Reflections on gender and the Brazilian comprehensive healthcare policy for men


Reflexões sobre gênero e a política nacional de atenção integral à saúde do homem



Eduardo Schwarz; Tarcila de Castro e Silva Machado

Ministério da Saúde. eduardo.chakora@saude.gov.br



The scope of this paper is to discuss issues raised in the article entitled Men, health and public policies: gender equality in question by Marcia Thereza Couto (USP) and Romeo Gomes (FIOCRUZ), which analyzes the challenges and the creation of the National Comprehensive Healthcare Policy for Men PNAISH established on August 27, 2009 by the Ministry of Health. It will discuss the fundamentals of the prominence given to this segment as part of health policies; factors that underpin the healthcare actions for men and the relationship between this agenda and other public policies aimed at the promotion of gender equality; contributions from research conducted and reflections made based on PNAISH, and what direction should be taken so that there is progress in overcoming health inequalities, specifically those mainstreamed by gender relationship issues.

The institutional discourse on the need of healthcare for men is often backed by epidemiological factors that show, through comparative research with women, a marked increase in morbidity and mortality among men. Socio-cultural factors are associated with these morbidity and mortality data, since healthcare and welfare in lifestyle habits are attributes that are not identified with the concept of masculinity. There is thus greater resistance from men to seek services at primary care level as they associate prevention and self-care with fragility and insecurity, contrasting with virility, exposure to risk situations and invulnerability, which are cultural traits of a hegemonic view of masculinity that lead, in contrast with women, to health issues and early death.

These studies have often been cited and used as a tool to raise awareness among men about the need for health promotion and prevention, especially at the level of primary healthcare. However, these arguments are far from exhausting the issue and do not mean that this is a simple relationship of cause and effect.

The introduction of the theme of masculinities and gender mainstreaming in public health policies reaffirmed by PNAISH are central to the debate on the limitations of the biomedical model for thinking about public health and circumscribing it in the field of social sciences. It proves the need for dialogue with the other health policies and programs related to gender equality and, in an equally complex perspective, to the issue of gender in the context of cultural diversity. The acknowledgement of the plurality of masculinities can contribute to the coherence of a policy that acknowledges diversity, formulated to reach different populations and institutional actions that reinforce uniqueness, based on general principles of equality and universality.

For different socio-historical reasons, a ground roots social movement with masculinities as the focus of attention in the health field and in relation to other movements of the same genre has never truly caught on. This fact seems to contribute to the fact that the necessary anthropological and political bias of men's health often loses out to a biomedical and welfare approach dispensed to the user. But this difference in approach is the foundation stone of a new model of healthcare in which the relationship perspective of gender is progressively built.

These arguments upon which the legitimacy of PNAISH is based are added to the socio-cultural data that underlie the epidemiological data. The latter, when interpreted in isolation, without the backing of a plural and interdisciplinary analysis of the context in which they are situated, cannot be answerable alone for the implementation actions and strategies of PNAISH, since these actions are weighted with meanings in terms of political progress and symbolic values.

It is also important to consider that health managers and professionals, living under the aegis of the domination of the same models of masculinity that they intend to fight, may also tend to strengthen the socio-cultural and institutional barriers that alienate male users of the service. Thus, the discussion of "masculinities" in the context of health is fundamental to all actors involved in the Unified Health System network and in conjunction with other public policies. These aspects of PNAISH foreshadow possibilities of profound change in the reorganization of practices and meanings about what being a man is, as well as the relations of gender equality and implications for the health-illness process.

The challenge launched at men by advertising campaigns, in which they are held responsible for their health, will raise questions, broaden the discussion, give rise to controversies, and involve everyone. This is not a case of blaming men as a whole for the deterioration in the health of the male population, reducing the matter to the behavior of men on the one hand and the exclusively medical-clinical services question on the other. The proposed actions are destined to fail if the political and symbolic field in which gender issues are included is disregarded. It is important to emphasize this aspect in the process of enhancement of actions directed by PNAISH. The image of men as being vulnerable and infantile, who do not take care of themselves because they do not want to or do not know how, is one of the angles that can be seen in directions announced by the Policy. It is initially necessary to get the male population to see themselves as the protagonists of their demands, by means of the plurality of biopsychosocial contexts and conditions, as subjects of needs, desires and care. This indeed demands a permanent dialogue with other public policies both in the health field, such as the National Humanization Policy PNH for example, and in the human rights field, such as the so-called Brazil without Homophobia Program, among others. This would foster the development of actions and the formulation of new practices by managers and health professionals, to encourage the provision of more friendly services that are truly able to think, feel and act with absolute respect for the social, cultural, ethnic, religious and gender differences and diversities.

It is also important to consider that the gender construct is in the field of power relationships, constituting separate and distinct intentionalities and subsidizing human practices that instrumentalize these relationships to maintain or alter them. In this sense, gender identity categories are in play in the power struggle between different, political, economic, corporate interests, etc. seeking to define what health and illness are, understanding the quality of care according to their own parameters.

So, although PNAISH is included in this affirmative action plan for the construction of autonomy and respect for human rights, care must be taken that there are no deviations in their intentions, as when the exclusive interests of medicalization of the male body seek to link themselves to the actions and strategies of PNAISH. In this case, the role of gender comes to be used for the duration of power relations contrary to the health and welfare of citizens, making use of their vulnerability, then pointing to solutions that serve other interests than those of the user. Therefore, at the level of primary care, the anthropological bias of health is critical, as it is a vast array of references in which medicalization should be questioned. The welfare and biomedical approach dispensed to the users is opposed, in general terms, to the effective emancipation of their citizenship in the health field.

Finally, it is seen that the legitimacy of PNAISH is created by the critical analyses that are based on the interlinked themes of men's health, public health and public policies, seeking support to think and rethink possible ways of managing the policy of men's health; and by its dialogue the policies that arise as a result of the campaigns of social movements, consolidating the relationship between gender, human health and the political agenda.

Primary care, the preferential entry point to the Unified Health System and benchmark for the structuring of local health systems, seeks to offer more than a specialized clinic for disease eradication. Since it is guided by the principles of universality, accessibility, bonding, ongoing care, humanization, equality and social participation, it is saying that this is a health model that considers the subjects in their uniqueness, in various socio-cultural and regional location contexts, and it is in this way that it provides comprehensive care.

The great challenge of PNAISH is to meet individual and collective needs of the various male populations based on democratic and participatory practices at all three levels of management federal, state and municipal showing and integrating the specific needs of male populations according to the logic of the services on offer, as guaranteed by primary care and advocated by the Healthcare Network.

ABRASCO - Associação Brasileira de Saúde Coletiva Rio de Janeiro - RJ - Brazil
E-mail: revscol@fiocruz.br