Health Equity in Brazil

Intersections of Gender, Race, and Policy

Kia Lilly Caldwell

• Publisher: University of Illinois Press
• Year: 2017
• ISBN:
  9780252099533
• Topic: Ciencias sociales
• Subtopic: Sociología

Brazil's leadership role in the fight against HIV has brought its public health system widespread praise. But the nation still faces serious health challenges and inequities. Though home to the world's second largest African-descendant population, Brazil failed to address many of its public health issues that disproportionately impact Afro-Brazilian women and men. Kia Lilly Caldwell draws on twenty years of engagement with activists, issues, and policy initiatives to document how the country's feminist health movement and black women's movement have fought for much-needed changes in women's health. Merging ethnography with a historical analysis of policies and programs, Caldwell offers a close examination of institutional and structural factors that have impacted the quest for gender and racial health equity in Brazil. As she shows, activists have played an essential role in policy development in areas ranging from maternal mortality to female sterilization. Caldwell's insightful portrait of the public health system also details how its weaknesses contribute to ongoing failures and challenges while also imperiling the advances that have been made.

1

Feminist Dreams and Nightmares

The Struggle for Gender Health Equity in Brazil

On December 26, 2011, Brazilian President Dilma Rousseff issued Provisional Measure 557 (Medida Provisória), also known as MP 557, which called for the creation of a National System of Registration, Tracking and Follow-up of Pregnant and Puerperal Women for the Prevention of Maternal Mortality (Sistema Nacional de Cadastro, Vigilância e Acompanhamento de Gestante e Puérpera para a Prevenção da Mortalidade Materna). MP 557 sought to establish a nationwide system for registering pregnant women, which would place them under state surveillance and possibly subject them to penal action if they were suspected of having an induced abortion. It also called for the provision of financial assistance to low-income pregnant women to cover transportation costs for medical appointments.

On May 31, 2012, MP 557 expired before being voted on by the Brazilian Congress. However it raised important issues related to state intervention in the areas of reproductive health and women’s health; it also created a firestorm of controversy and critique, particularly from public health professionals, including the Brazilian Center for Health Studies (CEBES) and the Brazilian Association of Collective Health (ABRASCO), as well as feminist activists. The National Health Council, a body comprised of health professionals, users of the public health system, and civil society representatives, also disapproved of the measure. The provisional measure was criticized for violating women’s human rights, since it sought to create surveillance mechanisms for pregnant women (Leme 2009). Given that MP 557 was issued during the 2011 Christmas and New Year’s Holiday, this timing further heightened activists’ concerns that it was a stealthy and ill-conceived policy.

Provisional Measure 557 reflected an authoritarian posture by Rousseff, Brazil’s first female president, that undermined the longstanding participation of feminist health activists in shaping health policies for women. This tradition of civil society involvement in policy development and implementation emerged during Brazil’s transition from a military dictatorship to democratic rule in the early 1980s, in large part due to the demands of feminist health activists and health reform advocates, and has been a key feature of health policy in recent decades. This chapter traces the development of health policies for women in Brazil since the early 1980s and examines the central role feminist health activists have played in calling for gender health equity. Women’s health, particularly reproductive health and abortion, has been a central organizing issue for Brazilian feminists for several decades. The analysis in this chapter explores the following questions: How have state policies on women’s health developed and changed since the early 1980s? What role have feminist health activists played in developing health policies for women? What challenges continue to exist in efforts to achieve gender health equity in Brazil?

PAISM and Feminist (Re)Conceptualizations of Women’s Health in Brazil

During the early 1980s, Brazilian feminists began to advance new conceptualizations of women’s health that challenged biomedical and maternal-child health paradigms that viewed women’s health as being limited to their biological function as reproducers (Diniz 2012). In addition, by 1980–1981, feminists began to insist that women had a “‘right’ to control their fertility and that the State had an ‘obligation’ to provide the means for women of all social classes to exercise that right’” (Alvarez 1990, 185). Feminist views of women’s health challenged population-control policies that were promoted by the military regime and private institutions such as BEMFAM, Sociedade Civil de Bem-Estar Familiar no Brasil (Civil Society for Family Well-being in Brazil) and CPAIMC, Centro de Pesquisas de Assistência Integrada à Mulher e à Criança (Research Center for Integrated Assistance to Women and Children) during the late 1970s and early 1980s.

