Abstract

This article discusses the meanings of differentiated health care guideline given by health professionals from the Indigenous Health Multidisciplinary Team (EMSI) who work at the Alto Rio Negro Special Indigenous Health District (DSEI-ARN). This exploratory, descriptive, analytical, and qualitative study conducted 15 semi-structured interviews with professionals from the Indigenous Health Multidisciplinary Teams of the DSEI-ARN, which were submitted to content analysis. The four meaning cores identified from the analyses were: Differentiated care as a way of providing primary care in the territory; Actions conducted under the population’s cultural differences; Self-care, traditional medicine, and the construction of therapeutic itineraries; and Professionals’ challenges and difficulties in addressing traditional indigenous health care. In the professionals’ perspective, differentiated health care is linked to the conditions for working in this primary care type. For their performance, they refer to the need to respect the cultural differences of the Indigenous population. Professionals recognize the use and effectiveness of Indigenous practices, knowledge, and regional specificities.

Key words:
Indigenous health service; Health of Indigenous populations; Amazonian ecosystem; Health personnel; Qualitative research

Introduction

The Indigenous Health policy results from an achievement that started in the 1980s to guarantee Indigenous peoples comprehensive and differentiated health care based on the constitutional recognition of their territorial and sociocultural rights¹1 Pontes ALM, Machado FRS, Santos RV, organizadores. Políticas antes da Política de Saúde Indígena. Rio de Janeiro: Editora Fiocruz; 2021.. The National Healthcare Policy for Indigenous People (PNASPI), established by Ordinance No. 254 of January 31, 2002, determines the implementation of a model of “differentiated and complementary health care in the organization of services for the protection, promotion, and recovery of health, ensuring Indigenous peoples’ exercise of their citizenship”²2 Brasil. Portaria nº 254, de 31 de janeiro de 2002. Aprova a Política Nacional de Atenção à Saúde dos Povos Indígenas. Diário Oficial da União 2002; 31 jan. (p.6). This policy also guarantees access to comprehensive care, aligned with SUS principles and guidelines, considering social, cultural, geographic, historical, and political diversity, always favoring overcoming factors that make this population more vulnerable to health problems³3 Pontes ALM, Machado FRS, Santos RV, Brito CAG. Diálogos entre indigenismo e reforma sanitária: bases discursivas da criação do Subsistema de Saúde Indígena. Saude Debate. 2011; 43(8):146-159.. Thus, access to the Unified Health System (SUS) services was recommended to occur articulated with Indigenous health systems, adopting a complementary and differentiated model of organization of services targeting the protection, promotion, and recovery of health²2 Brasil. Portaria nº 254, de 31 de janeiro de 2002. Aprova a Política Nacional de Atenção à Saúde dos Povos Indígenas. Diário Oficial da União 2002; 31 jan..

This health care organization model is implemented through 34 Special Indigenous Health Districts (DSEI) that underpin the Indigenous Health Care Subsystem (SASI). Each DSEI should have a service focused on “a dynamic ethnocultural space”⁴4 Fundação Nacional de Saúde (Funasa). Lei Arouca: A Funasa nos 10 anos de saúde indígena Brasília: Funasa; 2009. (p.30), seeking “efficiency and speed per each people’s specificity”⁴4 Fundação Nacional de Saúde (Funasa). Lei Arouca: A Funasa nos 10 anos de saúde indígena Brasília: Funasa; 2009. (p.30) toward differentiated health care. Districts should guarantee PHC actions based on the differentiated care guideline through the work of Multidisciplinary Indigenous Health Teams (EMSI) composed of Indigenous Community Health Workers, Indigenous Health Sanitation Workers, nursing technicians, nurses, doctors, dentists, and oral health technicians.

However, Pontes et al.⁵5 Pontes ALM, Rego S, Garnelo L. O modelo de atenção diferenciada nos Distritos Sanitários Especiais Indígenas: reflexões a partir do Alto Rio Negro/AM. Cien Saude Colet 2015; 20(10):3199-3210. observed that differentiated health care still has several limitations. Indigenous knowledge and practices are denied or disregarded by the hegemonic biomedical model, which is strengthened by the bureaucratic procedures of the Special Indigenous Health District (DSEI). Thus, the devaluation of other care that the Indigenous population provides is frequently observed.

