Confronted with this situation, the nongovernmental organization URIHI, responsible for delivering health care to 53% of the Yanomami in Brazil (located in Roraima and Amazonas states), has no other option but to bring its partnership with FUNASA to a close.

A done deal: the “new model” of indigenous health administration

From February 2-6, 2004, FUNASA and the Ministry of Health held the First Integrated Workshop on Indigenous Health, in Brasília, the nation’s capital. During this meeting, they explained the new guidelines for indigenous health, which were first unveiled on January 20, 2004, through the official publication of Directives #69 and 70.

The first two days of the Workshop were restricted to government agents, whose task was to ratify the changes in the structure of the 1999 reforms in indigenous health services. Nongovernmental organizations and indigenous leaders were invited to attend only during the last two days of the meeting, when they were merely allowed to learn about the “new model” and express their opinions during the limited time available after the speeches.

This short meeting with the organizations contracted by FUNASA to deliver health services was opened with a speech by Gastão Wagner S. Campos, Executive Secretary of the Health Ministry. Assuring the audience that indigenous health care was a government priority, he declared that the administrative role of the State will be strengthened. He announced that a Consultative Committee on Health Care Policies for Indigenous People will be created and that the 2004 budget for assistance to indigenous populations will be increased by 30%.

The next speech was delivered by Dr. Vali Camarcio Bezerra, President of FUNASA, who emphasized the importance of indigenous health and the necessity for policy changes. He claimed that the government and Brazilian society are not satisfied with the current situation, in which indigenous and indigenist organizations and, in a few cases, municipal agencies have been contracted through partnerships to operate almost all of the health programs in FUNASA’s 34 Special Indigenous Health Districts (DSEIs).

Later the same day, FUNASA representatives cited legal analyses concerning the State’s responsibility to administer and operate health care services for indigenous peoples. They concluded that the participation of partner organizations in running these services can only be “complementary.” However, nowhere in current legislation are the characteristics of this “complementarity” spelled out.

The last day of the meeting was dedicated to presenting the partner associations with a list of the functions of the Health Ministry and FUNASA in administering and operating health services. The “complementary” activities that the indigenous, indigenist, and municipal entities will be allowed are:

• hiring personnel
• providing supplies to villages
• transporting Indians from villages
• purchasing fuel for transportation from villages

The saga of reforms in indigenous health services, 1967-1999

To better understand the current model of indigenous health care management and the context of the “new model” that FUNASA will impose on April 1, it is necessary to recall the chronology of the models used for indigenous health care management and the chaotic institutional history of the Yanomami Health District (DSY), the first such district implemented in Brazil in 1991.

1967: Creation of the Nation Indian Agency (FUNAI). Health services are sporadically conducted by mobile teams created in each of FUNAI’s Regional Delegacies. The Health Ministry collaborates in the control of major endemics, while FUNAI signs various agreements over the years with governmental and nongovernmental entities to remedy the lack of adequate structures for health care. However, given the insufficient scale, operational capacities, and administrative framework, these activities gradually atrophy to the point of complete paralysis.

1986: First National Conference on Indian Health Protection held. The participants agree on: (a) the urgent necessity for establishing a model for health care that will guarantee indigenous peoples their universal and full rights to health; (b) the importance of respecting the ethnic and sociocultural particularities and therapeutic practices of each group; (c) the necessity of guaranteeing indigenous participation in health policies; (d) the creation of a health agency specifically for indigenous needs. The model of Special Indigenous Health Districts (DSEIs), to be administered by the Health Ministry, is proposed for the first time.

1988: Passage of the new Brazilian Constitution, which lays out the guidelines for the Unified Health Care System (SUS). At the Federal level, the Health Ministry is assigned the responsibility of administering the system. Indigenous rights come under Federal responsibility.

1991: Creation of the Indian Health Coordinating Board (COSAI) within the Operations Department of the National Health Agency (DEOPE-FNS). The Board is set up to meet requirements of Decree # 23/91, which transfers responsibility for coordinating health services for indigenous populations from FUNAI to the Health Ministry. The Yanomami Health District is then set up by FNS.

1992: Creation of the Intersectoral Commission for Indian Health (CISI) by Resolution # 11 of October 13, 1992. The function of CISI, made up of representatives of the Federal government (Ministries of Health and Justice), universities, nongovernmental organizations, and indigenous peoples, is to advise the National Health Council (CNS) in developing measures and guidelines for government policies in the field of indigenous health.

