Abstract

This paper analyzes the health care accessibility conditions afforded to Bolivian immigrants in the Brazilian health system and their perception of the right to health. This was a cross-sectional, quantitative and qualitative study carried out from 2013 to 2015. Data were collected by a questionnaire with closed questions answered by 633 Bolivian individuals; questions regarding access to health were answered by 472 immigrants over 18 years old. Semi-structured interviews conducted with 55 subjects (Bolivians, health professionals, representatives of Health Departments, Consulate of Bolivia, Public Defender’s Office, Federal Public Prosecutor’s Office and Non-Governmental Organizations) underwent content analysis. Most Bolivian immigrants know the Brazilian National Health System (SUS) and often use Primary Health Care; however, they described structural and systemic barriers to health accessibility, such as lack of documentation, working conditions, medium and high complexity procedures, language barriers, among others. The National Health Card (CNS) is an important gateway to access health care, playing a role of social integration. Interviewees recognize health as a social right, pointing it out as a human and solidary value. Ensuring this recognition, when not based on the consolidation of social policies aimed at strengthening universal social protection, is threatened.

Keywords:
Bolivian migration; Right to health; Access to health

Introduction

The inter-country population movements have generated constant challenges for the territories that receive these populations, regardless of the economic, political, cultural or environmental issues that motivated them. In the Americas, immigration has been associated with economic aspects, notably the precarious living conditions of population groups that move in search of better social insertion and well-being (Goldberg; Martin; Silveira, 2015GOLDBERG, A.; MARTIN, D.; SILVEIRA, C. Towards a specific field of studies on migratory and health processes within public health. Interface, Botucatu, v. 19, n. 53, p. 229-232, 2015.).

Bolivian immigration to Brazil began notably in the 1950s with the arrival of students stimulated for scientific-cultural exchange (Silva, S., 2012SILVA, S. A. Bolivianos em São Paulo: dinâmica cultural e processos identitários. In: BAENINGER, R. (Ed.). Imigração boliviana no Brasil. Campinas: Núcleo de Estudos de População - Nepo, Unicamp, 2012. p. 19-34.). The characteristics of this flow have changed dramatically in profile since the 1980s, when young people who were single and had mid-level education, in search of better wages, as well as family groups, in increasing numbers, have been precariously incorporated into the textile production process, within the informal labor market, in situations of social vulnerability, determining health risks (Silva, S., 2012SILVA, S. A. Bolivianos em São Paulo: dinâmica cultural e processos identitários. In: BAENINGER, R. (Ed.). Imigração boliviana no Brasil. Campinas: Núcleo de Estudos de População - Nepo, Unicamp, 2012. p. 19-34.; Melo; Campinas, 2010MELO, R.; CAMPINAS, L. S. L. Multiculturalidade e morbidade referida por imigrantes bolivianos na Estratégia Saúde da Família. O Mundo da Saúde, São Paulo, v. 34, n. 1, p. 25-35, 2010. DOI: 10.15343/0104-7809.201012535
https://doi.org/10.15343/0104-7809.20101... ).

The state of São Paulo, due to its prominence in Latin American socioeconomic development, has a strong attraction for Bolivian migration. It is estimated that 350 thousand Bolivians live in the Metropolitan Region of São Paulo, about 70% of the contingent present in Brazil, with concentration in the city of São Paulo, the state capital (Silva, S., 2006SILVA, S. A. Bolivianos em São Paulo: entre o sonho e a realidade. Estudos Avançados, São Paulo, v. 20, n. 57, p. 157-170, 2006. DOI: 10.1590/S0103-40142006000200012
https://doi.org/10.1590/S0103-4014200600... ).

Implications on the epidemiological profile, particularly in relation to communicable diseases, emerge in this context. A study in Bolivian immigrants in the city of São Paulo observed a prevalence of infection by Trypanosoma cruzi of 4.4%, being 6.1% in women of reproductive age, both higher than that found in the Brazilian population (Luna ., 2017LUNA, E. J. A. et al. Prevalence of Trypanosoma cruzi infection among bolivian immigrants in the city of São Paulo, Brazil. Memórias do Instituto Oswaldo Cruz, Rio de Janeiro, v. 112, n. 1, p. 70-74, 2017.).

