Abstract

In this interview, Weibe Tapeba, secretary of Indigenous Health at the Ministry of Health in the Lula Government, discusses the process of reorganizing the Secretariat of Indigenous Health (SESAI) and Indigenous protagonism in the new administration. Among the points highlighted by the interviewee are the assessment of the Indigenous health scenario within the current political context of the Ministry of Health, dialogues with Indigenous movement organizations, as well as collaboration with research and educational institutions. The interview highlights the importance of developing strategies aimed at restructuring SESAI and improving Indigenous health public policy in Brazil through extensive coordination, involving planning, management, funding, and Indigenous social participation with Social Control. The secretary emphasizes the need for political cooperation within the federal government to promote the development of a policy of “comprehensive care in Indigenous territories,” arguing that the concept of primary health care needs to be expanded to ensure that the principles of SUS are effectively guaranteed to Indigenous peoples in Brazil.

Key words:
Social movements; Indigenous peoples; Indigenous health services

Ricardo Weibe Nascimento Costa, born on June 8, 1983, belongs to the Tapeba people, who inhabit the Tapeba Indigenous Land, in the state of Ceará, Brazil. A law graduate, his activism in the field of indigenous rights began when he was still young, in the context of Indigenous School Education, working on several fronts in the struggle for differential education, the demarcation of the territory, and indigenous health. He has been a City Councilman in the municipality of Caucaia, Ceará, since 2016. He has extensive experience in the area of ​​Social Control and has worked as a legal advisor for several indigenous organizations. He currently holds the position of Secretary of Indigenous Health at the Ministry of Health.

Tell us about your background, your role in the indigenous movement, and your relationship with the indigenous health sector.

My parents and grandparents have long been indigenous leaders of the Tapeba people, and from a very young age, I began to attend meetings, assemblies, and land occupations and repossession. I grew up within the Indigenous movement. At the age of 14, I took on a strategic role in the community, helping my aunt, Professor Sinhá, one of the pioneers in Indigenous school education in Ceará, who started a differentiated education project in a school that operated under a cashew tree. At the age of 17, I was hired by the first agreement between SEDUC [Ceará Department of Education] and the Association of Tapeba Indigenous Communities of Caucaia. I was a school coordinator and director, and founded the Association of Tapeba Indigenous Teachers and, later, the Organization of Indigenous Teachers of Ceará. I worked for ten years in a Social Control body, the National Commission for Indigenous School Education, linked to the Ministry of Education. I was then appointed in 2006 to serve as rapporteur for the Land and Territory Subcommittee of the National Commission for Indigenous Policy, formerly the National Council for Indigenous Policy. Between 2006 and 2010, I was a regional advisor for the Northeast II Regional Coordination Office of FUNAI [National Foundation for Indigenous Peoples], which includes Piauí, Rio Grande do Norte, and Ceará. In my last year as coordinator, in 2010, I was a substitute regional coordinator, where I gained experience in broader management in that region. Also, in 2010, I was practically “pushed” into law school after being deceived by a FUNAI attorney in Brasília in a case in which our land demarcation had been annulled by a decision of the Supreme Court. I worked for the National Network of Indigenous Lawyers, and advised the Articulation of Indigenous Peoples of Brazil [APIB] and APOINME [Articulation of Indigenous Peoples and Organizations of the Northeast, Minas Gerais, and Espírito Santo]. In the health sector, I worked in the state’s Social Control bodies, in the Local Health Council, and in the District Council. My mother is an indigenous health agent, and my father is part of the historical group that has been fighting for health policy and has worked in this area of ​​Social Control since the time of FUNASA [National Health Foundation]. I consider myself an activist in the indigenous movement who works in several areas.

What was the scenario that led to your nomination and appointment as Secretary of Indigenous Health in the current Lula government?