1993: Second National Conference on Indigenous Peoples’ Health held. The participants reiterate support for the DSEI model as an operational foundation for meeting the health needs of indigenous populations. They assert that DSEIs must be part of SUS and directly linked to the Ministry of Health, administered by Health Councils in conjunction with indigenous participants. They identify the Federal government as the entity responsible for indigenous health in the country, without excluding the complementary contributions of state and municipal agencies or other governmental or nongovernmental institutions. The participants defend the creation of a special agency within the Health Ministry for administering health care policies for indigenous peoples.

1994: Passage of Decree # 1.141/94 and repeal of Decree # 23/1991. The Intersectoral Health Commission is set up and, in practice, returns the coordination of indigenous health services to FUNAI, which is given responsibility for the recuperation of sick Indians, while the Health Ministry is assigned the task of prevention services.

1999: Decree # 3156/99 and the “Arouca Law” (# 9.836) are passed. Health services are reassigned to the Health Ministry: “The Ministry of Health will establish policies and guidelines for promoting, preventing, and recuperating Indian health, while the programs will be implemented by FUNASA.”

Forgotten lessons: the history of the Yanomami Health District (1999-2003)

Starting in 1999, indigenous health services were elevated to the level of a special department in FUNASA, which inaugurated a new policy under the rubric of “Restructuring Indigenous Health Care.” In this context, 34 DSEIs were identified and set up throughout Brazil. Basic health and prevention services in each DSEI were operated according to a strategy of decentralization through agreements signed with civil society organizations, including indigenous, indigenist, and a few municipal entities.

The rationale for the 1999 reform arose in large part out of the pioneering experiences of the Yanomami Health District (DSY), created by the National Health Agency (known as FNS at the time) in 1991. Particularly notable was the model for human resources management used for personnel serving in the field under the extraordinarily difficult operational conditions in the Yanomami Indigenous Territory.

Thus, to confront the grave situation of the Yanomami, who were threatened with extinction by the disastrous epidemiological state caused by the invasion of their lands by gold miners in the late ‘80s, FUNASA experimented with all the possible forms for hiring personnel and health in the Yanomami Health District, without satisfactory results.

The failure of FUNASA’s direct operations

In 1990 and 1991, FUNASA began operating services directly in the Yanomami Indigenous Territory, contracting health professionals paid as “occasional collaborators” in emergency campaigns.

In 1992, to meet urgent needs, the first simplified selection process was held for temporary contracts lasting six months. When the contract came to an end, the consultant could be hired two more times until the end of 1993. The short period of contracts generated predictable operational and administrative problems, besides causing interruptions between the end of one contract and the beginning of the next.

For this reason, FUNASA opted to hold another simplified selection process in late 1994, this time for four-year contracts.

These precarious work conditions, the insufficient staffing, and the negative consequences for the quality of health assistance to the Yanomami led FUNASA to turn to the practice of holding competitive public exams for hiring professionals, which were eventually held in 1996. Because of the laws governing public competitions, candidates could receive passing grades on written exams without being evaluated on aspects such as professional experience, personal traits, and training necessary for the peculiarities and complexities typical of work in the Yanomami area. The positions were only partially filled and therefore, the temporary four-year contracts, which were supposed to end in 1998, were renewed for yet another year.

Not surprisingly, the coexistence of staff members of the same category with different types of contracts and salaries generated personnel conflicts. Loopholes in legislation were found in order to let go of most of the professionals who were working in the Yanomami area, mainly those who were public servants hired on the basis of written exams.

Finally, in 1999, after almost a decade of operations in the Yanomami Health District, there were only 30 health professionals actually working in the field, out of a total of 120 public servants who had contracts and 90 staff members who were temporarily hired. As a function of this situation, the deterioration of the Yanomami health situation had reached catastrophic proportions.

Throughout the 1990s, the Yanomami suffered an average annual rate of one case of malaria for every two inhabitants, a rate considered to be extremely grave by the World Health Organization. This disease was the main cause of death during this period. Tuberculosis increased at epidemic proportions, and diagnoses were only performed on the most advanced cases. Health assistance was precarious or absent in the most isolated villages, meaning that many deaths were not even reported. The Infant Mortality Coefficient (IMC) recorded during this period reached an average of 160 deaths of children under one year of age out of every one thousand live births. This rate was above those in the worst regions of the Third World, and almost four times higher than the IMC of the Brazilian population in general.