On the other hand, the lack of knowledge on the part of health professionals about epidemiological profiles in this population limits assistance and, thus, contributes to their vulnerability in health care (Carneiro Junior ., 2018CARNEIRO JUNIOR, N. et al. Migração boliviana e doença de Chagas: limites na atuação do Sistema Único de Saúde brasileiro (SUS). Interface, Botucatu, v. 22, n. 64, p. 87-96, 2018. DOI: 10.1590/1807-57622016.0338
https://doi.org/10.1590/1807-57622016.03... ).

Studies that analyze macro- and micro-structural dimensions involved in contemporary international migration contribute to the qualification of social protection systems, with particular power to those who understand these issues from the subjects involved. In this perspective, this article brings an empirical research with results of high relevance for understanding the current situation of the vulnerability of Bolivian immigrants in accessing the Brazilian health system. The results point to evidence about the perceptions of the immigrants themselves and of representatives of public agencies and civil society in relation to the right to health.

Methods

This was a cross-sectional study with quantitative and qualitative approaches, conducted from 2013 to 2015. A sample of 633 Bolivian individuals was previously sized to meet the objectives of a larger study (Luna ., 2017LUNA, E. J. A. et al. Prevalence of Trypanosoma cruzi infection among bolivian immigrants in the city of São Paulo, Brazil. Memórias do Instituto Oswaldo Cruz, Rio de Janeiro, v. 112, n. 1, p. 70-74, 2017.), with 111 children under 10 years of age selected from the enrollment register of a primary health care service, located in the central region of the city of São Paulo, a reference in the medical and health care of this population (Silva, R. ., 2020SILVA, R. A. et al. Awareness of Chagas disease and socioeconomic characteristics of Bolivian immigrants living in Sao Paulo, Brazil. Revista do Instituto de Medicina Tropical de São Paulo, São Paulo, v. 62, 2020. DOI: 10.1590/S1678-9946202062039
https://doi.org/10.1590/S1678-9946202062... ). Those selected or their guardians signed the Informed Consent Form (ICF), translated into Spanish, and answered a structured questionnaire applied in Spanish by an interviewer, addressing: date of birth, place (rural or urban), marital status, education, occupation and family salary; migration and length of stay in the city of São Paulo; access to health care, including language comprehension by the immigrant and health worker. Sociodemographic characteristics, such as gender, age group, length of residence in the city of São Paulo and family income, had their simple frequencies previously described (Luna ., 2017LUNA, E. J. A. et al. Prevalence of Trypanosoma cruzi infection among bolivian immigrants in the city of São Paulo, Brazil. Memórias do Instituto Oswaldo Cruz, Rio de Janeiro, v. 112, n. 1, p. 70-74, 2017.; Silva, R. ., 2020SILVA, R. A. et al. Awareness of Chagas disease and socioeconomic characteristics of Bolivian immigrants living in Sao Paulo, Brazil. Revista do Instituto de Medicina Tropical de São Paulo, São Paulo, v. 62, 2020. DOI: 10.1590/S1678-9946202062039
https://doi.org/10.1590/S1678-9946202062... ), being analyzed here together with other variables. To describe the access to health care of this population according to aspects such as occupation, family income and language comprehension, 472 individuals over 18 years of age were included. However, to describe access to health according to the place of care and other variables applicable to people of any age group, all 633 subjects in the sample were used.

The qualitative approach results from semi-structured, individual, recorded and later transcribed interviews, addressing questions about migratory aspects, health care and social rights. A total of 55 subjects participated, among them 27 Bolivian adults, 20 women and 7 men (randomly selected from 472 Bolivians and interviewed in Spanish); 19 health professionals - physicians, social workers, pharmacists, nurses and administrators. These professionals were invited from the indications of the managers of the respective health services, having as criteria those who addressed issues on care for Bolivian immigrants in the meetings of the unit issues on care for Bolivian immigrants; nine representatives of the following institutions with actions and/or care related to Bolivians: Consulate of Bolivia in São Paulo, state secretariat (SES) and the Municipal Health Secretariat of São Paulo (SMS), two primary care clinics located in the central region of the city of São Paulo, Pastoral do Migrante de São Paulo (Catholic church migrants’ pastoral), Association of Bolivian residents, the Public Defender of the Union and the Federal Public Ministry. All have signed the ICF; in the case of Bolivians, Spanish language version. The analytical treatment of this material was carried out through content analysis.

