Abstract
The story of Brazil's evolution in sexual and reproductive health and rights during the 1990s documents not only a decade of change in the population field, but the powerful role of social movements in a democracy. Between October and December 2002, 23 people were interviewed about where they believe progress has been made in Brazil and where there are still needs in relation to population trends, sexual and reproductive rights, and health policies. This paper contains excerpts from the full report and covers the economic and political background of Brazil; the role of non-governmental and women's organisations in influencing the national agenda; the intersection of national and international agendas on population and development, HIV/AIDS, human rights, racism and other issues; changes in sexual and reproductive health policies; HIV/AIDS policy progress, perhaps most importantly mandatory free treatment for people with HIV/AIDS; recent progress in women's health, especially in relation to antenatal and obstetric services, and services addressing violence against women. Finally it describes the role of policy accountability mechanisms that aim to ensure that the many excellent policies that have been passed since 1990 are implemented in a decentralised health system of national, state and local management and services.
Résumé
L'histoire de l'évolution du Brésil en matière de santé et de droits génésiques pendant les années 90 met en lumière des changements dans le domaine démographique et l'influence des mouvements sociaux dans une démocratie. Entre octobre et décembre 2002, on a demandé à 23 personnes d'indiquer les secteurs où le Brésil avait progressé et ceux où des lacunes demeuraient en rapport avec les tendances démographiques, les droits génésiques et les politiques de santé. Cet article, contenant des extraits du rapport, décrit l'environnement économique et politique du Brésil ; l'influence des organisations féminines et des ONG sur les politiques nationales ; l'intersection des priorités nationales et internationales en matière de population et développement, VIH/SIDA, droits de l'homme, racisme et autres questions ; les changements dans les politiques de santé génésique ; les progrès de la lutte contre le VIH/SIDA, avec le traitement gratuit obligatoire des séropositifs ; les récents progrès dans la santé des femmes, particulièrement les services prénatals et obstétriques, et les services spécialisés dans la violence à l'égard des femmes ; et enfin le rôle des mécanismes de responsabilité politique pour que les excellentes politiques adoptées depuis 1990 soient aussi appliquées dans un système de santé décentralisé avec une gestion et des services aux niveaux national, des États et local.
Resumen
La historia de la evolución de Brasil en salud y derechos sexuales y reproductivos durante los años noventa documenta una década de cambios en el campo de la población, y el poder de los movimientos sociales en una democracia. Entre octubre y diciembre de 2002, se entrevistaron a 23 personas respecto a los avances logrados en Brasil y las carencias aãn existentes con relación a las tendencias demográficas, los derechos sexuales y reproductivos y las políticas de salud. Este artículo contiene pasajes del informe y abarca los antecedentes económicos y políticos de Brasil; la influencia de las ONG y organizaciones de mujeres en la agenda nacional; la intersección de las agendas nacionales e internacionales respecto a la población y el desarrollo, el VIH-sida, los derechos humanos, el racismo y otros temas; los cambios en las políticas de salud sexual y reproductiva; los avances en políticas de VIH-sida, destacada la prestación obligatoria de tratamiento gratuito para las personas con VIH-sida; los recientes avances en la salud de la mujer, especialmente con relación a los servicios antenatales y obstétricos y los servicios que tratan la violencia contra las mujeres; y, por ãltimo, los mecanismos destinados a garantizar que las numerosas excelentes políticas aprobadas a partir de 1990 sean aplicadas en un sistema de salud descentralizado de administración y servicios nacionales, estatales y locales.
Brazil is a land of contradictions. While it is one of the world's top ten economies, it rates only an average score on the human development index. Though it is an influential giant in its region, Brazil's maternal mortality ratios are worse than those of some of its poorer neighbours. Inequality is at the heart of this contradiction. While the average income in Brazil in 1999 was US$3,000 a month, 40% of the population were living on a tiny fraction of that – just US$65 a month.
These inequalities express themselves in sexual and reproductive health as in many other aspects of life. The country's fertility rate has fallen sharply since 1970, from 5.8 births per woman to 2.34. Although rates are still high in the North (3.2) and in the Northeast (2.7), historical analysis indicates a clear convergence of fertility patterns across regions and social groups. This means that Brazil cannot be portrayed as a country experiencing a “population growth problem”. Rather, one of its major policy problems is that many people, especially women, cannot yet fully exercise their sexual and reproductive rights. The pace, features, and implications of Brazilian demographic changes achieved broad public visibility in the 1990s. The decline in fertility was first identified in the 1970s, and by the mid-1980s its core characteristics were already clear. The immediate causes were the increased use of contraception by women, especially the pill and the “preference” for female sterilisation – often associated with unnecessary caesarean sections – along with recourse to (illegal) abortion. Despite this general decline in fertility, reproductive health indicators such as maternal mortality and cervical cancer rates remained unacceptably high.
