Yanomami Health
Program: "New Model" or Step Backward ?
Displaying
bureaucratic centralism and a short memory, the National Health Agency
(FUNASA) has initiated a precipitous, poorly conceived reform, destabilizing
the Yanomami Health District it had set up in the previous reform
of indigenous health services in 1999 and developed into a model of
efficient health assistance.
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) |