This study is part of the research “Chagas disease in a population of Bolivian migrants in the city of São Paulo: an analysis of the prevalence of Trypanosoma cruzi infection and morbidity of Chagas disease; the population’s knowledge about the disease and access to different levels of health care”, approved by the Research Ethics Committee of the Hospital das Clínicas of the Faculty of Medicine of the University of São Paulo.

Results

Migration process, living and working conditions

In the migration circuit, only one Bolivian interviewee out of 472 over 18 years of age reported having passed through Argentina before arriving in Brazil. The rest came directly from Bolivia to the city of São Paulo.

In relation to the migratory flow, the interviewees point out economic, political, family and human trafficking aspects:

We can observe that having a secondary or higher level of schooling does not interfere with the family salary range, mostly up to two minimum wages. Another characteristic is that most of them work in sewing workshops (90.9%), regardless of schooling level (89.7% among those with primary education, 91.6% among those with secondary education and 81.0% among those with higher education). At the same time, this occupation is predominant in all monthly family income groups, 74.5%, when the family income is less than 1 minimum wage; 94.9%, with income between 1 and 2 minimum wages; 90.4%, between 2 and 3 minimum wages and 75% with family income greater than 3 minimum wages (Table 1).

Access to health care

Regarding access to health services, of the total of 633 immigrants interviewed, 96.5% use the public health system. As can be seen in the Table 2, 37.9% of women aged 20 to 39 years reported frequent visits to health services, while among men of the same age group it was 20.0%. Among children aged 1 to 9 years, this rate rose to 77.1%.

Regarding the use of hospital services, 38.9% used and 61.1% sought a primary care clinic (UBS). It should be noted that in hospital care women in the age group of 20 to 45 years represent the majority (Table 3).

Among the 633 Bolivians interviewed, 1.7% had access to private health plans or insurance, being mostly women aged 20 to 29 years, with a medium schooling level, working in sewing, with a family income of less than 1 minimum wage and living in São Paulo for up to 2 years. The Unified Health System (SUS) was the most likely destination for 96.5% when they had health problems. It is noteworthy that 86.4% reported knowledge about their constitutional principle of universality.

From health professionals to representatives of government institutions and civil society, many emphasize the importance of primary care services as a “gateway” to the health care network and the recognition of the public health system, identifying some access strategies, such as the presence of Bolivian community health agents:

Difficulties in access

The lack of regular documentation in Brazil and working conditions are issues that affect health care:

Another limitation of access is the omission of the place of residence by immigrants:

Communication is also also considered among the difficulties.

The language barrier represents an important limit in the use of health services by Bolivian immigrants (Table 4). Of the 472 Bolivians over the age of 18, 41.5% said that health professionals understood them well. However, 42.6% of respondents stated that they could not adequately understand the guidance of professionals (Table 4).

Finally, 282 individuals (59.7%) reported needing help due to difficulty in understanding the guidelines during care. Of these, 92.1% (312/339) reported not being understood by health professionals.

Barriers to communication were identified in the interviews:

Right to health

The perception of the right to health is expressed in the statements of Bolivians:

The absence of a visa to stay in Brazil is not an impediment for immigrants to have access to the public health system, according to institutional representatives:

The issue of documentation is central to the perception and guarantee of the right. In this sense, all interviewees emphasize the National Health Card (CNS) as the first document that many of these immigrants obtained in the country, seen as a condition of social insertion:

Discussion

The results expose a precarious social insertion of Latin American immigrants in Brazilian society, in the case of Bolivians in the city of São Paulo, evidenced by the working conditions to which most of them are subjected in the “sewing workshops” - part of the textile production chain -, driven by unregulated migration (Freitas, 2011FREITAS, P. T. Imigração boliviana para São Paulo e setor de confecção - em busca de um paradigma analítico alternativo. Informe Gepec, Curitiba, v. 15, p. 222-240, 2011. DOI: 10.48075/igepec.v15i3.6280
https://doi.org/10.48075/igepec.v15i3.62... ; Silva, S., 2006SILVA, S. A. Bolivianos em São Paulo: entre o sonho e a realidade. Estudos Avançados, São Paulo, v. 20, n. 57, p. 157-170, 2006. DOI: 10.1590/S0103-40142006000200012
https://doi.org/10.1590/S0103-4014200600... ).