Thanks to advocacy work by non-governmental organisations (NGOs) since the late 1980s, maternal mortality became a priority policy issue in the 1990s. In Brazil, despite the fact that about 95% of deliveries take place in hospitals, maternal mortality ratios are still high. Recent research sponsored by the Minister of Health concluded that the maternal mortality ratio was 84 deaths to 100,000 live births in 2001. These deaths resulted from lack of antenatal care, poor assistance at delivery and unsafe abortions. About 90% of them would be preventable with timely, good quality care. Nationally, abortion is the fourth most common cause of maternal mortality. In a country where abortions are only legal after rape or to save the life of the mother, and where even legal abortions are hard to obtain, there are many unwanted pregnancies, leading to somewhere between 700,000 and one million unsafe and illegal abortions annually, according to the public health system database. Some poor women go to unskilled abortionists, putting themselves at high risk of haemorrhage and infection; others use the prostaglandin drug misoprostol (Cytotec). Most of them go to a public hospital looking for help after a clandestine procedure.
Political and economic background
In 1990, Brazil was experiencing political troubles that would lead, two years later, to the impeachment of President Fernando Collor. The political institutional crisis of the late 1980s and early 1990s negatively affected the relationship between civil society and the state, especially in the area of sexual and reproductive health. One example was the downgrading of the status of the government's National Council on Women's Rights in 1989. In addition, the implementation of the 1988 Constitution's sections on the public health system were delayed.
After that crisis, civil society regained its strength and re-directed its energies towards reproductive health issues: instead of pressuring the executive, women's health and rights organisations began educating policymakers in the parliament. They also worked through the courts to overcome discrimination and to gain access to treatment. Many institutions were established in this period, including Casa de Cultura da Mulher Negra; Católicas pelo Direito de Decidir Brasil; Cidadania, Estudo, Pesquisa, Informa§ão e A§ão (CEPIA); Centro Feminista de Estudos e Assessoria (CFEMEA); the Commission on Citizenship and Reproduction; Cunhã Coletivo Feminista; ECOS Comunica§ão em Sexualidade; and Rede Nacional Feminista de Saãde e Direitos Reprodutivos (RedeSaude). Some strategies proposed by these and other NGOs would later be incorporated into law and policy. For example, their evidence to the Federal Parliamentary Commission on Sterilisation helped in the formulation and approval of Law 9263 (1996) regulating the Constitutional Provision of Family Planning. And a series of lawsuits paved the policy ground for the 1996 legislation ensuring free and universal treatment for people living with HIV/AIDS.
From 1989, the Brazilian AIDS movement opted for a judicial strategy because we did not have the time to wait for specific legislation to be approved. As we kept winning different lawsuits the Executive and Parliament were under pressure and this resulted in the National AIDS policy and later on (1996) in free access to treatment. (Miriam Ventura, Advocaci)
In 1994, a new Economic Stabilisation Plan (Plano Real) was adopted and Fernando Henrique Cardoso was elected President; he would be re-elected in 1998. Cardoso's long administration completely changed the Brazilian policy environment, creating paradoxical patterns in Brazilian policy. On one hand, the country experienced unusual economic, political, and institutional stability, which favoured the establishment of a wide range of mechanisms for social accountability and the legitimisation of a national policy agenda on human rights.
On the other hand, these were also years of erratic economic growth, with bouts of financial instability and fiscal stringency. There were major negative trends, including high levels of unemployment, stagnation of income and an increase in everyday violence. Fiscal stringency put the brakes on public investment in many strategic areas, particularly in social policy. However, these constraints were not as detrimental to health policy as they were in other areas, for two reasons. First, the 1988 constitutional changes provided a safeguard to the public health system. Second, beginning in 1993, the Integrated Health System (SUS) was decentralised and its managerial structure, operations, and accountability were tightened. After 1996, the health sector was kept relatively financially stable with additional resources from a bank and financial transaction tax (CPMF). In 1999, a new constitutional provision was adopted, dividing financial responsibility for SUS among federal, state and municipal levels and setting an annual increase in the health budget directly related to the increase in GDP.
Brazil is one of the few countries in the region that has retained the principle of universal access to health care. (Margareth Arilha, UNFPA technical advisor)
Since 1994, the institutional environment has favoured the expansion of primary health care and the use of sophisticated systems for epidemiological surveillance, health information collection and policy monitoring. These structural elements made possible the robust policy response to HIV/AIDS in 1992–93, and the revival in 1997–98 of strategic components of the Program for the Comprehensive Care of Women's Health (PAISM).
