ABSTRACT

This article analyzes how different configurations of the relationship between the state and social movements have produced different public policies on women’s health since the turn of the 21st century. Over the last four decades, various sectors of society have worked to develop and expand citizenship rights. Among these groups are the feminist movements, which have combined the struggles for the right to health and for democracy, building practices that affirm articulation with the state to influence the formulation of public policies grounded on human rights. Based on documentary research from an anthropological perspective, the documents and contexts in which the main national public policies on women’s health have been enacted since 2000 are analyzed. It argues that a systematic dialogue between social movements and government representatives, through popular participation in the formulation of public policies, can result in proposals that are more in line with collective demands in the field of women’s health, even if these achievements are subject to partisan influence and conservatism. This approach makes visible a process of mutual construction between gender and the state, which simultaneously makes it possible to influence the political-institutional scenario, redefine political-social agendas and operate a critical watch on government practices.

KEYWORDS
Health policy; Women’s health; Political activism; Gender identity; Reproductive rights

Introduction

This article discusses different configurations of the relationship between the State and social movements and their effects on the production of policies in the area of women’s health in Brazil since the 2000s. Our argument is that a systematic dialogue between social movements and government representatives, through popular participation, in the elaboration of public policies can produce proposals that are more aligned with collective demands in the area of women’s health, even if such achievements are vulnerable to partisan game and conservatism. This perspective highlights the articulations between social movements and the State, a process that allows, at the same time, a certain influence on the political-institutional scenario, repositioning of political-social agendas and the capacity for monitoring and criticism of government practices.

Influencing the State refers to a rights-based advocacy process in which civil society interacts with the State to demand citizenship and human rights¹1 Franke K. Dating the State: the moral hazards of winning gay rights. Colum Hum Rts L Rev [Internet]. 2012 [acesso em 2024 set 29];44:1-46. Disponível em: https://scholarship.law.columbia.edu/cgi/viewcontent.cgi?article=3110&context=faculty_scholarship
https://scholarship.law.columbia.edu/cgi... ,²2 Pitanguy J. Advocacy e direitos humanos. In: Barsted LL, Pitanguy J, organizadoras. O Progresso das Mulheres no Brasil 2003-2010. Rio de Janeiro: CEPIA; 2011. p. 20-57.. In the field of women’s rights, it is a strategy for confronting relations of oppression and subordination that occur between the convergence and divergence of positions, strategies and values³3 Ávila MB, Corrêa S. O movimento de saúde e direitos reprodutivos no Brasil: revisitando percursos. In: Galvão L, Díaz J, organizadores. Saúde sexual e reprodutiva no Brasil: dilemas e desafios. São Paulo: Hucitec; 1999. p. 70-103.,⁴4 Schumaher S. Os movimentos feministas ontem e hoje no Brasil: desafios da sua institucionalização. In: Matos M, Alvarez S, organizadoras. Quem são as mulheres das políticas para as mulheres no Brasil: o feminismo estatal participativo. Porto Alegre: Zouk; 2018. p. 21-56..

Women’s health as a human rights issue was marked internationally by the United Nations (UN) Conferences in Cairo and Beijing in 1990⁵5 Bandeira L, Almeida T. A transversalidade de gênero nas políticas públicas. Rev CEAM [Internet]. 2013 [acesso em 2024 set 25];2(1):35-46. Disponível em: https://periodicos.unb.br/index.php/revistadoceam/article/view/10075
https://periodicos.unb.br/index.php/revi... . In Brazil, still in the 1980s, before the proposal of a public and universal health system, national and regional experiences of public policies for women’s health emerged, anchored in the concept of comprehensiveness, whose objective was to contemplate women’s health needs beyond pregnancy, addressing the predominantly maternal-child-oriented nature of Brazilian public health⁶6 Ministério da Saúde (BR). Assistência Integral à Saúde da Mulher: bases de ação programática. Brasília, DF; 1984.,⁷7 Costa AM, Bahia L, Conte D. A saúde da mulher e o SUS: laços e diversidades no processo de formulação, implementação e avaliação das políticas de saúde para mulheres no Brasil. Saúde debate [Internet]. 2007 [acesso em 2024 set 29];31(75-77):13-24. Disponível em: https://www.redalyc.org/pdf/4063/406345310003.pdf
https://www.redalyc.org/pdf/4063/4063453... .

Built at the interface between public health and social activism, comprehensive care for women’s health bears the mark of feminist social movements that sought to influence the State, with an interest in expanding rights⁸8 Araújo M, Simonetti M. Saúde das Mulheres: questões que o debate sobre políticas públicas ainda tem que enfrentar. Rev Observatório Brasil Igualdade de Gênero. 2014;4(5):118-29.,⁹9 Centro Brasileiro de Estudos de Saúde [Internet]. Rio de Janeiro: Cebes; Ó2024. Costa AM. Saúde integral da mulher: quo vadis 30 anos depois?; 2013 março 7 [acesso em 2024 jan 25]. Disponível em: http://cebes.org.br/2013/03/saude-integral-da-mulher-quo-vadis-30-anos-depois/
http://cebes.org.br/2013/03/saude-integr... . This perspective guided the Comprehensive Women’s Health Care Program (PAISM)⁶6 Ministério da Saúde (BR). Assistência Integral à Saúde da Mulher: bases de ação programática. Brasília, DF; 1984., from 1983, and, later, the National Policy for Comprehensive Women’s Health Care (PNAISM)¹⁰10 Ministério da Saúde (BR). Política Nacional de Atenção Integral à Saúde da Mulher: princípios e diretrizes. Brasília, DF: MS; 2004., of 2004. Formulated in partnership between the federal government and civil society, the PNAISM was launched during the first administration of a left-wing government since the country’s redemocratization. Years later, the advent of a policy aimed at pregnancy and childbirth care, the Rede Cegonha (RC)¹¹11 Ministério da Saúde (BR). Portaria n° 1.459, de 24 de junho de 2011. Institui, no âmbito do Sistema Único de Saúde - SUS - a Rede Cegonha. Diário Oficial da União, Brasília, DF. 25 jun 2011; Seção 1., would show that the dispute between comprehensive care and maternal-infantilism in the arena of women’s health remains alive. Promulgated in 2011, under another left-wing administration, the RC demonstrates that the relations of the federal administration with the social activism of women and feminists happened differently compared to those seen in the PNAISM.