Approaching civil society organizations

In 1994, FUNASA invited the indigenist organization Pro-Yanomami Commission (CCPY, founded in 1978), which maintained a health assistance program for around 700 Yanomami, to develop its activities in partnership with the government agency, taking advantage of unused financial resources of the Amazonia Malaria Control Program (PCMAM). This led to the signing of the first agreement between FUNASA, as a government agency, with a nongovernmental organization, a new strategy for meeting indigenous health care needs. Within a short time, all of the goals stipulated in the partnership agreement were attained, leading to substantial improvements in the health of the portion of the Yanomami population served by the program. This provided a good example of the potential of a partnership between the third sector and the government’s health administration.

The successful experience of this partnership with CCPY contrasted with the inefficiency of FUNASA’s direct health care delivery in other parts of the Yanomami area, where the government agency was incapable of resolving the calamitous epidemiological situation. The alarming conditions in the areas where FUNASA was directly responsible for health services were widely reported by the national and international press, leading people and organizations around the world to become seriously concerned with the survival of the Yanomami. The Brazilian government, disconcerted by this negative publicity, responded to the constant denouncements about the “Yanomami genocide” by providing significant financial resources. These funds were wasted by the local FUNASA offices in Roraima through its operation of direct health services, conducted in an utterly inefficient manner and impaired by financial irregularities and embezzlements, as documented in successive audits by FUNASA itself.

In 1998, the Yanomami Health District had 210 employees (permanent and temporary), of which only 30, on the average, were working in the field. Confronted with the catastrophic health situation in the Yanomami Indigenous Territory, FUNASA’s administrators decided to propose that, in their next agreement, the Pro-Yanomami Commission (CCPY) contract more medical professionals in order to provide effective health services in the regions where the government agency had attempted to exercise direct control.

Even before CCPY could make a decision about the matter, however, FUNASA withdrew the proposal as a result of a review issued by its legal department, which categorically declared the proposed procedure illegal. According to the review, transferring public resources to private nonprofit entities for the purposes of contracting personnel who would work for a public service directly provided by the government would represent a form of “triangulation,” violating the legislation that regulated the administration of human resources by the Federal government.

Nevertheless, in late 1999, based on the experience gained in the Yanomami Health District (DSY) between 1990 and 1998, and with the decision to create Special Indigenous Health Districts throughout Brazil, the Federal government adopted a model of decentralization through partnerships, preferably with civil society organizations, or, when this was not possible, with municipal agencies.

Like other nongovernmental organizations working in the Yanomami Indigenous Territory, CCPY was importuned to widen its health program to cover areas of the DSY previously controlled directly by FUNASA. The NGO accepted this challenge to try to bring the decimation of the Yanomami to a halt. Members of CCPY founded URIHI-Yanomami Health, an organization created specifically with an orientation toward health assistance and education. URIHI began its activities in the field in January 2000 for approximately 50% of the Yanomami population residing in Brazil.

During its four years of activities, URIHI achieved impressive results that proved the potential effectiveness of partnerships between FUNASA and NGOs. The rate of malaria in areas served by URIHI was reduced by more than 99% during the period; since 2001, not been a single death from malaria has been recorded. Infant mortality was reduced by 65%, and diagnoses of tuberculosis were performed early and, whenever possible, treated within the reservation. Vaccination of children under one year of age attained the standards defined by the Health Ministry. Oncocercosis (“river blindness”), a disease limited in Brazil to the Yanomami areas, which the government has committed itself, through international accords, to eradicate, has been treated through one of the most complete rates of coverage in the Americas. The nutritional condition of children under five years old has been monitored monthly, making it possible to identify the need for intervention in cases of malnutrition. These measures have enabled a demographic growth rate of about 4% per year. In all meetings of the local and district health councils, Yanomami leaders have repeatedly expressed their great satisfaction with the improvement of health in their communities.

FUNASA and partner organizations: the government’s deafness

Upon restructuring the health care system in 1999, FUNASA guaranteed the civil society organizations it had invited to sign partnership agreements that they would receive all the technical, political, and administrative support necessary for developing their programs. However, despite this promise and the major advances achieved within the framework of these partnerships, FUNASA’s day-to-day relations with the partner organizations were marked by a hostile attitude, and even frank opposition, on the part of certain sectors of the government agency, due to corporatist or ideological motives and, at times, economic interests that infiltrated the institution.

The presidential elections of 2002, following the progressive stance of the Workers’ Party during the electoral campaign, raised the hopes of the indigenous movement and indigenist organizations. They strove to open up a dialogue with the transition team, holding a meeting with Dr. Humberto Costa, the future Minister of Health, and presenting their concerns about the continuity of health care assistance in the Special Indigenous Health Districts.

