This document summarizes the challenges in providing universal health care access to indigenous peoples in Brazil. It discusses how Brazil established a universal health system (SUS) in 1988, but the indigenous health subsystem managed by FUNASA struggled with management problems and stagnating progress. A coalition was formed to restart innovation, conducting workshops that stimulated discussion and spread of new ideas. This process, along with growing indigenous protests, led the government to establish a new Secretariat of Indigenous Health that may restart the innovation cycle and pursue quality and equity in health care access for indigenous communities.

1. Building a coalition
to make the right to health care real
for Brazil’s indigenous peoples
Alex Shankland (Institute of Development Studies)
Vera Schattan Coelho (Centro Brasileiro de Análise e Planejamento)
STEPS Centre & Future Health Systems Workshop
Beyond Scaling Up: Pathways to Universal Access
Institute of Development Studies, Sussex
25 May 2010

2. Universal access to
health care in Brazil
• “Unified Health System” or SUS (Sistema Único de
Saúde) established in 1988; response to social
movement for health reform (movimento sanitarista)
which secured a Constitutional declaration that
“health is the right of all and its provision is the duty
of the state” (Article 196).
• In two decades, the SUS has established near-
universal provision of PHC and of some other
interventions through successful scaling up of
regional innovations and pilots (e.g. Family Health
Programme, National HIV/AIDS Programme); focus
now shifting to quality and equity (hard-to-reach
groups).

3. Sustaining Brazil’s
health policy innovation cycle
• Initial struggle to establish the SUS resulted in clear
division of labour between municipalities (local health
system management), private sector (contracted
service provision) and MoH (policy and most
funding), with federal transfers providing incentives
to scale up innovations.
• Momentum for rights-based health reform
maintained by institutionalising movimento
sanitarista; massive investment in social oversight
bodies (Conselhos) and participatory policy fora
(Conferências); powerful “SUS epistemic community”
able to see off “neoliberal” challenges.

4. Indigenous peoples and the
challenge to the SUS
• Small minority of population (700,000 in a country
of 190 million); socially and economically
marginalised but politically highly visible.
• Constitutional right to difference (Article 231)
underpinning claims for recognition of different
framings of health; Constitutional status as a “federal
problem” meaning that indigenous health care
cannot simply be delegated to municipalities.
• Hyper-vulnerability and extreme epidemiological,
geographical and sociocultural heterogeneity; both
equity and effectiveness issues for “one size fits all”.

5. Universalisation and difference:
indigenous peoples and the SUS
Epidemiological specificity Physical accessibility
Attitudes and behaviour Policy processes

6. A broken innovation cycle in the
“Indigenous Health Subsystem”
• “Subsystem” established in 1999 under MoH agency
FUNASA; implementation process opened to regional
innovation through decentralisation to District level and
outsourcing to a mix of (mainly NGO) providers.
• Management problems triggered recentralisation by
FUNASA from 2003; abandonment of innovations and
return to blueprint approach, plus 100% spending hike.
• IMR cut by 27% (74.6-54.0) in 3 years to 2003 but
progress stagnated in following 3 years; 2006 IMR of
48.6 was 2.3 times more than that for Brazil as a whole
despite per capita PHC spend 5.6 times higher ($450).

7. Indigenous Health Subsystem
management units: the DSEIs
Amazonas:
7 DSEIs
DSEI Litoral Sul:
5 states

8. A coalition to restart innovation
in indigenous health care
• System performance falters amid growing
accusations of corruption; breakdown of trust between
FUNASA and NGOs; MoH divided on way forward;
indigenous leaders split along regional, party and
clientelistic lines.
• World Bank sector loan (VIGISUS II) requires
FUNASA to commission a situation analysis and new
“models” for the Indigenous Health Subsystem.
• IDS forms a consortium with a health rights NGO
(SSL) and a social policy think-tank (Cebrap) to bid for
“models” contract; team includes technocrats and
“bush medics”, Brazilians and internationals.

9. Navigating a “technical” process
through a political storm
• Low initial level of FUNASA ownership; mistrust of
NGO involvement; blueprint interpretation of “models”
and no interest in restarting innovation.
• Consultancy process includes regional workshops
with several hundred participants; framed as learning
process rather than prescription; stimulating horizontal
exchange for shared reflection and innovation spread.
• Increase in protests forces President to intervene;
FUNASA reframes consultancy process as evidence of
institutional commitment to change; MoH counter-
claims that consultancy enables it to do without
FUNASA.

10. A fresh start for the
Indigenous Health Subsystem?
• November 2008: MoH
responds to indigenous
protests by establishing a
Working Party to examine
options for replacing FUNASA.
• April 2010: Presidential
decree paves the way for a
new Special Secretariat of
Indigenous Health (SESAI);
head of SESAI promises DSEIs
“management autonomy”.

11. Two challenges and an opportunity for
restarting the innovation cycle
• Suspicion among the SUS epistemic community that
flexibility-for-equity opens the way to “neoliberal
targeting”; one size fits all as hallowed SUS principle.
• Internal MoH resistance to internalising the non-
standard; why deviate from established practice in the
interests of fewer than 0.5% of the population?
• Freedom from path-dependence and need to
manage rapid change encourage openness to a
learning approach; Indigenous Health Subsystem as
centre of experimentation for restarting innovation in
the SUS in pursuit of quality and equity?