Although the aforementioned policies have different legal statutes, they constitute the main federal initiatives regarding women’s health since 2000¹²12 Carvalho LDP. Da esterilização ao Zika: interseccionalidade e transnacionalismo nas políticas de saúde para as mulheres [tese]. São Paulo: Universidade de São Paulo; 2017. 212 p.,¹³13 Centro Feminista de Estudos e Assessoria (Cfemea). Atenção Integral à Saúde da Mulher ficou fragilizada. Jornal Fêmea [Internet]. 2011 [acesso em 2024 set 20]. Disponível em: https://www.cfemea.org.br/images/stories/colecaofemea/jornalfemea172.pdf.
https://www.cfemea.org.br/images/stories... . By combining different forms of articulation between government agents, social movements and partisan interests in their development processes, the PNAISM and the RC demonstrate how proposals for actions in women’s health have changed in Brazil in recent times.

The analysis of such dynamics can be especially fruitful for understanding the relationship between social activism and the State in the area of women’s health, under governments considered allies of social movements in Brazil. The debate about gains and losses in the interaction with the State has been raised by various segments of social movements in Brazil, with emphasis on the black, feminist and sexual dissident movements⁴4 Schumaher S. Os movimentos feministas ontem e hoje no Brasil: desafios da sua institucionalização. In: Matos M, Alvarez S, organizadoras. Quem são as mulheres das políticas para as mulheres no Brasil: o feminismo estatal participativo. Porto Alegre: Zouk; 2018. p. 21-56.,¹⁴14 Aguião S. Fazer-se no “Estado”: uma etnografia sobre o processo de constituição dos “LGBT” como sujeitos de direitos no Brasil contemporâneo. Rio de Janeiro: Eduerj; 2018.,¹⁵15 Werneck J. Racismo institucional e saúde da população negra. Saúde soc. 2016;25(3):535-49. DOI: https://doi.org/10.1590/S0104-129020162610
https://doi.org/10.1590/S0104-1290201626... . In this scenario, the different ways of conceiving the relationship between political parties and the State appear as historical dilemmas. Considering activists and the State – including governments – as agents interested in negotiating the recognition of people with rights can contribute to understanding impasses and limitations in the cycle of public policies.

Often understood as state responses to civil society demands, public policies can take on an instrumental and technical nature, jeopardizing a historical approach that would encompass the political and social elements that comprise them. In this framework, policies are seen as administrative acts that merely represent the elements they address.

From an anthropological perspective, public policies act as cornerstones in the ongoing process of State building, in which the art of governing and administrative activities are not in opposition¹⁶16 Souza Lima AC, Castro JPM. Notas para uma abordagem antropológica da(s) política(s) pública(s). Anthropológicas [Internet]. 2015 [acesso em 2024 set 2];26(2):17-54. Disponível em: https://periodicos.ufpe.br/revistas/revistaanthropologicas/article/view/23968
https://periodicos.ufpe.br/revistas/revi... . Inserted in the set of relationships that make up the State, policies involve multiple agents, agencies and practices, going beyond the strict territory of the State organism. By forging subjects and forms of subjection, policies also participate in the production of knowledge, subjectivities and relationships¹⁷17 Foucault M. Segurança, território e população. São Paulo: Martins Fontes; 2008..

The creation of the State implies sustaining practices that are necessarily hierarchical and segregating, even if they are distributed irregularly throughout the social fabric¹⁶16 Souza Lima AC, Castro JPM. Notas para uma abordagem antropológica da(s) política(s) pública(s). Anthropológicas [Internet]. 2015 [acesso em 2024 set 2];26(2):17-54. Disponível em: https://periodicos.ufpe.br/revistas/revistaanthropologicas/article/view/23968
https://periodicos.ufpe.br/revistas/revi... . Among the various forms of segmentation is the continuous production of sexual difference. According to Paul Preciado¹⁸18 Preciado P. Testo Junkie. São Paulo: n-1; 2018., sex and gender are seen as complex technologies through which the body is taken as an artifact, with its organs, functions and relationships artificially established as givens of nature. Functioning as a political regime through the inscription and re-inscription of binary codes, sexual difference is also formulated and recited in government tools, including through documents.

The framing processes that qualify and define subjects and the population are also projected onto the State, in a mutual, continuous and procedural construction¹⁹19 Vianna A, Lowenkron L. O duplo fazer do gênero e do Estado: interconexões, materialidades e linguagens. Cad Pagu. 2017;51:1-61. DOI: https://doi.org/10.1590/18094449201700510001
https://doi.org/10.1590/1809444920170051... . When considering the capacity to create subjects and subjectivities that gender and the State exercise in association, it is clear that women’s health public policies fit into this field in a special way because they formally combine the two terms.

If, currently, gender, sex and sexuality are not situated on the margins of power struggles, but rather at their very core²⁰20 Corrêa S, Parker R. Prologue. In: Corrêa S, Parker R, organizadores. SexPolitics: Trends and Tensions in the 21st Century – Critical Issues. Rio de Janeiro: ABIA; 2018. p. 4-7., investigating public policies aimed at women can allow us to understand one of the processes through which the State produces and defines who are the women who can be considered by citizens.

