Healing Across Cultures: Brazil’s Push for Indigenous Health Equity
The legacy of colonialism looms large. In societies around the world, Indigenous people,* on average, live shorter lives, suffer higher rates of chronic disease , and are more likely to have mental health conditions. Ongoing racism has erected additional barriers to leading safe and healthy lives. These factors all intersect with additional disparities related to sex, age, socioeconomic status, and geography, further complicating Indigenous people’s path to health equity.
While many governments have implemented some restorative practices, like Indigenous-led health initiatives or incorporating traditional healing methods into mainstream care, no country has achieved parity between Indigenous and non-Indigenous people, nor has one created a health care infrastructure that perfectly reflects Indigenous culture and experiences. In the United States, integrating Indigenous cultural practices in health care settings and reaching rural, often remote communities remain systemic challenges. Brazil, however, has made notable strides in doing just this.
Brazil’s Indigenous Health Care Infrastructure
Brazil is home to nearly 2 million Indigenous people — nearly 1 percent of the population — representing hundreds of tribes and languages, mostly in the Amazon region. They receive health care through the main health system, Sistema único de Saúde, which guarantees all residents and visitors to Brazil, including undocumented people, access to low-cost care. In addition, Indigenous Brazilians have access to a subsector of the main health system , Secretaria Especial de Saúde Indígena (SESAI), which enables access to a network of clinics in Indigenous territories for no- or low-cost preventive care services like vaccinations, routine exams, and treatment for some diseases. The SESAI employs more than 22,000 health professionals, over half of whom are Indigenous. Many have ancestral knowledge of native medicinal plants and healing practices or have trained for years with individual tribes to develop this knowledge.
Brazil also has 34 Distrito Sanitário Especial Indígena (DSEI), special health districts where officials appointed by the Brazilian Ministry of Health, in consultation with Indigenous leaders, are charged with providing general primary health care. DSEIs have their own governing councils that ensure care delivery is aligned with their communities, something that’s particularly important in Brazil’s remote Amazon regions. Both the SESAI and DSEIs are exclusively available to Indigenous people, providing culturally specific care that incorporates Indigenous healers and practices with Western medicine. The idea is that tailored care designed in a participatory and differentiated manner improves access and outcomes — though the reality is more complicated.
Like many countries, the Brazilian system faces logistical challenges and resource limitations that can hinder broader impact. High physician turnover and limited training for Brazilian health professionals providing care to people of different ethnic backgrounds are persistent challenges. For Indigenous communities in remote areas, barriers to improving health outcomes are compounded by the lack of funding and supplies and the continued emphasis on prevention and treatment of infectious diseases, despite climbing rates of chronic illnesses. After years of consistent growth in funding for Indigenous health in Brazil, investment has stalled in recent years, as governments have cut health budgets across the board : the 2022 budget for Indigenous health was 60 percent lower than the 2012 budget.
The U.S. Indian Health Service
The U.S. Indian Health Service (IHS) provides health care to all American Indian and Alaska Native (AIAN) people. Federally recognized tribes have sovereignty, allowing them to manage clinics, hospitals, and certain other services through their own tribal leadership and to tailor services to tribal communities. Much like the Brazilian system, the IHS is organized into 12 geographically defined service areas that cover 170 hospitals and clinics. with a service area board drawn from tribes in said areas. The U.S. also has developed mechanisms such as direct services , contract services , and compact services that provide federally recognized tribes with increasing levels of self-determination and flexibility in health service delivery. Underresourcing remains a problem , however: in 2022, the IHS budget was less than half of what was required to meet patients’ needs in these communities.
In the IHS, service units are generally situated in rural, remote, and isolated regions and are reported as providing good to excellent primary care . Insufficient funding for and access to complex, specialty care are some of the biggest challenges, with some patients forced to rely on private clinics often requiring out-of-pocket payment.
Efforts to strengthen cultural competence in the IHS through, for example, provider training programs have been underway. Outside the IHS, integration of traditional medicine is limited, although recent advancements — such as federal waivers for tribes to finance traditional practices, and an effort by the Veterans Health Administration to incorporate Indigenous healing — show progress. Structural racism within health care still impacts Indigenous people, but growing recognition and action may improve traditional medicine integration and overall health outcomes.
As well as looking to Brazil’s SESAI and DSEIs, the U.S. could learn from countries like Bolivia , which is bringing traditional healers into public clinics and hospitals; Ecuador , which is integrating traditional healing with Western biomedical health services; and Norway, which has an Indigenous parliament that manages health policies relevant to its community. These models show that turning power back to Indigenous populations to shape their own health care delivery can help improve outcomes.
*A note on language: “Indigenous” in this Insight — unless otherwise noted — refers to the peoples or population groups that inhabited an area first.
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The author would like to thank Dr. Spero M. Manson , Distinguished Professor and Director of Director the Centers for American Indian & Alaska Native Health at the Colorado School of Public Health, for review of this Insight.