The Origins of Strong Institutional Design: Policy Reform and Participatory Institutions in Brazil's Health Sector

Why do some participatory institutions develop strong institutional designs, when most have limited powers? Existing literature emphasizes the importance of institutional design in shaping the impact of participatory institutions, yet falls short in accounting for the origins of design. Through an analysis of Brazil's health councils, this article argues that bundling the creation of a participatory institution with substantive policy reform can 1) create opportunities to pass the laws and regulations needed for a strong design and 2) introduce incentives for otherwise reluctant stakeholders to support the participatory institution as an instrument to obtain their substantive policy goals. This article highlights an unexpected benefit of institutional conversion, demonstrating that shifting the base of stakeholder support can sometimes strengthen institutions rather than undermining them.