Thus, the objective of this article is to comparatively analyze the relationship between social movements and the State in the process of developing the two main national public policies on women’s health since the early 2000s in Brazil – PNAISM and RC¹⁰10 Ministério da Saúde (BR). Política Nacional de Atenção Integral à Saúde da Mulher: princípios e diretrizes. Brasília, DF: MS; 2004.,¹¹11 Ministério da Saúde (BR). Portaria n° 1.459, de 24 de junho de 2011. Institui, no âmbito do Sistema Único de Saúde - SUS - a Rede Cegonha. Diário Oficial da União, Brasília, DF. 25 jun 2011; Seção 1.,²¹21 Ministério da Saúde (BR). Política nacional de atenção integral à saúde da mulher: plano de ação 2004-2007. Brasília, DF: MS; 2004.,²²22 Ministério da Saúde (BR). Manual prático para implementação da Rede Cegonha. Brasília, DF: MS; 2011.. From an anthropological perspective on documents, the material corpus and the context of each regulation were studied and the results were then discussed in light of theoretical frameworks of feminism and anthropology of the State.

Material and methods

For the research from which this article derives, an extensive set of official government documents was examined (n=64), as well as documents from social movements and the academic production of people directly involved with the regulations studied. To fulfill the objectives of this article, ethnographic analysis of the inaugural documents of PNAISM¹⁰10 Ministério da Saúde (BR). Política Nacional de Atenção Integral à Saúde da Mulher: princípios e diretrizes. Brasília, DF: MS; 2004. and RC¹¹11 Ministério da Saúde (BR). Portaria n° 1.459, de 24 de junho de 2011. Institui, no âmbito do Sistema Único de Saúde - SUS - a Rede Cegonha. Diário Oficial da União, Brasília, DF. 25 jun 2011; Seção 1. was prioritized. Then, other official government documents linked to the policies were added to shed light on aspects related to their elaboration and promulgation processes²¹21 Ministério da Saúde (BR). Política nacional de atenção integral à saúde da mulher: plano de ação 2004-2007. Brasília, DF: MS; 2004.,²²22 Ministério da Saúde (BR). Manual prático para implementação da Rede Cegonha. Brasília, DF: MS; 2011.,²³23 Ministério da Saúde (BR). Simpósio Internacional de Redes de Atenção Integral à Saúde da Mulher e da Criança/Rede Cegonha. Brasília, DF: MS; 2015.. All documents are available on official platforms of the Ministry of Health (MH), with public and universal access.

Anthropological work with and based on documents involves paying attention to their content and form, as well as to the context in which they are inserted and to the set of elements that they manage and relate²⁴24 Vianna A. Etnografando documentos: uma antropóloga em meio a processos judiciais. In: Castilho SRR, Souza Lima AC, Teixeira CC, organizadores. Antropologia das práticas de poder: reflexões etnográficas entre burocratas, elites e corporações. Rio de Janeiro: Contra Capa; 2014. p. 43-70.. In fact, their characteristic of being something that must remain and last runs through the entire process of their elaboration. Also a field of intense disputes, whose effects go beyond state bodies, documents are part of the international political circuit and the management regime of bodies and life²⁵25 Lowenkron L, Ferreira L. Anthropological perspectives on documents. Ethnographic dialogues on the trail of police papers. Vibrant. 2014;11(2):76-112. DOI: https://doi.org/10.1590/S1809-43412014000200003
https://doi.org/10.1590/S1809-4341201400... .

The comparative study of policies was organized into two complementary axes: the study of the document and the study of the context. The first axis analyzed the content and format of the official documents promulgating the policies, with the aim of understanding how the policy produces its discourse, what priorities it establishes and what articulations it promotes. In the study of the context, the social, historical and political conditions surrounding the policies were investigated.

The inaugural document of PNAISM¹⁰10 Ministério da Saúde (BR). Política Nacional de Atenção Integral à Saúde da Mulher: princípios e diretrizes. Brasília, DF: MS; 2004. is composed of 82 pages and signed by the team of the Technical Area of Women’s Health and the Ministry of Health. Its content presents: concepts and principles adopted by PNAISM; historical summary of national policies on women’s health; sociodemographic analysis and situational health diagnosis. Among the objectives, the improvement of women’s living conditions through actions focused on: clinical-gynecological care; reduction of cancer mortality; care for women in situations of violence; strengthening of popular participation; and care for mental health.

Established by means of a 9-page executive order, the RC is signed by the Minister of Health, without including other stakeholders as co-responsible parties, giving it a more centralized aspect. The executive order presents the principles, guidelines and objectives of the policy, prioritizing the promotion of care during childbirth and the goal of reducing maternal and infant mortality, especially neonatal mortality.

More than two territories with well-defined contours, we are talking about plans that co-generate and derive from each other, enabling a look at the flows of circulation of forces in the open and uninterrupted disputes around sex and gender within the State.

Results

Analysis of documents on policies and their processes

The process of developing policies aimed at women in the health sector in Brazil has been intertwined with several non-governmental actors, including women’s and feminist social movements. However, the articulation between social movements and the State has proven to be irregular and unstable, with periods of greater proximity and others of distance and centralization of decisions in the government²⁶26 Cruz E. As estratégias de mobilização do movimento feminista para a aprovação da Política Nacional de Atenção Integral à Saúde da Mulher, de 2004 [dissertação]. Brasília, DF: Universidade de Brasília; 2015. 178 p.,²⁷27 Gonzalez D. Quando feminismos e Estado se encontram(?): Brasil e Chile no “ciclo progressista” [tese]. Campinas: Universidade Estadual de Campinas; 2019. 191 p.. Below, we present unique elements of the development process of each of the regulations, indicating how the incidence in the State happened and what effects were produced in relation to the political proposals.

PNAISM and expanded social participation

The PNAISM was established in 2004 as the first national health normative aimed at women, called a ‘policy’ rather than a ‘program’. It incorporates issues of gender inequality and racism, and covers specificities in the target group of its actions by including subgroups of women (black, indigenous, elderly, rural, etc.). The inaugural document¹⁰10 Ministério da Saúde (BR). Política Nacional de Atenção Integral à Saúde da Mulher: princípios e diretrizes. Brasília, DF: MS; 2004. announces the gender perspective, comprehensiveness and health as a citizenship right, including the participation of social movements in its elaboration as an expression of its democratic nature. The affirmation of women’s full citizenship, beyond their role as parents or mothers, adds to the approach to the relationship between illness and social inequalities, aiming to guarantee women’s human rights.

