Amazonian indigenous representation in state health institutions

An indigenous health activist participates in the 2007 State Health Conference, Brazil

A DRC research project in the Western Amazonian state of Acre, Brazil, is investigating the participation of indigenous peoples in health policy and health systems management. DRC researcher Alex Shankland, in association with health rights NGO Saúde Sem Limites, is carrying out action research and facilitating indigenous engagement in a series of policy events.

Early findings from the research (co-sponsored by the DRC and the Latin American indigenous health network RED RAICES) found that indigenous movement organisations have been employing a variety of strategies and tactics over the period of a decade. Their strategies combined engaging in ‘participatory sphere institutions’ such as Health Councilsand Conferences with intense involvement in party politics and also direct action including occupation of health facilities and “kidnapping” (see note 1) of government health teams.

These multiple strategies led to greater political visibility of indigenous peoples and significantly increased inclusion, both materially and symbolically. The share of health spending to meet their needs has increased, and some indigenous leaders are consulted more frequently by the state government on policy decisions that affect their communities.

However, there has been a fragmentation of indigenous representation. A regional movement collapsed acrimoniously after its leaders agreed to become involved in running outsourced government health services, and there are deepening inequalities between ethnic groups and communities. Some indigenous groups have been very successful in securing greater visibility and improved access to services; others remain marginalised and suffer from ill health and high death rates in comparison to the rest of the population.

This phase of work concluded with a workshop with Amazonian indigenous health activists allowing indigenous representatives to present their priorities to a group of state and federal government officials. It was a success and the state government then invited them to act as facilitators for indigenous participation at the State Health Conference, where the indigenous delegates managed to secure approval of various resolutions addressing issues that had been identified at the workshop. The group has also been invited to present the project findings in the Brazilian Senate in 2008.

The final phase of the project will look at the implications for the Brazilian health system and its participatory sphere institutions. It will also explore the wider questions they raise about representation, equity and different democratic processes based on universality and on difference.

Note 1: Although not a major focus of the research, it is worth explaining “kidnapping”. Although this strategy appears to be an unruly and even violent direct action strategy, it is actually a theatrical expression of demands. When an indigenous group gets angry about their lack of rights, a government health team arriving in the village may find themselves surrounded by warriors wielding bows and arrows. They may be refused permission to leave the indigenous territory until the government sends a high-ranking official to negotiate, or pays for indigenous leaders to travel to the state capital for a meeting with the “white chiefs”.

The meeting is then held, and indigenous demands ( for more frequent health team visits or more respectful treatment by officials and health professionals for example) are then put on the agenda for discussion in the health council, or at further meetings involving other political actors (such as the state governor’s office). Despite all the weapon-waving, no one actually gets hurt, and the “kidnapping” usually implies nothing more than the health team having to stay in the village a few days longer than scheduled.