The then presidential candidate, Luiz Inácio Lula da Silva, was at the Acampamento Terra Livre [ATL] in 2022 and, nominated by APIB and APOINME, I said that the Brazilian Indigenous movement was interested in ensuring his reelection, but that “we wanted to help govern this country.”¹1 Articulação dos Povos Indígenas do Brasil (Apib). Carta aberta do Acampamento Terra Livre ao pré-candidato à presidência da República Luiz Inácio Lula da Silva [Internet]. 2022. [acessado 2024 jun 18]. Disponível em: https://apiboficial.org/2022/04/12/carta-aberta-do -acampamento-terra-livre-ao-pre-candidato-a-presidencia-da-republica-luiz-inacio-lula-da-silva/
https://apiboficial.org/2022/04/12/carta... After the elections, President Lula committed to creating the Ministry of Indigenous Peoples [MPI]. During this period, I left the City Council of Caucaia, Ceará, where I had been a councilor since 2016, to join the government transition working group. At that time, I was part of APIB’s triple list, along with Joênia Wapichana and Sônia Guajajara, to take over the MPI. The indigenous organizations wanted to reach a consensus and help President Lula’s government project. So, as a member of the Workers’ Party (PT), I was the first to back down and initially received an invitation to take over FUNAI or SESAI. It was together with APIB and regional organizations that we agreed on the idea of ​​forming part of the government, and that´s when the Minister of Health Nísia Trindade invited me. I didn´t accept right away, because I needed to return, talk to [governor] Elmano of the PT, my family, the leaders of my people, the movement in Ceará, and reach an agreement with APOINME. Only later did I accept the minister’s invitation, initially raising two points that, for me, were fundamental²2 Brasil. Ministério da Saúde (MS). Ativista e advogado Ricardo Weibe Tapeba é o novo secretário de Saúde Indígena [Internet]. 2023. [acessado 2024 jun 18]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/noticias/2023/janeiro/ativista-e-advogado-ricardo-weibe-tapeba-e-o-novo-secretario-de-saude-indigena
https://www.gov.br/saude/pt-br/assuntos/... . The first was the restructuring of SESAI’s budget. President Bolsonaro had presented a proposal to cut the budget by 59%, which would practically end the Indigenous health policy. Thus, we managed, while still in transition, to secure two budget supplements of more than 500 million reais to guarantee the maintenance of contracts until the end of the year. And the other point, also a personal issue, was that, even at the beginning of 2022, there was a discussion in Brasília indicating that SESAI would be prevented from making investments in non-homologated [Indigenous] areas, which directly violated the rights of Indigenous communities. When I received the invitation, it was to show that it was possible to do things differently and, on the first day of management, I overturned this decision.

What is the significance and how do you assess the impact of having someone from the Indigenous movement as the head of SESAI?

It’s the demarcation of a policy focused on the land of Indigenous territories, aligned with the true interests of users, empowering Indigenous people to lead the Secretariat. We are experiencing a moment of Indigenous protagonism here in our country, which is the first point. The second is that there is a view that only a person linked to the health area could work at SESAI, or in any other secretariat of the Ministry of Health. Now, if in the last government the central level and the 34 Special Indigenous Health Districts (DSEIs) were handed over to the hands of military personnel, with no knowledge or commitment to the Indigenous cause, why is it now that questions are being asked about a person who comes from the territorial lands, whose mother is an Indigenous health agent, and who has experienced and continues to experience the same problems? I have two herniated discs from carrying loads of water for 8 to 9 km. So, I know what it is like to have difficulty in accessing drinking water and I know, on the inside, the problems that people experience in our territories. I can safely say that, of all the departments of the Ministry of Health, SESAI was the most impacted by the military intervention during the Bolsonaro administration. Absolute chaos was created in the area of ​​health care. There are many obstacles in regulation with regard to municipalities and states, which are linked to excessive prejudice. During the previous administration, APIB and its regional organizations were prevented from participating in the meetings of the Forum of Presidents [of the District Councils for Indigenous Health] (FPCondisi), an entity that was equipped with Indigenous representation to legitimize the actions taken. So, we are seeking to move in the opposite direction of the disorganization that occurred previously: strengthening Social Control; giving autonomy to FPCondisi, including APIB and its regional organizations; and guiding the District Councils to ensure more effective participation in the creation of the PDSI [District Plan for Indigenous Health].

Considering your experience on the “territorial grounds”, what was, at first, the main challenge as a manager who dialogues with the indigenous movement from the Ministry of Health?

The first strategy we used was to welcome everyone. It is important to engage in dialogue with the people, the leaders, the tuxaua, the chiefs, and the Indigenous organizations. There was a previous political orientation not to engage in dialogue with the Indigenous movement. So, in the first few months, we welcomed leaders, day and night, because there was a great expectation of immediate changes. We sought shared management with the interests of the Indigenous populations themselves, going to the territories whenever possible to establish commitments.

After a year of management, which began in 2023, what could you say about the progress and challenges?

