EMERGE blog 7: Can policies actually lead to progress for men’s health in Brazil?

At the end of the day, the goal of most activists, whether they find themselves in civil society organizations (CSOs), UN Agencies or in academic and research institutions, is to see the work they do become integrated into national and public policies. As activists, we know this because we’ve been advocating for years to redefine manhood, in ways that promote, rather than discourage men’s health.

There is a perception that when advocacy becomes policy, you’ve “made it.” At least in theory this means you’ve achieved sustainability; you’ve elevated your work to reach a much broader public. Of course, this is only partially true.

In our case – we were part of a team that realised a national men’s health policy in Brazil. Alongside Australia and Ireland, Brazil is now one of only three countries in the world to do so. Instead of representing the end of the road, however, “making it” actually imposes a new set of challenges. One of which is a concern that the policy actually reflects the realities on the ground. The work of an activist relies on a lot of data and experience over time. Making sure a policy reflects this, and that there’s a solid plan for implementing, monitoring, and evaluating it are all crucial steps in the process of sustainability and impact.

Ensuring cooperation and constant dialogue among policymakers, government agencies, CSOs and researchers is time consuming, but necessary to overcome these challenges. It follows that the failure to keep up communication is often the first step towards a policy that will likely fail.

This short introduction provides insights into the process of developing and implementing Brazil’s National Comprehensive Healthcare Policy for Men (PNAISH). The policy was created to improve men’s health outcomes by facilitating their access to healthcare services. However, it was launched in 2009 only after two years of tense debates among medical associations, health professionals, civil society, and academics. Its implementation has been complex, multifaceted, and challenging.

As highlighted by EMERGE’s case study on PNAISH, this policy was made possible due to four major factors: 1) the existence of the Brazilian Unified Healthcare System (SUS), which provided a platform for action; 2) the broader recognition of the high rate of male mortality from preventable diseases, and the low rate of men interacting with the health system; 3) the presence of a (former) Minister of Health who was sensitive and open to the need to address men’s health issues for themselves and for family well-being; and 4) a prolific and creative group of Brazilian CSOs and researchers who managed to incorporate men, masculinities and a relational gender perspective into the ongoing debate and turn it into action. 

Brazil’s Unified Healthcare System (SUS), although challenging, was founded on the principles of universal, comprehensive, and equitable coverage. Over several decades, SUS slowly paved the way for a complex and essential system that provides full and free healthcare coverage for over 140 million people: 70% of the country’s population.

SUS’s emphasis on equity highlighted the need for public health policy makers to push for the recognition of differences across living conditions and health needs of the most vulnerable populations, offering more (or singular) attention to people who need the most. Accordingly, from the 1980s, the Brazilian Ministry of Health (MoH) crafted much-needed national health policies targeting the needs of women of all ages (in 1984 and 2004); children (1988); adolescents (1989); elderly (1999); and people with disabilities (1999).

While services and policies traditionally overlooked adult men’s specific health needs, over time, the MoH could no longer ignore the fact that Brazilian women were outliving men by an average of over 7.3 years, while the world’s average remained around 4.5. A great number of Brazilian men were also dying of unnecessary external causes such as urban violence and automobile or occupational accidents, and also due to untreated chronic diseases. Among other interrelated factors, men were really dying because of norms about “being a man”, which were leading them to take greater risks and to seek primary/preventive health care less often (SUS’s centre pillar). The MoH began to realize that targeting men as key stakeholders could improve their own health outcomes, but also overall well-being for families.

Growing support and knowledge around men’s health as well as its linkages to harmful gender norms, however, didn’t immediately translate into a progressive policy. Over the course of seven years, the MoH and the National Men’s Health Coordination Unit (CNSH) had to prioritize which partners would inform and take this policy forward: the medical associations and pharmaceutical companies, who thought of men’s health outcomes as biomedical without the need to address social context; or the CSOs, academic researchers, and activists who advocated to address men’s health by breaking down norms around masculinities and gender. Despite all these actors presenting their arguments and participating in the MoH’s consultation process, the latter was strategically and correctly (we believe) chosen.

The decision to introduce gender and masculinities as an important social determinant of health, although progressive, was not an easy one. It brought attention to the limitations of thinking, addressing, and formulating public health policies exclusively (or at least, mostly) through a biomedical paradigm.

However, the decision also strengthened the role and opportunity of CSOs and academic institutions to influence PNAISH’s implementation. For example, Instituto Fernandes Figueira/Fundação Oswaldo Cruz (IFF/Fiocruz) was selected to monitor and evaluate PNAISH’s early implementation. Their role in this process contributed to the search for a more critical and complex approach to “men’s health”, recognizing the plurality and diversity that resides within masculinities (including intersections with race, class, sexuality, and more); and also to a broader understanding of how healthy men might lead to healthy women and children, and to gender equality.

After over 20 years of groundbreaking work around the world, the challenge of scaling up initiatives with boys and men to advance gender equality is certainly one of the biggest surrounding the field. More recently, in a partnership with Instituto Promundo, the CNSH launched an online education course on fatherhood and care targeting SUS’s professionals; another, on gender-based violence, in partnership with the Federal University of Santa Catarina (UFSC), has reached now more than 4,000 healthcare workers and other related professionals.

So while turning advocacy into policy alone isn’t “making it,” it’s a crucial place to start: to further political commitment and sustainability at federal level; to lobby for participatory processes involving diverse actors; and to provide clear guidance for state and municipal representatives to adequately implement, monitor, and evaluate change. For us, the process continues, but we welcome the challenge.

Find out more about PNAISH in our EMERGE case study and related story of change.

March 2016

Daniel Costa Lima

Psychologist and Master in Public Health, Daniel has worked nationally (Brazil) and internationally with the issues of gender, masculinities, men’s health, fatherhood and care, and gender-based violence prevention since the year 2000, in institutions like: Institituto Papai; Instituto Promundo; EngenderHealth (in Angola), and the Brazilian Ministry of Health, at the National Coordination of Men’s Health. 

Eduardo Schwarz Chakora

Eduardo has been working on issues related to masculinities, gender and relationships as a clinical psychologist and somatic psychotherapist for the last 18 years.Master in Policy and Management in Health by the University of Bologna/Italy, he was general coordinator of the National Comprehensive Healthcare Policy for Men (PNAISH), 2011-2015, and one of those responsible for his formulation and implementation in the Brazilian Unified Healthcare System (SUS) since 2007.