Intersection of national and international agendas
Brazil is a case study of key national players both shaping and being shaped by international discourse and agreements, including the 1993 World Conference on Human Rights in Vienna, the 1994 International Conference on Population and Development in Cairo, and the 1995 Fourth World Conference on Women in Beijing. For black feminist activists, the most important point of reference is the World Conference Against Racism, Racial Discrimination, Xenophobia and related forms of Intolerance (Durban, 2001), which made a breakthrough in the national debate on “denied racism” and affirmative policy measures. It is important to note that many consider that the major impact of Durban occurred in Brazil. During the 1990s, Brazilian HIV/AIDS activists also participated intensively in International AIDS Conferences and brought the impact of those conferences back into their work at the national level.
These conferences also helped bring about formal mechanisms and other initiatives aimed at monitoring the implementation of policy. The most frequently cited example is the creation of the National Commission on Population and Development in 1995. Its composition encompasses relevant ministries (Health, Education, Foreign Affairs, Labour, Social Security, Justice and Environment, Budget and Planning, and the Presidential Cabinet), specialised agencies dealing with data and policy analysis, and eight members from the academic sector and civil society organisations. The Commission's mandate is to follow up the implementation of ICPD and related international debates at national level, and to raise awareness of the demographic implications of public policies.
The 1993 Vienna Conference on Human Rights was also a turning point and is the origin of the National Human Rights Programme established in 1995, which was later (2002) reviewed and re-defined as a state priority policy. Its guidelines cover a wide range of issues, including gender violence, racial issues, sexual orientation, HIV/AIDS-related discrimination, and access to abortion. The preparations for and aftermath of Beijing+5 also influenced the human rights policy process, on several fronts: the creation of a National Secretary for Women's Rights, May 2002; the ratification of the Optional Protocol of the Convention on the Elimination of Discrimination against Women (CEDAW), June 2002; and governmental compliance under the Convention through national reports for the years 1988, 1994, 1998 and 2002. Currently, Brazilian NGOs are making increasing use of international instruments to call for government accountability and to promote new thinking about gender relations and access to health care.
Sexual and reproductive health policies: what has changed?
Since the 1980s a strong women's movement in Brazil has been campaigning for reproductive rights. In 1984 the Minister of Health designed a Comprehensive Programme for Woman's Health (PAISM), integrating antenatal, delivery and post-natal care, cancer prevention, STI care, adolescent and menopausal care and contraception. It acknowledged abortion as a public health problem, and included, for the first time, a public mandate for contraceptive methods. The programme was threatened by institutional instability, but after 1997 it would gradually regain its strength. Despite many ups and downs, PAISM has remained the main inspiration for policymaking and advocacy in women's health.
The new Constitution adopted in 1988 was one of the critical breakthroughs of the decade, establishing the principle of gender equality. In particular, it represented a victory for the health reform movement, which had been active since the 1970s. It guaranteed reproductive freedom of choice and access to family planning. It defined health as a right and set forth the Integrated Health System (SUS) as a universal, integrated policy with built-in public accountability through health councils at national, state and local levels.
Since the early 1980s, female sterilisation has been widely used as a method of contraception in Brazil; today more than half of married women who are using contraception have had a tubal ligation. In 1997 a law was approved to set criteria for access to family planning through the public health system. The full implementation of the new legislation is currently a major challenge faced by reproductive health and rights activists in the country.
In Brazil, as in most other countries, the age of first sexual experience is falling; in 1996 it was 16 years 4 months for girls and 15 years 3 months for boys. More than 60% of adolescents aged 16–19 are sexually active. One survey showed that one in seven girls under the age of 15 had already had a baby. Again, the statistics show stark inequalities. Girls who have less than four years of education are six times more likely to become young mothers than girls who complete nine years of education. Girls in the poorest region of Brazil, the Northeast, are much more likely to have a baby during adolescence than are girls in the more prosperous Southeast.
These inequalities are also related to ethnicity. In 1999, Brazil occupied the 74th position in the UNDP ranking for Human Development. However, when the Human Development Index for that year was calculated specifically for the white and black populations, the results indicated that “white Brazil” would rank 49, while “black Brazil” would occupy the 108th position.
While most Brazilian women say their ideal family size is two children, almost half of their pregnancies are not planned. Young women today know far more about contraception than did previous generations, yet many who are sexually active do not use it regularly.