São Gabriel da Cachoeira, in the state of Amazonas, has several ecosystems and geographic settings in which 23 Indigenous peoples coexist; that is, it has enormous sociocultural and linguistic diversity. The Indigenous territory of this municipality is part of the Alto Rio Negro Special Indigenous Health District (DSEI-ARN), and is a fascinating place to develop research to understand and implement public policies in the Indigenous context⁶6 Instituto Socioambiental (ISA). Federação das Organizações Indígenas do Alto Rio Negro (FOIRN). Povos indígenas do Rio Negro: uma introdução à diversidade socioambiental do noroeste da Amazônia brasileira. São Paulo, São Gabriel da Cachoeira: ISA, FOIRN; 2006..

Besides aspects related to the sociodiversity of this Brazilian region, we observed several challenges for the implementation of health actions, such as the inequalities in the health conditions of the Indigenous population that lives in remote places, the logistical difficulties due to the territory’s vast extension and its geographic characteristics and seasonality, the lack of adequate structures, and the unfavorable health indicators. In this context, this article aimed to discuss the meanings given to the guideline of differentiated health care by health professionals from the Indigenous Health Multidisciplinary Team (EMSI) who work at DSEI-ARN and address these diversities in their daily work. The lack of a concept of differentiated health care in the Indigenous Health policy documents hinders professionals from providing guidance and work in SASI⁵5 Pontes ALM, Rego S, Garnelo L. O modelo de atenção diferenciada nos Distritos Sanitários Especiais Indígenas: reflexões a partir do Alto Rio Negro/AM. Cien Saude Colet 2015; 20(10):3199-3210.. Therefore, we should understand the meanings attributed by health professionals to this guideline.

Methods

This is an excerpt from the results of the Master’s dissertation entitled “The Experiences of Health Professionals in Intercultural Contexts: Reflections from the Special Indigenous Health District of Alto Rio Negro/Amazonas”, presented in the Postgraduate Program in Living Conditions and Health Situations in the Amazon (PPGVIDA).

A qualitative study was conducted based on the perspective of hermeneutics-dialectics to deepen the meanings attributed by the subjects in their relationship with the social environment and their interpretations of their experienced reality⁷7 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo: Editora Hucitec; 1992.. This study was held at the headquarters of the Alto Rio Negro Special Indigenous Health District (DSEI-ARN), which is located in São Gabriel da Cachoeira, in the state of Amazonas. Some 852 km from Manaus, the capital of the state of Amazonas, it is located on the banks of the Rio Negro basin, in the extreme northwest of the state of Amazonas, bordering Venezuela and Colombia⁶6 Instituto Socioambiental (ISA). Federação das Organizações Indígenas do Alto Rio Negro (FOIRN). Povos indígenas do Rio Negro: uma introdução à diversidade socioambiental do noroeste da Amazônia brasileira. São Paulo, São Gabriel da Cachoeira: ISA, FOIRN; 2006..

Its coverage area is comprised of three municipalities: São Gabriel da Cachoeira, Santa Isabel do Rio Negro, and Barcelos. Although the DSEI-ARN encompasses three municipalities, this study was limited to the territory of São Gabriel da Cachoeira since this is where the District headquarters are located and where most EMSI professionals live. We also considered that this municipality is highly ethnically diverse, with 19 of the district’s 25 bases located and distributed along the riverbeds.

Data were collected through semi-structured interviews⁷7 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo: Editora Hucitec; 1992. administered individually and recorded by the researcher. The “Interview Guide” was structured into three thematic blocks: a) respondent profile; b) training experiences to work in the intercultural context; and c) differentiated health care guideline meanings. The semi-structured interviews adopted open-ended questions that allowed respondents to comment freely on the topic. In this article, we focused on the results regarding respondents’ differentiated care guideline meanings based on their life and work experiences at DSEI-ARN.

Fifteen professionals working at the EMSI of the DSEI-ARN were interviewed, with the following profile: six nursing technicians, five nurses, two doctors and two dentists, who agreed to participate voluntarily and with consent after the disclosure. In the statements presented in the results, we identified the professional category (without gender attribution) and whether or not they were Indigenous.

The decision to interview more nursing professionals is justified because they are the largest professional category, with the longest staffing seniority and accumulating the most significant responsibilities for implementing the EMSI work. We aimed to reach saturation in the response levels without intending to include the entire universe of DSEI-ARN workers. This research was submitted for analysis and approved by the Research Ethics Committee (CAAE 26483319.4.000.5240). It was presented and approved by the president of the Alto Rio Negro District Council for Indigenous Health (CONDISI).

The interviews were conducted with the respondents at a time previously scheduled, in a location of their convenience, and with privacy guaranteed. The researcher then transcribed the interviews, and their contents were categorized based on the dimensions that emerged from the subjects’ responses⁸8 Minayo MCS, organizadora. Pesquisa social: teoria, método e criatividade. Petrópolis: Vozes; 1994.^,99 Bardin L. Análise de Conteúdo. São Paulo: Edições 70; 2011.. Only the researcher and her advisor had access to the audio recordings and transcripts.