We conducted a diagnosis that has guided management to think about overcoming long-standing problems. Antivenom is a good example of an input purchased by the Ministry of Health that did not reach SESAI. After an internal debate, these inputs are starting to reach the base centers [territorial subdivision of the DSEI - Special Indigenous Health District] in our territories, teams are being trained, and the entire network is being restructured so that no one dies from venomous snakes attacks. Our units need better structure and our care needs to be more effective. There is a primary care model that needs to be improved, and we intend to discuss this. The second strategy was to recognize that there is a huge deficit in the structure of our health units. We are talking about working conditions for our professionals and care for our users. In only 20% of the more than 700 territories monitored by our health teams is there sanitation and some kind of drinking water solution. There are gaps in care, incomplete teams, and precarious service in several territories. And our budget has not kept up with this demand, which is one of our main challenges. There are management and planning challenges, and budgetary guarantees are essential. In 2023, we proposed an increase in our LOA [Annual Budget Law] and an additional 900 million was approved. I believe that this is still not enough, and that is why we are seeking new sources of financing. In the debate with the Civil House, we were able to include indigenous health in the Growth Acceleration Plan [PAC] for the first time. We also spoke with FIOCRUZ about projects with BNDES [National Bank for Economic and Social Development]. With the Amazon Fund, there is a favorable field, for the first time, for funding projects in the area of ​​infrastructure. The Ministry of Health has a program called Proadi-SUS [Program to Support the Institutional Development of the Unified Health System] that operates on the logic of a kind of tax exemption policy: excellent hospitals finance special projects to strengthen SUS. Throughout the existence of Proadi-SUS, SESAI has never received funding. We are also in a partnership involving Mercosur, focused on the area of ​​sanitation for Indigenous peoples in border regions. Last year, we ran a campaign at SESAI, sending letters to all senators’ and deputies’ offices seeking parliamentary amendments. The work is to get out of the hole of underfunding, organize part of the planning and management, and, in fact, move forward with a new policy. We propose restructuring by creating a General Health Coordination focused on isolated and recently contacted Indigenous peoples and a Coordination for Indigenous People with Disabilities, in addition to strengthening sectors, such as the Center for Indigenous Women’s Health, the Center for Indigenous Medicine, and the Center for Mental Health. We are reorganizing our structure with proposals to strengthen the management of the many Districts.

What are the possible lessons from the Yanomami Emergency for Indigenous Health?

First, I must say that 2023, our first year at the helm of SESAI, could have been a better year from the point of view of planning and improving management in indigenous health. This is because we had to deal with the first health emergency of national interest due to lack of health care in the entire history of the Republic. Many patient removals carried out in the Yanomami territory could have been avoided and hundreds of lives saved if the Subsystem had been better structured, with a policy that focused on what we call “comprehensive care”. We knew that Indigenous health, as a Subsystem, had many limitations in its relationship with the states and municipalities. What kind of primary care is this if there can’t be a specialist in the territory? What kind of primary care is this if so many patient removals are carried out by air transport? The Yanomami Emergency highlighted the more than urgent need to improve the policy. It has simple dimensions, such as RENAME (National List of [Essential] Medicines) focusing on serving the Indigenous population within the territory. This is in line with the principles of universality, comprehensiveness, and equity of SUS. Although there is a great deal of effort to provide healthcare to indigenous peoples, these principles are not applied in the sense of “comprehensive care”. We are currently contracting a specialized cargo service to give our teams autonomy and improve working conditions in order to implement and build new healthcare units to address the challenge of logistics. So, one of the lessons learned is that, in that type of territory, it is not possible to apply the same primary care that is more common in Indigenous healthcare. In addition to the impacts on health directly caused by mining, such as mercury contamination, malaria, and malnutrition, our teams were not allowed to enter certain communities dominated by armed miners. There is a need to remove intruders from the territory as quickly as possible, but there is also an urgent need to improve logistics, infrastructure, and expand the team of professionals, as well as the profile of professionals we need. There are structural problems that the Yanomami Emergency has helped to reveal. And many territories are being penalized by this same Indigenous health model.

How do you perceive SESAI’s dialogue with other structures of the Ministry of Health? Is Indigenous Health a priority within the government?

From a management perspective, SESAI did not engage before in dialogue with other departments of the Ministry of Health, or with other ministries in general. Indigenous health is very complex and requires partnerships, cooperation, and several agencies. So, we proposed breaking this isolation by repositioning indigenous health within the strategic institutional plan of the Ministry of Health and President Lula’s government. And this ended up changing because of the Yanomami Emergency. The Civil House established a National Coordination Committee and recently implemented a Government House in Roraima. But we insisted on repositioning Indigenous health policy as a cross-cutting theme for which other departments are jointly responsible. The Emergency is in force, but many departments do not understand that they are also responsible for the Indigenous health policy. We sought to strengthen this idea of ​​cooperation, attracting government agencies and taking this responsibility beyond the Ministry of Health. In the Yanomami Territory, if it were not for the Ministry of Mines and Energy, we would not have been able to bring photovoltaic kits to provide energy to health units. We are currently in discussions with the Ministry of Communications about connectivity in Indigenous territories. How can a health professional be placed in a territory, in a health unit, that does not have connectivity, electricity, or drinking water? In the area of ​​technology and focused on this “comprehensive care” strategy, we are intensifying and expanding the digital health strategy. The Indigenous Health Care Information System (SIASI) is a very fragile system that needs improvement. We are proposing, together with the Secretariat of Information and Digital Health (SEIDIGI) and DATASUS, as well as SAPS [Secretariat of Primary Health Care], to include indigenous health in the new e-SUS APS. We are going to develop an entry channel for Indigenous health that is fully operable with other systems so as to allow access to health information for the Indigenous population in all municipalities. The idea is to work with a system that also works offline. And that is more transparent and accessible for any researcher who is interested in seeking information on indigenous health. And the other issue is the SISREG [Ministry of Health’s Regulatory System] in which indigenous health has no direct impact. There is a lot to be done, and I can say that the internal information system is a priority.