The PNAISM was developed through regular meetings between representatives of the Ministry of Health, mixed bodies such as the National Council for Women’s Rights (CNDM) and the Intersectoral Commission for Women’s Health (CISMU), and women’s and feminist social movements. The normative¹⁰10 Ministério da Saúde (BR). Política Nacional de Atenção Integral à Saúde da Mulher: princípios e diretrizes. Brasília, DF: MS; 2004. mentions the following civil society groups among the partners: National Feminist Network for Health, Sexual Rights and Reproductive Rights; Articulation of Brazilian Women; National Articulation of Rural Women Workers; and National Network for the Humanization of Childbirth and Birth.

With regard to the MH team, a considerable group of feminist activists were present in Luís Inácio Lula da Silva’s team since the presidential race in 2002, advising on the preparation of proposals and campaign material²⁶26 Cruz E. As estratégias de mobilização do movimento feminista para a aprovação da Política Nacional de Atenção Integral à Saúde da Mulher, de 2004 [dissertação]. Brasília, DF: Universidade de Brasília; 2015. 178 p.. In the formation of ministerial staff, including those in health, many activists from feminist and women’s movements were incorporated, mainly in the so-called second and third echelons of the Workers’ Party (PT) government in the executive branch. This period is recognized as a milestone in the strengthening of participatory spaces in the federal government, and is considered a fruitful phase for the articulation between the State and social movements, including in the scope of policies for women.

Regarding the impacts of social inequality on the health conditions of women, the document cites references linked to social movements and civil society meetings, highlighting the articulation with actors beyond the jurisdiction of the executive branch. The intense networks of discourse and influence indicate that social movements did more than inform the government, as they also provided legitimacy and opportunities for the implementation of actions²⁶26 Cruz E. As estratégias de mobilização do movimento feminista para a aprovação da Política Nacional de Atenção Integral à Saúde da Mulher, de 2004 [dissertação]. Brasília, DF: Universidade de Brasília; 2015. 178 p..

This process demonstrates the existence of a triple input of organized civil society regarding public administration and the formulation of the PNAISM, as there was a composition between: the government’s tension front in favor of the defended agendas (advocacy), institutionalized popular participation and the direct occupation of positions in the structure of the State by people linked to activist agendas. This dynamic transformed the relations historically forged between the different spaces of power within the scope of institutional politics. One of its effects was the diversification of the actors formally involved in the construction of public policies, with the emergence of different social groups as subjects of rights⁸8 Araújo M, Simonetti M. Saúde das Mulheres: questões que o debate sobre políticas públicas ainda tem que enfrentar. Rev Observatório Brasil Igualdade de Gênero. 2014;4(5):118-29..

By meeting with members of the black, indigenous, homeless workers, and lesbian movements, among others, the MH team expanded its field of vision beyond the health and feminist movements that already inhabited it – given the trajectory of the women who made up the team. The participation of sectors outside the white-urbanized middle class axis in the deliberative spaces of health policies forced other forms of oppression and discrimination onto the agenda, leading to a review of concepts and priorities, both in activist groups and in government sectors¹²12 Carvalho LDP. Da esterilização ao Zika: interseccionalidade e transnacionalismo nas políticas de saúde para as mulheres [tese]. São Paulo: Universidade de São Paulo; 2017. 212 p..

The participatory nature of the PNAISM is evident not only in official government texts, but also in documents from civil society organizations and activists. In these documents, the PNAISM is described as an expanded women’s health policy, the product of interaction between government representatives and various social movements²⁹29 Centro Feminista de Estudos e Assessoria (Cfemea). Planejamento com perspectiva de gênero. Jornal Fêmea [Internet]. 2004 jan [acesso em 2023 jul 10]. Disponível em: https://www.cfemea.org.br/images/stories/colecaofemea/jornalfemea132.pdf
https://www.cfemea.org.br/images/stories... ,³⁰30 Oliveira F. Ministério da Saúde adoça a boca do Vaticano. Viomundo [Internet]. 2011 abr 15 [acesso em 2023 jul 10]. Disponível em: https://www.viomundo.com.br/entrevistas/fatima-oliveira-ms-adoca-a-bo-ca-do-vaticano-ao-retomar-conceito-de-saude-ma-terno-infantil.html
https://www.viomundo.com.br/entrevistas/... .

Rede Cegonha and focusing on actions

The setbacks in the agendas and documents related to women’s health were felt in less than a decade. In 2011, the RC was enacted, whose proposal consists of implementing a care network focused on women and children, in order to promote changes in the model of care offered to women during pregnancy and childbirth, from the perspective of humanized care¹¹11 Ministério da Saúde (BR). Portaria n° 1.459, de 24 de junho de 2011. Institui, no âmbito do Sistema Único de Saúde - SUS - a Rede Cegonha. Diário Oficial da União, Brasília, DF. 25 jun 2011; Seção 1.,²²22 Ministério da Saúde (BR). Manual prático para implementação da Rede Cegonha. Brasília, DF: MS; 2011..

Among the milestones recognized by the ordinance¹¹11 Ministério da Saúde (BR). Portaria n° 1.459, de 24 de junho de 2011. Institui, no âmbito do Sistema Único de Saúde - SUS - a Rede Cegonha. Diário Oficial da União, Brasília, DF. 25 jun 2011; Seção 1. are the Millennium Development Goals (MDGs), namely those related to reducing maternal and neonatal mortality. Among the principles of the policy, the gender focus and ethnic and racial diversity are mentioned, however, these perspectives are not developed by or related to the proposed actions. There is no mention of the PNAISM or of comprehensive care for women’s health. Popular participation in the process of formulating the RC is absent from the document, which also does not list any guidelines reserving a seat for social movements in deliberative spaces of the policy.

In a publication subsequent to the ordinance²²22 Ministério da Saúde (BR). Manual prático para implementação da Rede Cegonha. Brasília, DF: MS; 2011., the RC places the participation of the population in the set of partnerships that the MH relies on to support its implementation, that is, in only one of the dimensions of the public policy cycle, ruling out the involvement of civil society in the formulation and evaluation stages. Among the partners, within the scope of civil society, the Network for the Humanization of Childbirth and Birth (REHUNA) and women’s movements are listed.