This work situation is strongly denounced by the interviewed health professionals, who relate it to vulnerabilities in health status and to the limits on access to services, noted in studies that show determinants of health inequities in the processes of social exclusion of this population determinants of inequities in health (Silveira ., 2013SILVEIRA, C. et al. Living conditions and access to health services by Bolivian immigrants in the city of São Paulo, Brazil. Cadernos de Saúde Pública, Rio de Janeiro, v. 29, n. 10, p. 2017-2027, 2013. DOI: 10.1590/0102-311X00113212
https://doi.org/10.1590/0102-311X0011321... ).

The presented schooling and income indicators demonstrate a segment of socially disadvantaged social classes, expressing well the profile of social inequality of contemporary migratory flows (Cucunuba ., 2017CUCUNUBA, Z. M. et al. How universal is coverage and access to diagnosis and treatment for Chagas disease in Colombia? A health systems analysis. Social Science & Medicine, Bethesda, v. 175, p. 187-198, 2017. DOI: 10.1016/j.socscimed.2017.01.002
https://doi.org/10.1016/j.socscimed.2017... ; Forsyth ., 2018FORSYTH, C. J. et al. “It’s like a phantom disease”: patient perspectives on access to treatment for Chagas disease in the United States. American Journal of Tropical Medicine and Hygiene, Bethesda, v. 98, n. 3, p. 735-741, 2018.; Manne-Goehler; Reich; Wirtz, 2015MANNE-GOEHLER, J.; REICH, M. R.; WIRTZ, V. J. Access to care for Chagas disease in the United States: a health systems analysis. American Journal of Tropical Medicine and Hygiene, Bethesda, v. 93, n. 1, p. 108-113, 2015. DOI: 10.4269/ajtmh.14-0826
https://doi.org/10.4269/ajtmh.14-0826... ; Martini, 2005MARTINI, G. A globalização inacabada: migrações internacionais e pobreza no século 21. São Paulo em Perspectiva, São Paulo, v. 19, n. 3, p. 3-22, 2005. DOI: 10.1590/S0102-88392005000300001
https://doi.org/10.1590/S0102-8839200500... ). It is also noteworthy that Bolivian immigrants correspond to 1/3 of the total number of immigrants admitted to hospitals in the municipality of São Paulo and that, 75% of Bolivians correspond to pregnancy, childbirth and postpartum (Aguiar; Neves; Lira, 2015AGUIAR, B. S.; NEVES, H.; LIRA, M. T. A. M. Alguns aspectos da saúde de imigrantes e refugiados recentes no município de São Paulo. Boletim CEInfo Análise, São Paulo, n. 13, p. 49, 2015.).

The lack of opportunity for professional practice in the period of arrival in the country from 2008 onwards, with 75.5% receiving up to 2 or 3 minimum wages, as well as the predominance of work in sewing workshops have been previously pointed out (Silva, R. ., 2020SILVA, R. A. et al. Awareness of Chagas disease and socioeconomic characteristics of Bolivian immigrants living in Sao Paulo, Brazil. Revista do Instituto de Medicina Tropical de São Paulo, São Paulo, v. 62, 2020. DOI: 10.1590/S1678-9946202062039
https://doi.org/10.1590/S1678-9946202062... ). Therefore, they are individuals without social or economica resources requiring support of intersectoral prolicies and programs.

