Bolsonaro government wants to deepen the privatization of indigenous healthcare, organizations warn.

Brasil de Fato - The government of Jair Bolsonaro (PL) plans to increase private influence in indigenous healthcare, perpetuating a model already considered ineffective in guaranteeing care for the most vulnerable and geographically isolated communities.

Indigenous organizations point to the intention of the Special Secretariat for Indigenous Health (Sesai), linked to the Ministry of Health, to outsource strategic functions that, by law, would be the responsibility of the state to private entities.

The alarm was raised after Sesai released a proposed call for bids in November to contract NGOs that will provide manpower - technicians, nurses, doctors and others - to work in the 34 Special Indigenous Health Districts (DSEIs) spread across Brazil.

The National Indigenous Mobilization (MNI), a platform for coordinating more than 100 indigenous, pro-indigenous, and environmental organizations, prepared a technical note classifying the measure as "an advance in the privatization of indigenous health."

"It seems to us that the public call for proposals is transferring a set of responsibilities from Sesai to private entities, mainly regarding the planning, coordination, supervision, monitoring, and evaluation of actions," the document states.

"Even more alarming is the indication that political dimensions such as inter-federative coordination with municipal, state, and federal managers are being transferred to private entities, which do not have a seat on the inter-managerial bodies of the SUS (Unified Health System) and will not have the support to negotiate the comprehensiveness of care," the statement continues.

Criticisms of outsourcing 

Currently, according to the Ministry of Health, 800 indigenous people are served by 15 health professionals, half of whom are also indigenous.

The service is mediated by eight charitable social assistance entities, most of them linked to churches. Together, they received almost R$1,5 billion from the Federal Government in the last two years (2021), according to the Ministry of Health's Transparency Portal.  

“Privatization will be a huge loss. If it’s difficult now, it will become much more so. The driving force behind private affairs is profit,” criticized Alberto Terena, executive coordinator of the Articulation of Indigenous Peoples of Brazil (Apib). 

"When they say millions are going to Sesai, I believe it. But what's lacking is serious management from secretaries and coordinators to ensure that these millions they talk about actually reach where they're needed," he stated.

In Terena's experience, the more private entities take over the management of healthcare, the more difficult it becomes to demand improved quality and expanded services for the population. 

“When you outsource, they [Sesai] say: 'don't talk to me because it's no longer my responsibility, it's the responsibility of the contracted company that is providing services to us.' What happens is a denial of care to our people,” she states.

Persecution and precarious employment 

Outsourced workers in indigenous healthcare told Brasil de Fato that the model based on hiring labor through philanthropic entities directly affects the quality of healthcare services. 

According to them, there are cases in which the contracted companies do not take responsibility as they should for the quality of the professionals hired, and the teams have high turnover, harming the continuity of the service. The Ministry of Health needs to demand an improvement in health indicators. 

“We observe a very large shortage of qualified professionals with an understanding of epidemiological profiles, with a more problem-solving profile. What we do is not just basic care, but care at all levels of complexity,” says an employee who spoke on condition of anonymity.

Another factor that interferes with the quality of care is the working conditions, which are more precarious compared to those of employees directly hired by the State. There is a lack of Personal Protective Equipment (PPE), and the annual health assessments – both clinical and psychological – of the teams are not always carried out. 

“When we go to the territories, we receive a per diem allowance of R$ 35, which is still deducted. Meanwhile, the civil servants receive full daily allowances and more. The amount we receive is to cover food and to maintain the team during the workdays, but it barely covers food expenses,” reports another worker. 

The work became even more arduous after the start of the Bolsonaro government. Fearing persecution and dismissal, employees requested that their names and the region where they work not be revealed. 

“From 2019 onwards, relations with the central level [Ministry of Health] became hostile. In some cases, there is evidence of abuse of power, unfounded guidelines that deviate from what is stipulated in the complementary laws on Indigenous health and the International Labour Organization itself. Not to mention the weakening of the autonomy of the districts,” attested a contracted employee. 

The Yanomami are dying. 

One of the biggest victims of the shortcomings of the current model are the 35 Yanomami people, who inhabit the largest Indigenous Territory (TI) in Brazil, on the border with Venezuela. The same size as Portugal, the territory has higher infant mortality and malnutrition rates than Sub-Saharan Africa.

According to the Federal Public Prosecutor's Office (MPF), the Yanomami Special Indigenous Health District (DSEI) does not have enough professionals to serve the entire territory, nor does it have guaranteed air transport to connect isolated communities. Year after year, health care targets are not met, reaching only 30% of what was planned. 

The organization responsible for providing assistance to the Yanomami people is the Caiuá Evangelical Mission, created in Dourados (MS) almost 100 years ago by the American Presbyterian pastor Albert Maxwell, with the goal of converting indigenous people to Christianity.

Since then, it has become the largest philanthropic entity working in indigenous health, but it has the worst results, as admitted during a meeting of the National Health Council (CNS) by the former Minister of Health, Luiz Henrique Mandetta, who signed agreements with the entity in January 2019. 

The NGO currently operates in nine Special Indigenous Health Districts (DSEIs), covering the entire states of Mato Grosso do Sul, Amazonas, Acre, and Roraima. To support this, it has received over R$ 430 million from the Brazilian government in the last two years, representing 30% of the total budget allocated to private entities. 

In 2012, the NGO, along with the Union, was the target of a public civil labor lawsuit. The Labor Prosecutor's Office (MPT) demanded improvements in safety, health, and hygiene conditions for the teams, and the process ended with an agreement between the parties. 

Requests for clarification sent to the Caiuá Evangelical Mission have not been answered. 

Reformulation

One way out of the crisis would be to reduce outsourcing in health management, argues the coordinator of Apib. "Sesai would have to have well-structured departments so that it could fulfill the purpose for which it was created," says Terena.

For outsourced workers, the solution involves opening public recruitment processes and selecting employees with proven experience working with indigenous peoples. It is also necessary to demand higher quality indicators and expand services in critical areas. 

“This way we could produce information that can generate effective policies that meet local realities. Indigenous health is beautiful on paper, but its growth is slow due to political interference in the maturation process of SESAI,” opined one worker. 

The other side 

When questioned by reporters, the Ministry of Health responded that the proposed public notice criticized by indigenous peoples' organizations is an "opportunity to improve this model" and was submitted to public consultation. 

"Distorted interpretations can be easily refuted by examining the documentation from the public consultation, the content of which will be debated during the 6th National Conference on Indigenous Health," says a note sent to Brasil de Fato. 

"Sesai clarifies that the current agreement model for entities working in indigenous health dates back to the creation of Sesai itself (Law No. 12.314/2010), which inherited this modality from the National Health Foundation (Funasa), according to a policy established by previous governments," points out the Ministry of Health.

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