REHUNA is the only civil society organization cited in the set of documents that make up the RC¹¹11 Ministério da Saúde (BR). Portaria n° 1.459, de 24 de junho de 2011. Institui, no âmbito do Sistema Único de Saúde - SUS - a Rede Cegonha. Diário Oficial da União, Brasília, DF. 25 jun 2011; Seção 1.,²²22 Ministério da Saúde (BR). Manual prático para implementação da Rede Cegonha. Brasília, DF: MS; 2011.. The alignment between REHUNA’s agenda and the RC is no coincidence; after all, the formulation of the policy included the direct involvement of members of the organization who already held positions within the MH, including the coordinator of the Technical Area for Women’s Health and the RC³¹31 Castro MS. A integralidade como aposta: etnografia de uma política pública no Ministério da Saúde [tese]. Brasília, DF: Universidade de Brasília; 2012. 343 p.. The presence of activists in government agencies was one of REHUNA’s main strategies for action, in order to gain allies in federal public management and successfully advance its agendas²⁸28 Abers R, Tatagiba L. Institutional activism: mobilizing for women’s health from inside the brazilian bureaucracy. In: Rossi F, Bülow M, organizadores. Social movement dynamics. Nova Iorque: Routledge; 2015. p. 73-101..

In 2011, in the team of Dilma Rousseff’s first term (Lula’s successor and also a member of the PT), social activists took up positions in the ministries, especially those associated with the movement for the humanization of childbirth in MH. The focus on childbirth and child health was defined during the electoral campaign²³23 Ministério da Saúde (BR). Simpósio Internacional de Redes de Atenção Integral à Saúde da Mulher e da Criança/Rede Cegonha. Brasília, DF: MS; 2015.. The controversy generated around abortion and same-sex unions led the PT to form conservative alliances in order to garner support for the election. In this way, the defense of more recognizably feminist issues was overlooked, and, along with this, a distancing of feminist social movements was also observed in the construction of the campaign and the government program³²32 Werneck J. O governo Dilma está chocando o ovo da serpente. Viomundo [Internet]. 2012 fev 9 [acesso em 2023 jul 10]. Disponível em: https://www.viomundo.com.br/denuncias/jurema-werneck-o-governo-dil-ma-esta-chocando-o-ovo-da-serpente.html
https://www.viomundo.com.br/denuncias/ju... .

Regarding the distribution of budgetary resources, the overlap of policies becomes even more evident, since the funds allocated to the PNAISM were drastically reduced after the enactment of the RC¹²12 Carvalho LDP. Da esterilização ao Zika: interseccionalidade e transnacionalismo nas políticas de saúde para as mulheres [tese]. São Paulo: Universidade de São Paulo; 2017. 212 p.,¹³13 Centro Feminista de Estudos e Assessoria (Cfemea). Atenção Integral à Saúde da Mulher ficou fragilizada. Jornal Fêmea [Internet]. 2011 [acesso em 2024 set 20]. Disponível em: https://www.cfemea.org.br/images/stories/colecaofemea/jornalfemea172.pdf.
https://www.cfemea.org.br/images/stories... . The persistence of high maternal mortality rates, even after Lula’s two terms, may have contributed to justifying the focus on care during pregnancy and childbirth³³33 Vilela E. Coordenadora do Ministério da Saúde fala sobre o Rede Cegonha [DVD]. Brasília, DF: TV Brasil; 2011.. At the same time, it also offered a way to avoid the controversy surrounding abortion, allowing party alliances to be maintained.

When analyzing the issues prioritized in women’s health regulations by the MH in 2011¹¹11 Ministério da Saúde (BR). Portaria n° 1.459, de 24 de junho de 2011. Institui, no âmbito do Sistema Único de Saúde - SUS - a Rede Cegonha. Diário Oficial da União, Brasília, DF. 25 jun 2011; Seção 1.,²²22 Ministério da Saúde (BR). Manual prático para implementação da Rede Cegonha. Brasília, DF: MS; 2011., we see that one of the struggle’s agenda – humanization of labor and birth – gained more strength than others – comprehensiveness and gender equity, for example. As a result, a significant conceptual and instrumental baggage in the area of women’s health was neglected, obscuring the dimension of sexual and reproductive rights.

In addition to the direct occupation of positions, there was no government investment in popular participation in the formulation of the RC. Nor were official bodies, such as the CNDM, involved, which triggered questions from feminist activists, including those who saw themselves as supporters of President Dilma³⁰30 Oliveira F. Ministério da Saúde adoça a boca do Vaticano. Viomundo [Internet]. 2011 abr 15 [acesso em 2023 jul 10]. Disponível em: https://www.viomundo.com.br/entrevistas/fatima-oliveira-ms-adoca-a-bo-ca-do-vaticano-ao-retomar-conceito-de-saude-ma-terno-infantil.html
https://www.viomundo.com.br/entrevistas/... ,³⁴34 Castilhos C. Senhora presidenta, ouça as mulheres. Viomundo [Internet]. 2011 abr 2 [acesso em 2024 jul 25]. Disponível em: https://www.viomundo.com.br/politica/clair-castilhos-senhora-presidenta-ouca-as-mulheres.html
https://www.viomundo.com.br/politica/cla... . Critics argued that the lack of dialogue with civil society resulted in a narrow-minded approach to the ordinance, disregarding issues that are crucial to the health of Brazilian women, such as racism and gender inequality³⁵35 Negrão T. Compromissos assumidos pelo Ministério da Saúde com a Rede Feminista de Saúde não são cumpridos. Viomundo [Internet]. 2011 jul 7 [acesso em 2024 jul 25]. Disponível em: https://www.viomundo.com.br/entrevistas/telia-negrao-portaria-da-rede-cegonha-deixa-a-desejar.html
https://www.viomundo.com.br/entrevistas/... . In these statements, the Minister of Health and his team were accused of placing themselves in the position of spokespeople for society in an illegitimate way.