A question worthy of better understanding refers to the uniqueness of the Bolivian migratory circuit in São Paulo. This refers to the length of residence in São Paulo, which shows a period of less than five years among most young immigrants (81.9% in those aged 20 to 29 years and 69.1% in those aged 20 to 39 years). Freitas (2011FREITAS, P. T. Imigração boliviana para São Paulo e setor de confecção - em busca de um paradigma analítico alternativo. Informe Gepec, Curitiba, v. 15, p. 222-240, 2011. DOI: 10.48075/igepec.v15i3.6280
https://doi.org/10.48075/igepec.v15i3.62... ) calls attention to this particularity, calling it “circulatory territory”, characterized by constant movement of comings and goings Bolivia/Brazil, associated with the seasonality of textile production. This aspect appears in the statements of health professionals as obstacles in the control of diseases. Shikanai-Yasuda . (2017SHIKANAI-YASUDA, M. A. et al. Interdisciplinary approach at the primary healthcare level for Bolivian immigrants with Chagas disease in the city of São Paulo. PLOS Neglected Tropical Diseases, San Francisco, v. 11, n. 3, 2017. DOI: 10.1371/journal.pntd.0005466
https://doi.org/10.1371/journal.pntd.000... ) analyzed the implications of such periodic returns of this population to Bolivia in the lack of adherence to treatment and medical follow-up for Chagas disease.

In addition to these, other dimensions related to the characteristics of the population group in focus are implied and constitute challenges for health care, that is, when we have 59.2% origin from rural areas (Silva, R. ., 2020SILVA, R. A. et al. Awareness of Chagas disease and socioeconomic characteristics of Bolivian immigrants living in Sao Paulo, Brazil. Revista do Instituto de Medicina Tropical de São Paulo, São Paulo, v. 62, 2020. DOI: 10.1590/S1678-9946202062039
https://doi.org/10.1590/S1678-9946202062... ), influencing the perception of the health-disease care process (Martes; Faleiros, 2013MARTES, A. C. B.; FALEIROS, S. M. Acesso dos imigrantes bolivianos aos serviços públicos de saúde na cidade de São Paulo. Saúde e Sociedade, São Paulo, v. 22, n. 2, p. 351-364, 2013. DOI: 10.1590/S0104-12902013000200008
https://doi.org/10.1590/S0104-1290201300... ).

In the results, we highlight the communication as an obstacle towards care and health services. The non-mastery of the Portuguese language by Bolivians, as well as of Spanish by professionals, hinders care, a limiting factor in the performance of Public Health Services, demanding, therefore, training of public agents (Aith; Forsyth; Shikanai-Yasuda, 2020AITH, F. M. A.; FORSYTH, C.; SHIKANAI-YASUDA, M. A. Chagas disease and healthcare rights in the Bolivian immigrant community of São Paulo, Brazil. Tropical Medicine and Infectious. Disease, Bethesda, v. 5, n. 2, p. 62-73, 2020. DOI: 10.3390/tropicalmed5020062;5,62
https://doi.org/10.3390/tropicalmed50200... ; Aguiar; Neves; Lira, 2015AGUIAR, B. S.; NEVES, H.; LIRA, M. T. A. M. Alguns aspectos da saúde de imigrantes e refugiados recentes no município de São Paulo. Boletim CEInfo Análise, São Paulo, n. 13, p. 49, 2015.; Martes; Faleiros, 2013MARTES, A. C. B.; FALEIROS, S. M. Acesso dos imigrantes bolivianos aos serviços públicos de saúde na cidade de São Paulo. Saúde e Sociedade, São Paulo, v. 22, n. 2, p. 351-364, 2013. DOI: 10.1590/S0104-12902013000200008
https://doi.org/10.1590/S0104-1290201300... ). In this scenario, other aspects are also added, such as the lack of knowledge of health problems of the Bolivian population, for example Chagas disease (which is endemic in Bolivia), not only by health professionals in Brazil, but also in countries such as the United States (Carneiro Junior ., 2018CARNEIRO JUNIOR, N. et al. Políticas públicas no contexto dos processos migratórios no Brasil: a experiência da construção da política municipal de saúde para imigrantes e refugiados na cidade de São Paulo (2015-2016). In: GOLDBERG, A.; SILVEIRA, C.; COSTELLO, D. M. (Org.). Migração, refúgio e saúde. Santos: Editora Universitária Leopoldianum, 2018. p. 251-260.; Manner-Goehler; Reich; Wirz, 2015MANNE-GOEHLER, J.; REICH, M. R.; WIRTZ, V. J. Access to care for Chagas disease in the United States: a health systems analysis. American Journal of Tropical Medicine and Hygiene, Bethesda, v. 93, n. 1, p. 108-113, 2015. DOI: 10.4269/ajtmh.14-0826
https://doi.org/10.4269/ajtmh.14-0826... ; Manne ., 2013MANNE, J. M. et al. Barriers to treatment access for Chagas disease in Mexico. PLOS Neglected Tropical Diseases, San Francisco, v. 7, 2013. DOI: 10.1371/journal.pntd.0002488
https://doi.org/10.1371/journal.pntd.000... ).

