The document summarizes Brazil's efforts to provide universal healthcare coverage, particularly for indigenous peoples, through its public health system (SUS). It discusses how the SUS expanded coverage from 1.1 million people in 1994 to 96.1 million in 2009, and reduced infant mortality rates from 47.1 to 19.3 per 1000 births from 1990 to 2007. It also notes indigenous peoples still face health inequities, with infant mortality rates of 22.9 for whites, 34.9 for blacks, and 51.14 for indigenous peoples. The document outlines Brazil's creation of an Indigenous Health Subsystem in 1999 to decentralize services and improve quality and access for indigenous communities, but notes challenges remain around uneven health gains and centralization.

1. First Global Symposium on Health Systems Research
Montreux
November, 2010
Making the right to health a reality to
Indigenous People in Brazil
Innovation cycles, quality and equity
Vera Schattan Coelho - CEBRAP
Alex Shankland - Institute of Development Studies

2. The Brazilian Public Health System:
A large scale change
“Health is the right of all and its provision is the
duty of the state” (1988 Constitution, article 196)
Population Covered by FHP
1994 -2010
Infant Mortality Rate (per 1000 births)
1990 - 2007
47.1 (1990) 19.3 (2007)1.1 million (1994) 96.1 million (2009)
Source: SIAB / SCNES
Source: MS

3. A cycle of innovation: lessons learnt
• PSF, HIV-AIDS
• Partnerships for implementation
• Contracts, clear division of labour
• Councils and Conferences

4. New challenges: focus shifting to
equity and quality
Infant Mortality Rate (per 1000 live births)
among different ethnic groups in Brazil
22,9
34,9
51,14
White Black Indigenous
Source: IBGE, Censo 2000

5. How to reach the ‘hard to reach’?
• MoH resistance to ‘target’/differentiate services
- Why deviate from established practice in the case of well
adapted urban Afro-descents?
- Why create a subsystem for 700 thousand Indigenous in
a country of 190 million?
• Indigenous Health Subsystem as centre of experimentation
for restarting innovation in the SUS in pursuit of quality and
equity?
• Mobilization of Afro-Brazilians, Indigenous, Quilombolas
and the creation of special programs

6. A radical experience: universalization
and difference
• 1999, creation of the
Indigenous Subsystem
Amazonas:
7 DSEIs
DSEI South Coast:
5 states
• Decentralisation &
outsourcing to a mix of
providers (mainly NGO)
• 34 Indigenous Health
Districts; 5.561 municipalities

7. 0,00
100,00
200,00
300,00
2000 2001 2002 2003 2004 2005 2006
Source: MS/SVS and DSEI/COMOA/DESAI
Opportunities for improvement and
institutional challenges
TB Incidence Rate (per 10.000 hab.)
Among Indigenous peoples
30
40
50
60
70
80
2000 20012002 2003 2004 20052006 2007
Indigenous IMR
(per 1000 live births)
Source:DESAI/ SIASI
• Uneven health gains, management problems,
centralization and blueprint approach
• Per capita spending is
5.6 times higher than the
Brazilian PHC average
0
150
300
450
600
2003 2004 2005 2006 2007
Indigenous Health Resources
(in millions R$)
Source:CGPAS/DESAL/DOU,
ASTEC/CGASI/DESAI/FUNASA

8. A learning approach to restart
innovation in indigenous health care
• IDS, SSL and Cebrap formed a
consortium, a learning process rather
than prescription
•Regional workshops with several
hundred participants stimulating
horizontal exchange for shared
reflection and innovation spread
• October 2010: Presidential decree
creates a new Special Secretariat of
Indigenous Health (SESAI)

9. An opportunity for restarting the cycle:
innovation and institutional alignment
Social oversight: accountability + flows of information
Partnership: MoH + states +district + municipalities +
NGOs + communities
Authority and Autonomy: clear responsibilities (health
care + administrative) and degrees of autonomy

10. Thank you !
veraspc@uol.com.br
a.shankland@ids.ac.uk