By exposing the glaring gaps in the RC, the debate generated in the feminist circuit did more than just enunciate the neglected issues: it denounced the centralizing and exclusionary character adopted by the MH in the process of drafting the RC. Seen as responsible for giving the policy a verticalized aspect, the coordination of the policy was oblivious to the diversity of women’s social movements, giving it a character impoverished in terms of democratic power. Furthermore, it blatantly abdicates the concept of comprehensiveness in health and reifies women based on the biological dimension of reproduction.

Discussion

Co-production of public policies and the State

When discussing the structural effect of the State, Silvia Aguião¹⁴14 Aguião S. Fazer-se no “Estado”: uma etnografia sobre o processo de constituição dos “LGBT” como sujeitos de direitos no Brasil contemporâneo. Rio de Janeiro: Eduerj; 2018. emphasizes the importance of studying the practices that systematically make the State, as a structure, seem to exist. Considering that public policies occupy a central place among the practices that forge the State, while also contributing to the formation of the population itself, it is important to think of them as a point of convergence in which women, the State, health and social movements co-produce each other. Thus, it is necessary to understand these categories not as isolated points, but as lines that intertwine, making one immanent to the other.

The involvement of civil society groups in the development of public health policies did not begin in the 2000s in the area of women’s health. Popular participation in governments in Latin America began to increase in the 1980s, at a time when many countries were rewriting their constitutions and beginning to incorporate issues related to women into their government plans²⁷27 Gonzalez D. Quando feminismos e Estado se encontram(?): Brasil e Chile no “ciclo progressista” [tese]. Campinas: Universidade Estadual de Campinas; 2019. 191 p.,³⁶36 Curiel O. La Nación Heterosexual. Bogotá, DC.: Brecha Lésbica; 2013.,³⁷37 Diniz CSG, Cabral CS. Reproductive health and rights, and public policies in Brazil: revisiting challenges during covid-19 pandemics. Glob Public Health. 2022;17(11):3175-88. DOI: https://doi.org/10.1080/17441692.2021.1995463
https://doi.org/10.1080/17441692.2021.19... . In the case of Brazil, this period coincided with the transition from the authoritarian regime of the civil-military dictatorship to the democratic regime of presidentialism, and was marked by intense mobilization of society in favor of greater popular participation in the different spheres of government, and with a strong presence of feminist activism³3 Ávila MB, Corrêa S. O movimento de saúde e direitos reprodutivos no Brasil: revisitando percursos. In: Galvão L, Díaz J, organizadores. Saúde sexual e reprodutiva no Brasil: dilemas e desafios. São Paulo: Hucitec; 1999. p. 70-103.,³⁸38 Silveira PS, Paim JS, Adrião KG. Os movimentos feministas e o processo da Reforma Sanitária no Brasil: 1975 a 1988. Saúde debate. 2019;43(esp8):276-291. DOI: https://www.doi.org/10.1590/0103-11042019S820
https://www.doi.org/10.1590/0103-1104201... .

In the 1990s, several Latin American countries, even under governments of various political stripes, were not only promoting social participation but also creating state bodies dedicated to women’s issues and including some feminist terms in their agendas³⁶36 Curiel O. La Nación Heterosexual. Bogotá, DC.: Brecha Lésbica; 2013.,³⁹39 Galindo M. No se pude descolonizar sin despatriarcalizar. La Paz: Mujeres Creando; 2013.. Brazil’s trajectory gains prominence in this panorama due to the experiences lived even before the 1990s, with the formulation and implementation of PAISM in 1984 and the creation of CNDM in 1985. PAISM was a pioneer on the global scene in designing a health program for women under the guideline of comprehensiveness⁷7 Costa AM, Bahia L, Conte D. A saúde da mulher e o SUS: laços e diversidades no processo de formulação, implementação e avaliação das políticas de saúde para mulheres no Brasil. Saúde debate [Internet]. 2007 [acesso em 2024 set 29];31(75-77):13-24. Disponível em: https://www.redalyc.org/pdf/4063/406345310003.pdf
https://www.redalyc.org/pdf/4063/4063453... . The CNDM, in turn, inaugurated the official entry of feminist activists into the federal sphere of government, whose hybrid function simultaneously articulated social movements and government representatives.

After redemocratization, feminists accumulated reflections, experiences and criticisms about the ‘state machinery’ related to women⁴⁰40 Alvarez S. Falas do Estado ou o estado das falas sobre as mulheres nas administrações democrático-populares. In: Godinho T, Silveira M, organizadores. Políticas públicas e igualdade de gênero. São Paulo: CEM; 2004. p. 103-12.. One of the findings concerned the fragile deliberative, executive and budgetary power of government agencies designed to deal with women’s issues. Another pointed to the key role that the position occupied by these agencies in the government organization chart had on the relevance and survival of the actions promoted⁴⁰40 Alvarez S. Falas do Estado ou o estado das falas sobre as mulheres nas administrações democrático-populares. In: Godinho T, Silveira M, organizadores. Políticas públicas e igualdade de gênero. São Paulo: CEM; 2004. p. 103-12..

In addition to the significant presence of activists in the federal administrations studied, differences in visions and objectives were observed among the groups of activists who held government positions. Considering the agendas that achieved some hegemony in the MH, it is possible to identify divergences between the priorities listed and the method used to develop proposals between the team that made up Lula’s first administration, at the time of the PNAISM, and the team that made up Dilma’s first administration, at the time of the RC. Popular participation, including participation in deliberative processes, stands out as a dissonant element.