The described information contributes to the debate on the potential and limits of the SUS when it is observed that public health services are expressly referenced by this population. About 40% of Bolivian immigrants reported frequent visits to such services, with the UBS being the most used service (61.2%), mainly by children and women. The reports of health professionals and immigrants themselves ratify these results, mentioning welcoming attitudes in care. Thus, the service fulfills one of its main attributes in the organization of the health system: being preferential access in Brazil (Brasil, 2017BRASIL. Ministério da Saúde. Gabinete do Ministro. Portaria n. 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Brasília, DF, 2017. Disponível em: <Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html >. Acesso em: 27 set. 2019.
http://bvsms.saude.gov.br/bvs/saudelegis... ) and in other countries (Stafield; Shi, 2015STARFIELD, B.; SHI, L. Policy relevant determinants of health: an international perspective. Health Policy, Bethesda, v. 60, n. 3, p. 201-2018, 2002. DOI: 10.1016/s0168-8510(01)00208-1
https://doi.org/10.1016/s0168-8510(01)00... ).

Noteworthy, in this context, are technical-managerial arrangement initiatives that promote the guarantee of Bolivian immigrants’ access to health actions; that is, flexibility of schedules, insertion of health professionals of Bolivian origin, acceptance of spontaneous demands, communication strategies, among others (Steffens; Martins, 2016STEFFENS, I.; MARTINS, J. “Falta um Jorge”: a saúde na política municipal para imigrantes em São Paulo (SP). Lua Nova, v. 98, p. 275-299, 2016. DOI: 10.1590/0102-6445275-299/98
https://doi.org/10.1590/0102-6445275-299... ; Martes; Faleiros, 2013MARTES, A. C. B.; FALEIROS, S. M. Acesso dos imigrantes bolivianos aos serviços públicos de saúde na cidade de São Paulo. Saúde e Sociedade, São Paulo, v. 22, n. 2, p. 351-364, 2013. DOI: 10.1590/S0104-12902013000200008
https://doi.org/10.1590/S0104-1290201300... ; Silva, E., 2009SILVA, E. C. C. Rompendo barreiras: os bolivianos e o acesso aos serviços de saúde na cidade de São Paulo. Travessia: Revista do Migrante, São Paulo, v. 63, p. 26-31, 2009. DOI: 10.48213/travessia.i63.268
https://doi.org/10.48213/travessia.i63.2... ). This organization of work processes oriented to the specificities of a certain population group points to the principle of equity in health (Campos, 2006CAMPOS, G. W. S. Reflexões temáticas sobre equidade e saúde: o caso do SUS. Saúde e Sociedade, São Paulo, v. 15, n. 2, p. 23-33, 2006.).

On the other hand, these potentialities observed in the SUS are stressed by internal and external conditions of the health sector, as well as by the particularities involved in Bolivian migration, which impose limits and compromise the guarantee of the right to health.

In recent years, the Brazilian state has been adopting non-redistributive social policies, which greatly affect the financing of the SUS, and making changes in its management, thus causing weaknesses in the integrality of health care (Mendes; Carnut, 2018MENDES, A.; CARNUT, L. Capitalismo contemporâneo em crise e sua forma política: o subfinanciamento e o gerencialismo na saúde pública brasileira. Saúde e Sociedade, São Paulo, v. 27, n. 4, p. 1105-1119, 2018. DOI: 10.1590/S0104-12902018180365
https://doi.org/10.1590/S0104-1290201818... ).

