- which means it's not going to be done." Such a concern seems warranted following a scathing internal report on the State Department's Bureau of African Affairs, whose public affairs shop was declared to be utterly failed and ineffective due to a lack of coordination and poor leadership.

Not everyone agrees, however, that the Pentagon would be more effective. In its report on defense, the House Committee on Appropriations, chaired by Sen. John P. Murtha (D-Penn.), has cut DoD's $1 billion funding request for information operations in fiscal year 21010 in half. "The Committee has serious concerns about not only the significant amount of funding being spent on these programs, but more importantly, about the Department's assumption of this mission area within its roles and responsibilities." The report cites poor documentation, a lack of oversight, and concerns about effectiveness, and calls for the secretary of defense to file a report within 180 days, detailing the Pentagon's information operations programs. The Senate Armed Services Committee raised similar concerns in June and has asked Defense Department to clarify its spending on strategic communication in its 2011 budget proposal.

The picture that emerges is one without a central organizing strategy for outreach abroad, even as Obama has made renewed dialogue a hallmark of his administration. "You have a situation where the enemy understands the importance of strategic communications. You have space that enemy is now filling and we're trying to fill it. But now, because of these attacks on DoD, it may create a complete vacuum," allowing extremists the communications upper hand, worries the former State Department official.

In West Africa, countries in the Sahel region have long worried analysts as possible breeding grounds for terrorism or extremist organizations, because of their majority Muslim populations, prevalent poverty, and expanses of largely ungoverned geographical regions. According to the Africom spokesman, "Support for violent extremism and actual violent extremist activities are rising at an alarming pace throughout the Sahel. This region has been specifically targeted by the Al Qaeda network for 'liberation'. Recently we've seen unprecedented violent extremist organization activities in Mali and Mauritania. Violent extremist organizations continue activities in Algeria. We saw an alarming percentage of foreign fighters in Iraq originate from the Maghreb. The ideology that spawned those foreign fighters continues nearly unabated."

In fact, this project is just the latest U.S. effort to address extremism in the Sahel region. The U.S. Trans-Sahara Counterterrorism Partnership program -- one of several ongoing military assistance programs -- for example, trained 150 soldiers in four Saharan countries "to enhance border capabilities against arms smuggling, drug trafficking, and the movement of trans-national terrorists." Other communications and outreach programs, such as sports programs and news Web sites, have also been ongoing in the region for a number of years.

"Victory will not be determined by kinetic action. Rather, we believe that a focus on communicating the truth, with information that clearly describes the impacts of extremist ideology on the people offers them choices they would not otherwise have available. Once the truth is involved in the conversation, we believe extremist ideology will begin to lose its momentum," the Africom spokesman wrote.

Plans for the Sahel regional marketing campaign are set to be finalized by today, Sept. 1, according to the timeline in the PWS, though Africom says that the contracting action "has not yet been completed at this time." The U.S. Embassy in Dakar, Senegal, is named as the organizing entity, working with the embassies in Niger, Mauritania, and Burkina Faso. FP has seen a second document, a Military Interdepartmental Purchase Request dated Aug. 7 and signed Aug. 14, indicating that funds in the amount of $250,000 have been transferred to the Dakar embassy. The PWS explains that the embassy in Dakar will then contract with a private company to run the campaign. The State Department did not reply to queries by the time of publication, three business days after FP's first request.

Correction: This article originally described a debate over "how the message should be carried (whether clandestine or not)". The correct term is "clandestine," not "covert." Additionally, the piece stated that the State Department did reply to queries. It failed to do so. FP regrets the errors.