Such divergences indicate that there is no consensus among activists who deal with the State or on the dimension of issues linked to women and feminism within political parties. More than a well-established field within parties, feminism in the State appears as an effect of political alliances built throughout electoral campaigns and governments³3 Ávila MB, Corrêa S. O movimento de saúde e direitos reprodutivos no Brasil: revisitando percursos. In: Galvão L, Díaz J, organizadores. Saúde sexual e reprodutiva no Brasil: dilemas e desafios. São Paulo: Hucitec; 1999. p. 70-103.. Even in governments considered partners, feminists “need to work in the countercurrent of the practices and speeches of the State in which they participate”⁴⁰40 Alvarez S. Falas do Estado ou o estado das falas sobre as mulheres nas administrações democrático-populares. In: Godinho T, Silveira M, organizadores. Políticas públicas e igualdade de gênero. São Paulo: CEM; 2004. p. 103-12.⁽¹⁰⁸⁾.

Advances and setbacks of the feminist agenda in the State

The focus on efforts to establish connections with the State has been the subject of controversy within social movements since the 1980s³3 Ávila MB, Corrêa S. O movimento de saúde e direitos reprodutivos no Brasil: revisitando percursos. In: Galvão L, Díaz J, organizadores. Saúde sexual e reprodutiva no Brasil: dilemas e desafios. São Paulo: Hucitec; 1999. p. 70-103.,⁴4 Schumaher S. Os movimentos feministas ontem e hoje no Brasil: desafios da sua institucionalização. In: Matos M, Alvarez S, organizadoras. Quem são as mulheres das políticas para as mulheres no Brasil: o feminismo estatal participativo. Porto Alegre: Zouk; 2018. p. 21-56.,²⁷27 Gonzalez D. Quando feminismos e Estado se encontram(?): Brasil e Chile no “ciclo progressista” [tese]. Campinas: Universidade Estadual de Campinas; 2019. 191 p.,⁴⁰40 Alvarez S. Falas do Estado ou o estado das falas sobre as mulheres nas administrações democrático-populares. In: Godinho T, Silveira M, organizadores. Políticas públicas e igualdade de gênero. São Paulo: CEM; 2004. p. 103-12.. The “long and turbulent path”³3 Ávila MB, Corrêa S. O movimento de saúde e direitos reprodutivos no Brasil: revisitando percursos. In: Galvão L, Díaz J, organizadores. Saúde sexual e reprodutiva no Brasil: dilemas e desafios. São Paulo: Hucitec; 1999. p. 70-103.⁽⁷¹⁾ of institutionalizing the feminist agenda caused concern among activists, since it could lead to the mischaracterization of the issues through their selective translation and incorporation. On the one hand, the increased capacity to influence the political-institutional scenario was celebrated, since it hinted at the possibility of increasing the State’s permeability to the feminist agenda. On the other hand, there was fear that the movements would be contaminated by technocratic action, creating distance from the popular base and making it difficult to exercise a more direct and radical opposition to the government, the State and capitalism⁴4 Schumaher S. Os movimentos feministas ontem e hoje no Brasil: desafios da sua institucionalização. In: Matos M, Alvarez S, organizadoras. Quem são as mulheres das políticas para as mulheres no Brasil: o feminismo estatal participativo. Porto Alegre: Zouk; 2018. p. 21-56..

Bringing issues related to women’s living conditions into the field of rights and public policies aims to foster the transformation of this scenario⁴4 Schumaher S. Os movimentos feministas ontem e hoje no Brasil: desafios da sua institucionalização. In: Matos M, Alvarez S, organizadoras. Quem são as mulheres das políticas para as mulheres no Brasil: o feminismo estatal participativo. Porto Alegre: Zouk; 2018. p. 21-56.,³⁸38 Silveira PS, Paim JS, Adrião KG. Os movimentos feministas e o processo da Reforma Sanitária no Brasil: 1975 a 1988. Saúde debate. 2019;43(esp8):276-291. DOI: https://www.doi.org/10.1590/0103-11042019S820
https://www.doi.org/10.1590/0103-1104201... , especially in a context in which poverty and violence systematically threaten lives themselves, as is the case in Brazil. Thus, seeking state protection would meet the very possibility of staying alive, making the partnership with the State in the name of expanding rights and citizenship something “that we cannot not want”⁴¹41 Spivak G. Outside in the teaching machine. Nova Iorque: Routledge; 1993.⁽²⁷⁹⁾.

Getting closer to the State requires social movements to learn the grammar of the State in an effort to translate the sensitive issues on their agenda into the language of documents and laws¹⁴14 Aguião S. Fazer-se no “Estado”: uma etnografia sobre o processo de constituição dos “LGBT” como sujeitos de direitos no Brasil contemporâneo. Rio de Janeiro: Eduerj; 2018.. The production of academic and scientific knowledge, as well as the circulation of teachers and researchers in spaces linked to social movements and the government, make up the process of influencing the State in the Brazilian experience in reproductive and sexual rights⁴²42 Rosa H. Políticas do feminino: saúde, sexo, gênero. Rio de Janeiro: Fiocruz; 2023..

The significant flow of social movements seeking to interact with the State since the end of the 1980s was, in part, encouraged by the selective incorporation of terms from the feminist vocabulary by international agencies such as the World Bank, the International Monetary Fund, the Rockefeller Foundation and the UN⁴⁰40 Alvarez S. Falas do Estado ou o estado das falas sobre as mulheres nas administrações democrático-populares. In: Godinho T, Silveira M, organizadores. Políticas públicas e igualdade de gênero. São Paulo: CEM; 2004. p. 103-12.. These organizations adopted a discourse in which gender equality was central to their platform of action with countries, especially those considered peripheral³⁹39 Galindo M. No se pude descolonizar sin despatriarcalizar. La Paz: Mujeres Creando; 2013..

The adoption of the ‘gender equality agenda’ or the ‘gender perspective’ by international agencies, which would impact social movements and governments, was made effective, above all, through the definition of goals aimed at women⁴³43 Farah M. Políticas públicas e gênero. In: Godinho T, Silveira M, organizadores. Políticas públicas e igualdade de gênero. São Paulo: PMSP; 2004. p. 127-42.. In view of this, one can identify the reinforcement of paradigms in which the body susceptible to medicalization, regulation and control is the female one⁴⁴44 Rosa H, Cabral CS. Uma cidadania da fertilidade – as políticas de saúde da mulher como tecnologias de produção do sexo e do gênero. Saúde Soc. 2023;32(2):1-13. DOI: https://doi.org/10.1590/S0104-12902023220534pt
https://doi.org/10.1590/S0104-1290202322... . The fact that the gender perspective informs and subsidizes policies committed to what makes a body be designated as female – namely, reproductive capacity –, instead of policies aimed at housing, immigration, employment, agriculture, mobility, the environment, is something that needs to be urgently considered. What complex set of problems does the evocation of gender within the State respond to?