In April 2003, the partner associations sponsored a meeting in Manaus, inviting Dr. Ricardo Chagas, who was then an advisor (and future director) of the Department of Indigenous Health (DESAI) of FUNASA, in order to search for solutions to problems with the implementation of partnerships. They highlighted the lack of political, technical, and administrative support from FUNAI so far to carry out the agreements, as well as the omission of the Health Ministry as the administrative agency.

In May 2003, the civil society entities were invited to a seminar held in Brasília in which the qualifications to be required of the partner organizations were explained. FUNASA presented new guidelines for “Civil Society Organizations in the Public Interest” (OSCIPs) as the only form acceptable to the government for continuing the partnerships.

In June 2003, a commission of the partner organizations requested a meeting with the Health Ministry to express their concerns, which had been raised earlier in the Manaus meeting, to Dr. Gastão Wagner, FUNASA’s Executive Secretary. During this meeting, the commission found out that the government had abandoned the proposal to form OSCIPs.

Finally, in November 2003, faced with the lack of definition and the government’s surprising interruption of the dialogue, the civil society organizations that held partnerships with FUNASA took the initiative of requesting a new meeting with the Health Ministry.

On this occasion, the commission representing the partner associations presented the Executive Secretary of the Health Ministry with the text, “Indigenous Peoples of Brazil, through their organizations and leaders, request that the Health Ministry express its responsibility for the administration of indigenous health in a direct, full, and definitive manner.”

This text analyzed the serious deficiencies of FUNASA’s administration and its negative impact on health programs conducted by the partner organizations in the various DSEIs. In their criticism, the NGOs were, however, less severe than FUNASA’s own legal counsel, which, in its opinion of 2003 (501/PGF/FUNASA/GAB/2003), did not hesitate to speak of the agency as “relegated to the scrap heap.”

In view of this situation, the text written by the indigenous and indigenist organizations requested that the Health Ministry take over the direct administration of indigenous health services. The commission expressed its dissatisfaction and perplexity over the lack of communication from the new government. Nonetheless, it proposed the creation of a Consultative Committee on Health Care Policies for Indigenous Peoples.

Finally, the NGOs obtained FUNASA’s promise that there would be a “Health Care Workshop” in 2003, which would include all the partner organizations and indigenous leaders. This would provide an opportunity to debate the problems with their relations with FUNASA and allow them to have a say in future decisions concerning the changes that everyone agreed were necessary.

After this meeting, the current directors of the Indigenous Health Department (DESAI) of FUNASA began a systematic defamation campaign against the nongovernmental organizations, unduly imputing them with all the failures in the administration of the DSEIs that, in large part, were due to the inefficiency of the governmental agency itself. This campaign culminated in the declarations of Dr. Ricardo Chagas (now Director of DESAI) to the newspaper Folha de São Paulo (October 20, 2003) that the partner entities represent “a parallel power that violates the law,” and the abrupt postponement of the Health Care Workshop to February 2004.

Shortly afterwards, Directives #69 and 70 defined the new guidelines for indigenous health services and, only then held the First Integrated Workshop on Indigenous Health, which FUNASA conducted in a strikingly antidemocratic manner.

The “new model”: amnesia in the “reform of the reform”

The policy of decentralization through partnerships with civil society entities, which gave rise to the instituting of DSEIs throughout Brazil from 1999 onward, was not conceived on ideological grounds.

This policy, to the contrary, was founded on specific, concrete experiences with operating health services that were accumulated throughout the 1990s in the Yanomami Health District. The DSY constituted a pioneering experiment that was achieved at the cost of great human sacrifice and substantial investments of public resources.

The obstacles to an efficient administration of human resources by the government in the unusual and often onerous work conditions in indigenous areas weighed heavily in FUNASA’s decision to enter into partnerships with NGOs in the 1999 reform. However, this was not the only factor. The social and political experience of indigenous and indigenist organizations in dealing with the culturally specific nature of indigenous health issues were equally decisive in the creation of a differentiated system of basic health care in each district.

In contrast to what has been broadcast in recent months by the Indigenous Health Department (DESAI) of FUNASA, for corporativist and ideological reasons, the overall quality of medical assistance since civil society associations took over direct operations has improved dramatically, despite the difficulties encumbering a few districts. The improved health conditions of Brazilian Indians over the last four years are indisputable.