BEMFAM was created in 1965 as a private, nonprofit organization and was the first institution to provide family planning services in Brazil (Costa 2009). The organization became affiliated with the International Planned Parenthood Federation (IPPF) and attained federal recognition in 1971. BEMFAM was heavily involved with creating contraceptive clinics in poor communities throughout the country. It was active in hundreds of municipalities, particularly in the Brazilian northeast. Writers such as Ana Maria Costa have noted that BEMFAM distributed contraceptive methods “without criteria and without clinical monitoring,” which posed a danger to women who received services from the organization (2009, 1075). CPAIMC also held nonprofit status and was financed by the United States’ Agency for International Development (USAID) by means of Family Planning International Assistance (FPIA), the Pathfinder Foundation, and other organizations. CPAIMC’s activities promoted an interventionist ideology regarding contraception within the Brazilian medical community (Costa 2009). The organization financed professionals who provided medical training for doctors and nurses, and supported a network of doctors who performed surgical sterilizations by donating equipment and subsidizing their activities (Costa 2009). Organizations such as BEMFAM and CPAIMC were also instrumental in promoting population-control policies in Brazil, which sought to curb reproduction, particularly among poor and nonwhite populations. Such policies gave little regard to women’s health needs beyond reproduction.

The Program for Integral Assistance to Women’s Health (Programa de Assistência Integral à Saúde da Mulher, PAISM) was elaborated in 1983 and adopted by the Brazilian government in 1985, the final year of a military dictatorship that began in 1964. Close examination of the development of PAISM provides important insights into how women’s health policies developed within the context of the military dictatorship and the subsequent lag in their full implementation. An integral or comprehensive approach to women’s health was central to the conceptualization of PAISM. The program sought to meet women’s health concerns on a lifelong basis and to move beyond the emphasis on reproductive health that had characterized earlier initiatives. PAISM was intended to address a range of health issues, including cancer prevention, gynecological care, contraception, and fertility treatment, as well as all phases of women’s lives, from infancy to advanced age.

PAISM represented a sharp break with earlier population-control policies and marked the first time women’s health came under focus within the Brazilian federal government. In addition, fertility regulation was viewed as a social right, women were viewed as subjects, not only as reproducers, and there was also an educational dimension of the program that focused on altering the sexist character of health values and practices (Costa and Aquino 2000). Surprisingly PAISM was developed during the military dictatorship and at a time when little dialogue between women’s health advocates and the military regime was possible (Oliveira 2005a). During the military dictatorship of the early 1980s, President João Batista Figueiredo created a Parliamentary Inquiry Commission (Comissão Parlamentar de Inquérito, CPI) to study issues related to population growth. Then Minister of Health, Waldir Arcoverde, participated on the commission and decided to create a proposal for attention to women’s health. Minister Arcoverde’s proposal for the creation of PAISM was presented to the commission in June 1983. After receiving criticisms from the women’s movement and health professionals about the ways in which PAISM promoted population control, the Ministry of Health incorporated the demands of civil society and reconceptualized its approach to maternal-infant health (Oliveira 2005a).