The discussion on contemporary migratory flows in countries with universal social policies is necessary, enabling qualification and strengthening of them, in a scenario of increasing restrictive conceptions of immigrants’ access to social services (Fortes; Carvalho; Louvison, 2015FORTES, P. A. C; CARVALHO, R. R. P.; LOUVISON, M. C. P. Crise econômica e contrarreforma dos sistemas universais de saúde: o caso espanhol. Revista de Saúde Pública, São Paulo, v. 49, p. 34-36, 2015. DOI: 10.1590/S0034-8910.2015049005469
https://doi.org/10.1590/S0034-8910.20150... ).

In this context, it should be highlighted important local initiatives for the formulation and implementation of policies and programs in public administration, particularly in the municipality of São Paulo, aimed at the social inclusion of immigrant populations, such as the creation in 2013 of the Coordination of Policies for Immigrants and Promotion of Decent Work/Municipal Secretariat for Human Rights and Citizenship to promote intersectoral actions, the Municipal Law no. 16,478/2016 that instituted the Municipal Policy for the Immigrant Population, the Municipal Health Policy for Immigrants and Refugees in 2015, among others (Carneiro Junior ., 2018CARNEIRO JUNIOR, N. et al. Políticas públicas no contexto dos processos migratórios no Brasil: a experiência da construção da política municipal de saúde para imigrantes e refugiados na cidade de São Paulo (2015-2016). In: GOLDBERG, A.; SILVEIRA, C.; COSTELLO, D. M. (Org.). Migração, refúgio e saúde. Santos: Editora Universitária Leopoldianum, 2018. p. 251-260.; Otero; Lotta, 2020OTERO, G. A. P.; LOTTA, G. S. International migration and federative co-ordination in Brazil: São Paulo and Porto Alegre case studies between 2013 and 2016. Contexto Internacional, Rio de Janeiro, v. 42, n. 2, p. 277-301, 2020. DOI: 10.1590/S0102-8529.2019420200004
https://doi.org/10.1590/S0102-8529.20194... ).

As part of the approved Municipal Policy, the City Hall of the municipality of São Paulo, implementing the law, organized in 2019 the 2nd Municipal Conference of policies for immigrants, of São Paulo, with expressive participation of immigrant groups. As a result of the conference, the 1st Municipal Policy Plan for Immigrants 2021-2024 was prepared, which was an instrument for planning, implementing, monitoring and evaluating municipal policies for the population of other nationalities living in the city (São Paulo, 2020SÃO PAULO. Secretaria Municipal de Direitos Humanos e Cidadania. Coordenadoria de Políticas para Imigrantes e Promoção do Trabalho Decente. 1º Plano municipal de políticas para imigrantes 2021-2024. São Paulo, 2020.).

Although the 1988 Constitution expressly recognizes health as a fundamental right in Brazil, including for immigrants, and even with the efforts of municipal bodies to welcome them in the city of São Paulo, the vulnerability of immigrants in Brazil is still present, either due to their lack of knowledge of their rights, or due to possible irregularities in the documents necessary to stay in the country, with consequences including in health care by the SUS (Aith; Forsyth; Shikanai-Yasuda, 2020AITH, F. M. A.; FORSYTH, C.; SHIKANAI-YASUDA, M. A. Chagas disease and healthcare rights in the Bolivian immigrant community of São Paulo, Brazil. Tropical Medicine and Infectious. Disease, Bethesda, v. 5, n. 2, p. 62-73, 2020. DOI: 10.3390/tropicalmed5020062;5,62
https://doi.org/10.3390/tropicalmed50200... ; Baeninger; Demetrius; Domeniconi, 2019BAENINGER, R.; DEMÉTRIO, N. B.; DOMENICONI, J. Imigração internacional na macrometrópole paulista: novas e velhas questões. Cadernos Metrópole, São Paulo, v. 22, n. 47, p. 17-40, 2019. DOI: 10.1590/2236-9996.2020-4701
https://doi.org/10.1590/2236-9996.2020-4... ).