The responsibility for failures in certain districts and with a few partner organizations hampered by still-fragile administrative structures lies directly with FUNASA’s own incompetence. In these cases, it did not fulfill its obligation and promise to offer technical and administrative support through daily accompaniment, which it said it would provide when the agreements were first signed. To the contrary, the omission of such support and even outright opposition to the model instituted by the 1999 reform marked the stance of many staff members in some of the sectors of FUNASA.

It is perplexing that FUNASA, under the pretext of adjusting its policies to the law, intends to assume direct responsibility for delivering health care services in the DSEIs by April without even having resolved the main problem, which is finding a viable way for contracting personnel. This perplexity turns into anxiety when one reads more of the diagnosis of the agency’s current state rendered by its own legal counsel:

...FUNASA, having been relegated to the scrap-heap, does not have sufficient staff for exercising the minimum degree of control over [health care] activities... should private entities cease their activities, FUNASA has no way of directly contracting personnel nor does it have the logistical structure for serving the population.

Instead of taking advantage of new means, both concrete and efficient, for reforming its practices, based on lessons from past experiences the institution had in trying to deliver health care services directly to indigenous peoples, FUNASA’s current directors are apparently overcome by social amnesia. They are now proposing a so-called “new model” to partner organizations, which, in light of the history of the Yanomami Health District, is nothing less than a major step backward.

The proposal that the NGOs handle the hiring of human resources is, in fact, no more than a reissue of an old proposal from FUNASA for an administrative procedure for managing human resources that its own Legal Department denounced as illegal in 1998. A provision such as this, based on “triangulation,” reduces civil society entities to mere fronts for FUNASA to swell its human resources, a ploy for getting around legislation concerning hiring in the public sector – something that is as unacceptable when done by the State as when done by NGOs.

It is necessary to underscore the antidemocratic and fickle conduct of the current directors of FUNASA in decreeing indigenous health policies, so inconsistent with the hopes raised by the election of the Lula Administration. Nongovernmental organizations were emphatically requested by FUNASA in 1999 to collaborate in creating an innovative health system that was decentralized and participatory for indigenous peoples. The NGOs accepted this challenge and, even without the promised administrative support, and subjected to constant local political resistance, confronted the chaos that had prevailed for years in the health care system in the majority of indigenous territories. Today, FUNASA pretends to have forgotten this context and has opted to freeze the democratic dialogue with civil society, launching a defamation campaign against its organizations in an attempt to weaken their legitimacy. Finally, in an exercise of archaic bureaucratic centralism, FUNASA is imposing changes that have proved unworkable from a historical perspective, unrealistic in light of its technical-managerial abilities, and illegitimate in terms of current legislation.

To conclude, what is actually in question today in the crisis of indigenous health services, for which the present directors of FUNASA and DESAI have assumed the onerous responsibility of initiating, is not a theoretical, bureaucratic question of discussing whether the government ought to go back to directly delivering health assistance to indigenous peoples to a greater or lesser degree. The crucial question is whether the public agency is actually capable, whatever the model of its intervention be, of effectively and responsibly meeting its obligation to provide the means necessary for offering indigenous peoples quality health care.

What is clear about the situation exposed here is that nongovernmental organizations now find themselves prevented from participating in the public system of indigenous health care because of the administrative, legal, and political improprieties of the terms of the “reform of the reform” proposed by the current directors of FUNASA and DESAI.

Faced with this regrettable and unexpected step backward in Brazilian indigenist policies, URIHI is informing public opinion that, after the four years of courageous and dedicated work by its staff members, and after having achieved a remarkable improvement in the Yanomami’s health situation, it finds itself obliged to interrupt its partnership with FUNASA in the near future and, therefore, its health care services in the Yanomami Indigenous Territory.

Concerned first and foremost with the health of the Yanomami, URIHI will nevertheless do what it can, as far as possible, to negotiate the transition with FUNASA in a manner that will maintain the quality of health care in the Yanomami Health District, until the public agency effectively assumes responsibility for directly delivering health services in the Yanomami Health District under its new guidelines.

The future of meeting the health care needs of the indigenous peoples in Brazil is now uncertain, at best. URIHI will be alert to the actions and results of the “new model” and will criticize any deterioration in the Yanomami’s health, consistent with its mission of supporting the Yanomami in defending their rights.

URIHI-Yanomami Health
Boa Vista, Roraima, Brazil
February 16, 2004
(English translation by Catherine V. Howard)