In your opinion, what are the priority research agendas, considering the presence of indigenous researchers, involving the Indigenous Health Subsystem?

There are topics for which indigenous communities themselves create a protective filter to prevent traditional knowledge from being captured. Special attention is needed, especially regarding Indigenous medicine, which deal with many forms of spirituality and rituals. Ultimately, this is a very sensitive topic for the communities themselves. I believe that academia has been attracted to the agenda of Indigenous health, as well as education, in recent years. We also want to resolve the difficulties in the relationship between academia, SESAI, and direct assistance, such as internships. Our Districts are currently not authorized to enter into agreements with universities. I have already made a proposal to regulate the role of the District coordinator to enable interns to work at the base centers. Now, in the area of ​​research in general, I believe that we have had important partnerships. ABRASCO [Brazilian Association of Public Health] itself is an entity that, in addition to working with SESAI as an institution, brings together groups of researchers who have a long history and activism in this area and who have presented good products that can help in the new direction of the policy. Fiocruz has supported SESAI in conducting the preparation and approval of the WHO resolution. They are also collaborators of the indigenous movement. I believe that, in this phase of improving the policy, in addition to the regional seminars for consulting the Indigenous population, we also need the support of researchers.

You have been talking about the review of the PNASPI [National Policy for Health Care for Indigenous Peoples]. Could you talk more about this process?

I have talked a lot about improving the Indigenous health policy³3 Articulação dos Povos Indígenas do Brasil (Apib). Retrospectiva 2023: direitos indígenas não se negociam [Internet]. 2023. [acessado 2024 jun 18]. Disponível em: https://apiboficial.org/2023/12/27/retrospectiva-2023-direitos-indigenas-nao-se-negociam/
https://apiboficial.org/2023/12/27/retro... ^,44 Passos J. Em 2024, vamos aperfeiçoar a Política Nacional de Atenção à Saúde dos Povos Indígenas. Entrevista com o secretário da Secretaria de Saúde Indígena do Ministério da Saúde (Sesai/MS) Weibe Tapeba [Internet]. 2024. [acessado 2024 jun 18]. Disponível em: https://www.epsjv.fiocruz.br/noticias/entrevista/em-2024-vamos-aperfeicoar-a-politica-nacional-de-atencao-a-saude-dos-povos
https://www.epsjv.fiocruz.br/noticias/en... . We do not want to revise it, because we do not want to do it again. There are positive aspects of the PNASPI, such as Social Control and the relationship with Indigenous medicines. Although the PNASPI text clearly emphasizes the importance of traditional medicines and knowledge, in practice it is very difficult to guarantee this. Last year, in Geneva, an important resolution was approved at the 76th World Health Assembly. After 75 years since the founding of the WHO [World Health Organization], it was the first time that [this body] adopted a Resolution placing Indigenous health as a priority issue in the global health plan. This resolution points to the need to improve the policy. In the context of ADPF [Action for Non-Compliance with a Fundamental Precept] 709, which is being processed at the Brazilian Federal Supreme Court (STF), Minister [Luís Roberto] Barroso points to the need to improve the policy. We have documents, such as the CMAP [Public Policy Monitoring and Evaluation Council] Report, a statement from the Inter-American Court of Human Rights, and analyses by the [Federal] Comptroller’s Office, that point to the same need. Our work is geared toward improving the policy toward “comprehensive care.” We need to review all the normative acts of Indigenous health, and of other departments, that have been drafted and implemented to date. We want to conceptually develop what basic care is in Indigenous territories. And, especially considering medium complexity, we want to guarantee specialized Health care within the territory. We want to discuss a new strategy for managing what we are calling “comprehensive health care in Indigenous territories” beyond this current primary care model. We want to transform or bring into the policy the concept of health equipment that goes beyond the idea of ​​a basic Indigenous health unit. Why can’t a Indigenous prayer house or a birthing center be recognized as a type of health equipment and receive some type of funding from the Indigenous health policy? What is the role of the Indigenous midwife in health teams? Obviously, we will consult the Indigenous population, their representative bodies, the entities that already work in this area, and, in fact, we will hold regional seminars to discuss the improvement of the new policy.

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