The content analysis method was used from the perspective of hermeneutics-dialectics to analyze the interviews, searching for meanings the social stakeholders gave in their actions⁷7 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo: Editora Hucitec; 1992.

8 Minayo MCS, organizadora. Pesquisa social: teoria, método e criatividade. Petrópolis: Vozes; 1994.^-99 Bardin L. Análise de Conteúdo. São Paulo: Edições 70; 2011.. The readings of the transcripts aimed to identify at a deeper level the main sets of meanings attributed to the topic by the professionals. The material was organized in an Excel spreadsheet and then articulated with the concepts for the analysis. This article focused on the results of the core meanings attributed to the differentiated health care guideline.

Results and discussion

We highlight some characteristics of the health professionals interviewed who work at DSEI-ARN. Most were Indigenous, with six participants belonging to the Baré people, three to the Tukano people, and one each to the Piratapuia and Tariano peoples. Four of the fifteen respondents were non-Indigenous.

We identified four core meanings for the differentiated care guideline by analyzing the data, as follows: a) Differentiated health care as a way of providing primary care in the territory; b) Actions conducted under the population’s cultural differences; c) Self-care, traditional medicine, and the construction of therapeutic itineraries; and d) Professionals’ challenges and difficulties in addressing traditional health care.

Differentiated care as a way of providing primary care in the territory

The first meaning given by professionals for differentiated health care was regarding the characteristics of the work process that involves the deployment of teams to the communities and the service provided by active search in the territory, and not only by the spontaneous demand.

This meaning relates to structuring health care based on the territory and programmed actions with active search and the frameworks of primary health care (PHC)¹⁰10 Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO, MS; 2002.. PHC is the basis for structuring Special Indigenous Health Districts, breaking with previous strategies of focusing on the walk-in spontaneous demand of users seeking the service¹¹11 Pontes ALM. Debates e embates entre a Reforma sanitária e Indigenismo na criação do Subsistema de Saúde Indígena e do modelo de distritalização. In: Pontes ALM, Machado FRS, Santos RV, organizadores. Políticas antes da política de saúde indígena. Rio de Janeiro: Editora Fiocruz; 2021.. However, we believe that there is a lack of in-depth understanding among professionals about PHC.

In other reports, professionals point out that differentiated care is linked to the conditions under which work is performed in this primary care modality, as it occurs in collective spaces.

In the statements above, we point out that the professionals highlight the differences in the workspaces since care is provided in the communities and is more precarious per the reports. Professionals have to adapt to their operating context. Thus, the respondents compare the work in the Indigenous territory with the urban context; in this process, according to the statements above, the professionals highlighted the dimensions of organization and service flows, but they emphasized the precariousness and the need for improvisation in the municipality’s rural areas.

Another characteristic of the organization of primary care highlighted as different is the 24-hour service nature, which often involves more complex cases and emergencies:

The fact that they have to perform the activities of other professionals was also attributed as a characteristic of differentiated care. This may be related to several issues that we were unable to delve into, such as improvisation, precariousness, team irregularity, turnover, function diversion, or even a more complementary team approach.

In this differentiated health care meaning core, we include work’s organizational characteristics, precarious conditions, and other aspects of PHC. We also observe the need for professionals to perform different functions to meet the assisted population’s demands.

Actions conducted under the population’s cultural differences

The second differentiated health care meaning core refers to professionals recognizing the sociocultural differences and diversities of the region’s 23 Indigenous peoples, particularly noticeable for those from other regions. Thus, differentiated health care is related to understanding the sociocultural specificities of the population assisted. Some respondents reported that providing differentiated health care means respecting the cultural differences of the population assisted, and the respondents highlighted the diversities per each riverbed.

The professionals recognize the ethnic differences between Rio Negro’s several channels and the need to adapt the service to the ethnic reality. Thus, they indicate that the professional work’s dynamics depend on the characteristics of the assisted population.

Health professionals mentioned the need to have previous knowledge about the people and communities served to provide differentiated health care that respects cultural differences. Professionals affirm that the information provided about the population, whether by management or professionals who already work with this population, contributes to successful activities developed by health professionals.

Professionals also recognize that Indigenous peoples’ relationships with biomedicine vary between groups and regions depending on each community’s history of contact and characteristics. However, conflicts and refusals regarding biomedical care are perceived as “resistance” by health professionals.