Although women’s groups initially rejected the proposal for PAISM because they opposed collaboration with the military government, they eventually supported its development. Due to concern that the program not become subject to bureaucratic manipulation, women’s health activists became involved in the development of technical guidelines and educational materials for PAISM, as well as in the implementation of policies at the national, state, and municipal levels (Alvarez 1990).1 As Sonia Alvarez has observed, the Brazilian feminist movement “successfully mobilized against those State factions who promoted controlista solutions and ‘beat’ the outgoing authoritarian regime ‘at its own game’” (1990, 194). In addition to having to contend with the anti-natalist policies of the military regime, feminist activists also had to navigate claims from the political Left that any form of family planning was inherently anti-natalist (Alvarez 1990). PAISM’s emphasis on an integral or comprehensive approach to women’s health sought to be more holistic than previous efforts. According to Simone Diniz:

“Comprehensive” health (integralidade) is a complex concept, more used in Latin America than elsewhere. In the case of the PAISM, comprehensiveness included the notions of primary, secondary and tertiary care; the physical, emotional and social aspects of health, and of care for women from infancy until old age, not only for the reproductive years. [2011, 126]

The establishment of PAISM within the context of the military regime has been attributed to three main factors: the move toward decentralization of health care, the presence of women activists within the government, and the call for a wider choice in contraceptives from within the women’s movement (Alvarez 1990; Dixon-Mueller 1993). As Ruth Dixon-Mueller has observed: “Designed by feminists and physicians, the program intended to correct inadequacies in the provision of contraception and other basic health services for women, to emphasize high quality care, and to raise the consciousness of health providers to respect women’s rights and autonomy” (1993, 89). However, some feminist scholars and activists have noted that a shortcoming of PAISM was its failure to address abortion, even in cases where it was legally allowed (Pitanguy 1999). Brazil’s 1940 Penal Code criminalizes abortions except in cases of pregnancies resulting from rape and when there is a risk to the mother’s life. Moreover, the Penal Code has continued to be important, because it set the terms for defining when abortion is legally allowed during the twentieth and into the early twenty-first century in Brazil.

During the mid-1980s, developments regarding women’s issues at the federal level facilitated greater discussion of reproductive rights and programs such as PAISM. In 1984, the women’s movement proposed the creation of a national council focused on women’s issues (Alvarez 1990). The Conselho Nacional de Direitos da Mulher (National Council on Women’s Rights, CNDM) was created by Law 7.353 in August 1985 (Bohn 2010). Establishment of the CNDM provided an important opening for feminists to affect political change and influence state policy as Brazil returned to civilian rule. However, there was not universal agreement among feminists about the creation of the CNDM, since it would encourage a close relationship with the state. Though some feminists supported the creation of the CNDM and wanted to be directly involved with it, others supported it from a distance, and still others believed that the council would lead to the cooptation of the feminist movement by the state (Pitanguy 1993). The CNDM mirrored state and city councils for women that had been established in the city and state of São Paulo and the state of Minas Gerais in the early 1980s (Alvarez 1990; Dixon-Mueller 1993).2 The CNDM played a critical role in supporting the women’s movement in its efforts to promote reproductive rights. The Comissão de Estudos dos Direitos da Reprodução Humana (Commission on Reproductive Rights) of the Secretaria Nacional de Programas Especiais da Saúde (National Secretariat for Special Health Programs, SNPES) was established by the Brazilian Ministry of Health in 1985 to coordinate and implement PAISM. The commission included representatives from the women’s movement, the CNDM, members of other government ministries, and the academic community (Dixon-Mueller 1993). The commission existed until 1988, with prominent demographer Elza Berquó serving as its first president from 1986 to 1987 (Oliveira 2005a).3

Feminists who participated in the health reform movement (movimento sanitário) of the 1980s were important advocates of women’s health issues. Women made up a significant number of the participants in the 8th National Health Conference, which was held in March 1986 (Costa 2009). The conference had five thousand participants and was an important milestone in efforts to create a new public health system with input from civil society as Brazil returned to democratic rule, following federal elections in January 1985. This national conference is often seen as the origin of the development of Brazil’s public system, the Sistema Único de Saúde (Unified Health System, SUS), and an important marker and victory in the health reform movement’s efforts to achieve an equitable health system that would address the needs of all Brazilian citizens. The resolutions from the 8th National Health Conference also called for the immediate convocation of a national conference on women’s health.