During the period covered by the PNAISM, from 2003 to 2005, it can be seen that the effort to mainstream gender issues among ministerial portfolios was more successful in the areas of health and education than in others such as the economy, public security, foreign affairs and the executive office. Going further, when considering the mainstreaming of gender issues in the Brazilian federal government, from the 2000s onwards, one can think of two layers of composition: in the first, health stands out as the field that has shown itself to be most permeable to feminist demands; and, in the second, within public health policies, some of the agendas of social movements that are most palatable to government projects were more successful in gaining space³⁷37 Diniz CSG, Cabral CS. Reproductive health and rights, and public policies in Brazil: revisiting challenges during covid-19 pandemics. Glob Public Health. 2022;17(11):3175-88. DOI: https://doi.org/10.1080/17441692.2021.1995463
https://doi.org/10.1080/17441692.2021.19... . The engagement of feminist movements with the State achieved, in health, a unique articulation with government technologies in order to inscribe, albeit unstable, their marks on public policy.

In the RC, the prioritization of care during pregnancy and childbirth, in line with the MDGs, was supported by social movements such as Rehuna⁴⁴44 Rosa H, Cabral CS. Uma cidadania da fertilidade – as políticas de saúde da mulher como tecnologias de produção do sexo e do gênero. Saúde Soc. 2023;32(2):1-13. DOI: https://doi.org/10.1590/S0104-12902023220534pt
https://doi.org/10.1590/S0104-1290202322... . The use of the language of rights to promote maternal and child rights and suppress issues such as sexuality and abortion proved to be an important resource for securing party support³¹31 Castro MS. A integralidade como aposta: etnografia de uma política pública no Ministério da Saúde [tese]. Brasília, DF: Universidade de Brasília; 2012. 343 p.. Such conservative alliances forced a retreat in the comprehensiveness guideline and in the feminist agenda for women’s health, demonstrating the fragile institutionality of policies such as PNAISM and also the disputes surrounding the role of women in society.

Setbacks in the expansion of public policies based on human rights have only increased in recent years⁴⁵45 Brandão E, Cabral CS. Sexual and reproductive rights under attack: the advance of political and moral conservatism in Brazil. Sex Reprod Health Matters. 2019;27(2):76-86. DOI: https://doi.org/10.1080/26410397.2019.1669338
https://doi.org/10.1080/26410397.2019.16... . The loss of rights for women in Brazil is alarming and, considering that we are at the beginning of a new federal administration, it is important to observe where the debate and proposals for women’s health will go and what articulation will be forged with feminist social movements.

Final considerations

The analysis showed that the State is inhabited by forces that are not reconciled with each other and that undergo changes over time, according to the different circumstances. Among the most relevant aspects of the policies analyzed, the relationship between the State and women’s and feminist social movements stood out. The final form of the documents of each normative reveals the influence of the incidence of social activism in the formulation of policies, both in terms of the conception of the subject and of public health care policy. In the PNAISM, a policy aligned with the perspective of sexual and reproductive rights, the diversity of social movements left its mark on the expansion of women’s rights in health and the democratization of the process of elaborating public policies. In the RC, the partnership limited to a single representative of the social movement led to an impoverishment of the scope of actions and also of the target subject.

The visibility of tensions within the different feminist and women’s movements problematizes the universalization of women and, consequently, their living conditions and health needs. The strengthening of a diversification of the agenda at the time of the PNAISM expanded the figure of the political subject by making black, indigenous, lesbian, rural, disabled and incarcerated visible. The fundamental contribution of the black women’s movement is noted in making feminisms more sensitive to differences and taking such demands to participatory spaces⁴⁶46 Carneiro S. Mulheres em movimento. Estud Av. 2003;17(49):117-33. DOI: https://doi.org/10.1590/S0103-40142003000300008
https://doi.org/10.1590/S0103-4014200300... .

The occupation of ministerial positions by women’s rights activists has had implications for both social movements and the State itself. For the activists, it meant being in constant negotiation of the agenda, seeking partnerships among managers, while for the State it resulted in assuming a set of propositions, concepts and prerogatives in its framework of reference.

It was identified that the partnership with the State practiced by women’s and feminist social movements suffered significant impacts from the electoral processes (2010 and 2014) for the presidency of the Republic and also in the face of the different party agreements²⁷27 Gonzalez D. Quando feminismos e Estado se encontram(?): Brasil e Chile no “ciclo progressista” [tese]. Campinas: Universidade Estadual de Campinas; 2019. 191 p.,³¹31 Castro MS. A integralidade como aposta: etnografia de uma política pública no Ministério da Saúde [tese]. Brasília, DF: Universidade de Brasília; 2012. 343 p.. By submerging a policy (PNAISM) and its respective set of paradigms, in favor of promoting another (RC), the game of political-party interests used elements of the vocabulary of social movements in the fight for rights in order to establish conservative alliances. This aspect becomes especially relevant in view of the scenario of profound resurgence in women’s rights experienced in Brazil in recent years.

Finally, the analysis of policies points to the successive constitution of gender and the State, including in relation to disputes over meaning and power in the public domain. In this scenario, sexual difference operates at the center of the process of producing segregation, ordering and hierarchization of bodies, practices and ways of life. Therefore, it is a question of considering the strategic role that sex and gender play in the formation of government technologies and state dynamics.

Acknowledgements

Our most sincere thanks to Ana Maria Costa and Elisabeth Meloni Vieira for their attentive and careful reading of this manuscript and for their generous comments.

References

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