Also, some aspects of the differences between gender relationships and social roles in care were highlighted in this meaning core. For example, it is pretty standard for Indigenous women not to feel comfortable with care provided by a male professional.

In their reports, health professionals highlight the relevance of knowing the specificities of the health knowledge and practices of each ethnic group in each region, as this contributes to understanding their behaviors and way of thinking about health.

Given the relevance of this dimension, we present a meaning core below, deepening this dimension.

Self-care, traditional medicine, and the construction of therapeutic itineraries

“Differentiated health care is best understood not as incorporating traditional practices into PHC services, but as promoting the articulation between these services and the self-care practices in the private community”¹³13 Langdon EJ. Uma avaliação crítica da atenção diferenciada e a colaboração entre antropologia e profissionais de saúde. In: Langdon EJ, Garnelo L, organizadoras. Saúde dos povos indígenas: reflexões sobre antropologia participativa. Rio de Janeiro: Livraria/Associação Brasileira de Antropologia; 2004. p. 33-51. (p.42). Thus, Esther Jean Langdon¹³13 Langdon EJ. Uma avaliação crítica da atenção diferenciada e a colaboração entre antropologia e profissionais de saúde. In: Langdon EJ, Garnelo L, organizadoras. Saúde dos povos indígenas: reflexões sobre antropologia participativa. Rio de Janeiro: Livraria/Associação Brasileira de Antropologia; 2004. p. 33-51. articulates the concept of differentiated health care with that of self-care, proposed by Eduardo Menendez¹⁴14 Menéndez E. Modelos de atención de los padecimientos: de exclusiones teóricas y articulaciones prácticas. Cien Saude Colet 2003; 8(1):185-207.. Thus, the health care practiced by the Indigenous population of the Upper Rio Negro can be understood as self-care¹⁴14 Menéndez E. Modelos de atención de los padecimientos: de exclusiones teóricas y articulaciones prácticas. Cien Saude Colet 2003; 8(1):185-207.. This care process involves different behaviors, interactions, negotiations, and conflicts, besides knowledge about the construction of the body, identity, and personality related to the cosmopolitical dimensions that involve the biological and social production of each group¹⁴14 Menéndez E. Modelos de atención de los padecimientos: de exclusiones teóricas y articulaciones prácticas. Cien Saude Colet 2003; 8(1):185-207.. The forms of knowledge about the health of Indigenous peoples are related to cosmologies, coexistence with nature, eating habits, and other reproductive processes of daily routine¹³13 Langdon EJ. Uma avaliação crítica da atenção diferenciada e a colaboração entre antropologia e profissionais de saúde. In: Langdon EJ, Garnelo L, organizadoras. Saúde dos povos indígenas: reflexões sobre antropologia participativa. Rio de Janeiro: Livraria/Associação Brasileira de Antropologia; 2004. p. 33-51.^,1515 Langdon EJ. Os diálogos da antropologia com a saúde: contribuições para as políticas públicas. Cien Saude Colet 2014; 19(4):1019-1029..

In this meaning core on differentiated health care, we will seek to understand how health professionals understand the healthcare practiced by DSEI-ARN Indigenous communities.

Thus, professionals emphasize the autonomy of Indigenous users in choosing the health resources that will be adopted for each problem and the need to negotiate therapeutic projects.

Therefore, the respondents highlighted that differentiated care is related to constructing the therapeutic itinerary, which involves self-care and articulation with traditional indigenous healing systems. In these itineraries, self-care practices are the first care form to be activated in the community, with the community elders as the primary references:

In this meaning core, we observed that a central issue for health professionals is the need to reflect on the legitimacy and effectiveness of Indigenous medicines for treating illnesses and protecting the population. Thus, the respondents highlighted experiences with positive results:

We should underscore that health professionals from the Alto Rio Negro region also highlighted the use of indigenous knowledge for their protection - particularly, precautions related to visits to “sacred places” and to “poison”.

We noticed that the professionals interviewed recognize the importance of Indigenous experts in the communities, especially in the absence of the team, as alluded to in the following responses:

Some respondents highlighted the role of Indigenous experts in constructing the therapeutic itinerary for families, including referring them to the professionals on the teams. However, there is a gap:

In general, we observed the complementarity and negotiation between the different care forms in the territory in the respondents’ statements. Most Indigenous population uses several medical systems simultaneously, both for different problems and for the same health problem, which Eduardo Menendez calls medical pluralism¹⁴14 Menéndez E. Modelos de atención de los padecimientos: de exclusiones teóricas y articulaciones prácticas. Cien Saude Colet 2003; 8(1):185-207..