The National Conference on the Health and Rights of Women took place in October 1986 and was organized by the CNDM, with support from some sectors of the women’s movement, the Ministry of Health, and the Ministry of Social Welfare. Nine hundred representatives from every state in Brazil attended the conference. Proposals related to women’s health were also developed in regional pre-conferences held prior to the national conference. This event “reaffirmed and detailed the guiding directives of policies for women’s health in line with PAISM, transforming them into programmatic resolutions” (Costa 2009, 1077). The final report from the conference contained resolutions addressing the importance of including a comprehensive approach to women’s health in the development and consolidation of the new health system. The resolutions also called for the reinforcement of PAISM, the provision of family planning services to challenge the influence of private agencies with population-control objectives, and the legalization of abortion (Costa 2009). The resolutions addressing reproductive rights focused on women’s free choice of contraceptive methods, access to all existing methods, with proper orientation regarding their use, and the involvement of the state and its health-related entities, as well as the women’s movement, in actions related to conception and contraception. The resolutions on reproductive rights also stated that private interests, whether domestic or international, should not interfere with reproductive health policies and practices.

The resolutions from the 1986 National Conference on the Health and Rights of Women were transformed into a political document known as the Carta das Mulheres Brasileiras aos Constituentes (Letter from the Brazilian Women to the Constituents). While this letter addressed women’s political rights and their expectations for Brazil’s new democracy, it also reaffirmed health as the central theme in the agenda of the women’s movement and was used as part of the process of drafting the 1988 constitution. It also emphasized that health was a right of all Brazilians and a duty of the state, and that women had the right to have their health attended to, regardless of whether or not they were mothers (Costa 2009).

The ideas and demands articulated in the resolutions from the 1986 National Conference on the Health and Rights of Women and “Letter from the Brazilian Women to the Constituents” have played a fundamental role in how health has been conceptualized in Brazil since the mid-1980s. Furthermore, the impact of feminist health activists on the 1988 Constitution is evident in article 226, paragraph 7, which states that “family planning is the free decision of the couple, it is the responsibility of the State to provide educational and scientific resources for the exercise of this right and to impede any coercion on the part of official and private institutions” (Constituição da República Federativa do Brasil 1988). This description of family planning was important symbolically, since it was included as part of the democratic “people’s constitution” of 1988, which conferred new rights on previously marginalized sectors of society and also called for state recognition of health as a citizenship right. Moreover, despite pressure from the Catholic Church to include a statement in defense of life beginning at conception, the 1988 Constitution did not include provisions related to abortion, neither those in favor nor those in opposition (Costa 2009).

PAISM’s Incomplete Implementation

Though PAISM represented a progressive approach to addressing women’s health comprehensively, it was never fully implemented. PAISM included nearly all of the reproductive health-care elements that were called for ten years later in the Program of Action from the 1994 International Conference on Population and Development (ICPD), which was held in Cairo, Egypt (Corrêa et al. 1998). Ironically, in the Carta de Brasília (Letter from Brasília), which resulted from a 1994 preparatory national meeting for the Cairo conference, Brazilian women’s health activists called for the immediate implementation of PAISM. This highlights the fact that Brazilian feminists recognized that PAISM was in peril and were attempting to use the U.N. conference process as a way to call attention to its precarious state. As later sections of this chapter discuss, feminist health activists in Brazil repeatedly have used the U.N. conference process to push for the implementation of PAISM and other forward-looking policies designed to meet women’s health needs and promote gender health equity.

During the height of PAISM’s implementation (1984–1994), women’s health services improved in some municipalities and states; however the progress and results were uneven (Corrêa et al. 1998). As discussed above, the first women’s health program was implemented in the city of São Paulo, and the departments of health of both the city of Recife and state of Pernambuco made investments in reproductive health. Initiatives focusing on prenatal and obstetric assistance had already been developed in the northeastern state of Ceará, and PAISM trainings led to a more comprehensive approach to women’s health there. Correa et al. (1998) note that, in the early 1990s, only 20 percent of the state services and 46 percent of the municipal services offered prenatal assistance to more than 40 percent of the population. In addition, only three municipal health departments provided contraception services to more than 40 percent of th...