Still, it is noteworthy that for immigrants the SUS represents a possibility of social insertion, a policy of guaranteeing social rights, expressly in opposition to the reality in their country (Martes; Faleiros, 2013MARTES, A. C. B.; FALEIROS, S. M. Acesso dos imigrantes bolivianos aos serviços públicos de saúde na cidade de São Paulo. Saúde e Sociedade, São Paulo, v. 22, n. 2, p. 351-364, 2013. DOI: 10.1590/S0104-12902013000200008
https://doi.org/10.1590/S0104-1290201300... ). In this sense, the reports of immigrants and authorities that highlight the right to health in Brazil embodied in obtaining the National Health Card stand out.

Indeed, many immigrants use the “SUS card”, provided they present some identification document, even from their country of origin. This card represented one of the main forms of integration with society, being sometimes the only Brazilian document they had. According to an institutional representative, the National Health Card can be an important mean for the exercise of citizenship for this vulnerable group. As recorded in the present study and pointed out by Xavier (2010XAVIER, I. R. Projeto Migratório e Espaço: os migrantes bolivianos na Região Metropolitana de São Paulo. Dissertação (Mestrado em Demografia) - Instituto de Filosofia e Ciências Humanas, Universidade Estadual de Campinas, Campinas, 2010.), immigrants use the SUS and expressed perceptions of the same right to health as natural-born or naturalized citizens.

Finally, it is worth noting the lack of therapeutic routes for Chagas disease (Aith; Forsyth; Shikanai-Yasuda, 2020AITH, F. M. A.; FORSYTH, C.; SHIKANAI-YASUDA, M. A. Chagas disease and healthcare rights in the Bolivian immigrant community of São Paulo, Brazil. Tropical Medicine and Infectious. Disease, Bethesda, v. 5, n. 2, p. 62-73, 2020. DOI: 10.3390/tropicalmed5020062;5,62
https://doi.org/10.3390/tropicalmed50200... ), as well as the need for training for doctors in primary care, implementing strategies such as Chagas disease care manuals, as well as guidance applications, via cell phone, with specificities for Bolivian immigrants (Shikanai-Yasuda et al., 2017SHIKANAI-YASUDA, M. A. et al. Interdisciplinary approach at the primary healthcare level for Bolivian immigrants with Chagas disease in the city of São Paulo. PLOS Neglected Tropical Diseases, San Francisco, v. 11, n. 3, 2017. DOI: 10.1371/journal.pntd.0005466
https://doi.org/10.1371/journal.pntd.000... ). The approval of a protocol of guidelines for diagnosis and therapy for Chagas disease opens the possibility of qualifying the care of this disease in Brazil for infected individuals, mostly asymptomatic, particularly women of childbearing age and young adults (Shikanai-Yasuda ., 2017SHIKANAI-YASUDA, M. A. et al. Interdisciplinary approach at the primary healthcare level for Bolivian immigrants with Chagas disease in the city of São Paulo. PLOS Neglected Tropical Diseases, San Francisco, v. 11, n. 3, 2017. DOI: 10.1371/journal.pntd.0005466
https://doi.org/10.1371/journal.pntd.000... ).

This study, despite a considerable sample of 633 individuals, has limitations. The sample of Bolivians studied lives in a restricted area of the city of São Paulo, being users of a health service. A greater number of qualitative interviews, including social care services, would also be desirable.

Final Considerations

The lack of documentation, working conditions and low wages, associated with the difficulty in communication point out as important barriers to access to health, requiring different political and programmatic interventions, such as having professionals and/or cultural mediators who speak the Spanish language to resolve such difficulties.

The data in this article point out the fundamental role of obtaining the National Health Card, not only as a gateway to health, but as a means of social integration of the immigrant.

The results add knowledge to the existing literature on the subject, discussed throughout the text, especially with regard to the need to organize new forms of care aimed at these specific communities.

Acknowledgements

Our thanks to the primary care and Immigration Research Groups on Chagas disease and Immigration (Lia M. Brito Silva, Noemia Barbosa Carvalho, Ruth Moreira Leite, Magda Atala, Rosário Q. Ferrufino, Luzia Martinelli, Camila Sáfolo, Sonia Regina de Almeida e Cássio Silveira).

References

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