Therefore, we consider it essential that professionals actively participate in initiatives to strengthen Indigenous medical systems among the population in healthcare:

Finally, respondents highlighted strategies for discussing traditional care with healthcare professionals in this meaning core.

Professionals’ challenges and difficulties in addressing traditional care

In the fourth differentiated care meaning core, we will encompass the conflicts and difficulties reported by the respondents when addressing self-care practices and Indigenous experts in Indigenous territories. We can point out that ethnocentrism is present in the vision of some professionals:

Several authors⁵5 Pontes ALM, Rego S, Garnelo L. O modelo de atenção diferenciada nos Distritos Sanitários Especiais Indígenas: reflexões a partir do Alto Rio Negro/AM. Cien Saude Colet 2015; 20(10):3199-3210.^,1313 Langdon EJ. Uma avaliação crítica da atenção diferenciada e a colaboração entre antropologia e profissionais de saúde. In: Langdon EJ, Garnelo L, organizadoras. Saúde dos povos indígenas: reflexões sobre antropologia participativa. Rio de Janeiro: Livraria/Associação Brasileira de Antropologia; 2004. p. 33-51.^,1515 Langdon EJ. Os diálogos da antropologia com a saúde: contribuições para as políticas públicas. Cien Saude Colet 2014; 19(4):1019-1029.^,1616 Langdon EJ, Diehl EE. Participação e autonomia nos espaços interculturais de saúde indígena: reflexões a partir do sul do Brasil. Saude Soc 2007; 16(2):19-36. warn that national health systems and biomedicine tend to deny, ignore or marginalize other care forms. The hegemonic biomedical model that overemphasizes the biological dimension of the health-disease process is also expressed in the use of technologies in diagnosing and medicalizing various health and life problems in general. In some circumstances, biomedicine scientifically legitimizes other health systems and incorporates them into its repertoire of health services with acupuncture. However, Menendez¹⁴14 Menéndez E. Modelos de atención de los padecimientos: de exclusiones teóricas y articulaciones prácticas. Cien Saude Colet 2003; 8(1):185-207. emphasizes that, despite recognizing other medical systems, only the biological dimensions involving healing procedures are legitimized. In the interviews, we observed that professionals perceive a process of increasing medicalization in communities:

Two decades after the implementation of SASI, respondents reported a lack of debate on differentiated care. Therefore, we point out that professionals must be qualified to work in an intercultural context at the beginning of their work with Indigenous communities.

When referring to differentiated health care, Langdon¹³13 Langdon EJ. Uma avaliação crítica da atenção diferenciada e a colaboração entre antropologia e profissionais de saúde. In: Langdon EJ, Garnelo L, organizadoras. Saúde dos povos indígenas: reflexões sobre antropologia participativa. Rio de Janeiro: Livraria/Associação Brasileira de Antropologia; 2004. p. 33-51. suggests that it means producing care articulated with self-care forms. The author emphasizes that the interaction and complementarity between care forms, biomedics, and traditional medicine occur from the users and do not generate contradictions. However, given the tremendous sociocultural diversity of Indigenous users and the lack of preparation of health services, differentiated care is still a challenge for health professionals.

Final considerations

In SASI’s more than twenty years, we have made little progress in implementing the differentiated health care guideline as a link between the official system and Indigenous medical systems, as recommended in the National Healthcare Policy for Indigenous People (PNASPI). We believe that understanding the meanings attributed by health professionals to this guideline is essential for devising strategies to strengthen it.

We observed that the differentiated care meanings are linked to the characteristics and conditions of primary health care work in Indigenous territories, such as the emphasis on active search, work in collective spaces, and precarious infrastructure. On the other hand, the respondents showed that primary care in Indigenous territories involves emergency care in severe cases and emergencies. The accumulation or diversion of other professionals’ functions to meet the communities’ demands was also reported as a characteristic. However, we observed in the interviews a greater recognition of medical pluralism by health professionals.

Professionals also express another set of meanings about differentiated care related to recognizing the diversity of the population assisted so that their care has to adapt to each place of activity, whether due to linguistic or geographical characteristics or contact methods. The meaning of medical pluralism in Indigenous communities stands out among these aspects, so another differentiated care core meaning is constructing therapeutic itineraries and valuing self-care and articulation with traditional healing systems, particularly those of Indigenous experts. Thus, the work of professionals involves negotiation and complementarity with other care forms.

Although we have identified an essential recognition by health professionals of medical pluralism in Indigenous communities, strategies for training professionals and valuing Indigenous medical systems are necessary, as the hegemonic biomedicine and ethnocentrism are still very present in health training and Brazilian society.

References

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