Since many women over 25 are already sterilised, the relative contribution of young and adolescent women to overall fertility has increased. This has encouraged a “crisis discourse” on teenage pregnancy. Although teenage pregnancy may have a negative impact on young women's education, Maria Luiza Heilborn (Instituto de Medicina Social) reminds us that young people themselves do not always experience early pregnancy as a crisis. She considers that the high visibility given to teenage pregnancy may lead to conservative policy approaches, such as promoting sexual abstinence. Demographers have also noted that if the average age of female sterilisation continues to fall, it may accelerate the pace at which Brazil moves towards a fertility rate radically below replacement level. This is a strong argument in favour of improving and expanding young people's access to reversible contraception.
HIV/AIDS policy and research in the 1990s
The HIV/AIDS pandemic first appeared in Brazil in 1982 and quickly expanded, through both blood contamination and sexual transmission. The absence of scientific knowledge and treatment caused fear, panic and discrimination. But in Brazil, the social response was energetic, led by civil society. Well-known people who had been infected – including Betinho, a progressive NGO leader, and Cazuza, a popular singer – talked publicly about their experiences and spoke out against discrimination. They called for a public health policy response to the crisis not simply as an epidemiological problem, but as a political and social issue. The first State policy initiative was in São Paulo in 1984; and a national programme was formalised in 1988, although at times its structure was undermined and its effectiveness impeded by institutional turmoil.
In the 1990s, over the course of three World Bank loan cycles (AIDS I (1994), AIDS II (1998), AIDS III (2002)) the programme emphasis changed in response to the changing pattern of the epidemic. In the first phase, the focus was on the groups that were then most vulnerable, including homosexuals, sex workers, transvestites and drug users. In the next cycle, the focus shifted to the poor and women, where AIDS was then taking hold. More recently, emphasis is again being given to men who have sex with men (MSM) and, in partnership with the women's health programme, to vertical (mother-to-child) transmission. Clearly, the financial investment and policy prioritisation of HIV was a crucial step in the political strategy that led, in 1996, to legislation mandating free treatment for people with HIV/AIDS. That strategy sustained Brazil's commitment to universal access to drugs against all odds – including the strong reluctance of the World Bank – and underpinned Brazil's open challenge to pharmaceutical companies regarding the patenting and prices of HIV drugs in 2000 and 2001. Most analysts today recognise that free access to treatment provided a favourable environment to expand preventive health care, not least because people, particularly those in disenfranchised groups, gained confidence in the health system.
“In the 1990s, the study of the social and cultural construction of sexuality, with research performed on the patterns of transmission of HIV/AIDS, has greatly advanced the better understanding of the epidemic. Academic institutions and the health sector started using the concept of vulnerability in order to assess behavior and other factors’structural, social and cultural’that can make people more or less at risk and more or less able to protect themselves.” (Cristina Pimenta, ABIA-AIDS)
Another critical contribution of research in the 1990s was the development of effective approaches to social interventions in sexuality education and HIV prevention. In this area, as we are reminded by Vera Paiva (Nepaids), Brazilian researchers and activists developed a unique model, inspired by Paulo Freire's popular education methodologies, that made possible a consistent critique of the dominant behaviourist approach, and views individuals as “rational beings” who do not make sexual and reproductive decisions in a vacuum. The Brazilian model of intervention emphasises the need to understand how people themselves perceive sexuality. It also gives great attention to inter-subjective relations and context, and most principally recognizes the complexity and fluidity of sexual practices (and identities). It addresses HIV awareness, prevention and treatment within a comprehensive framework that draws on both the personal and collective ability of people to deal with the individual aspects of their sexual experience and of the disease, with the medical discourse, and the power of health institutions. This model has also shown very positive results in sexuality education, as it integrates other dimensions of life that are as relevant as sex in young people's experience.
Recent progress in women's health
The national coordination body of the Women's Health Programme has concluded an assessment of policies implemented during the period 1998–2002. The assessment identified a number of areas where clear progress had been made:
| • | In obstetric care, there was investment in hospital equipment and training of health professionals, especially nurses. An award was created to give higher visibility to services that provide good quality care in childbirth. A major achievement has been the reduction in caesarean sections from 34% to 25% of all births in SUS hospitals. | ||||
| • | The focus on obstetric care contributed to a reduction in hospital-based maternal mortality from 34 to 24 deaths for every 100,000 women attended in a hospital. The number of states that set up committees to investigate maternal deaths increased from seven to twelve. There are also 387 municipal maternal mortality committees. Epidemiological investigation was carried out on all deaths (199) of women of fertile age that occurred in 26 state capital cities in the first six months of 2002. Of these 199 deaths, only 58 had originally been classified as maternal deaths. The investigation raised that number to 93. This study allowed epidemiologists to adjust maternal mortality ratios in different parts of Brazil, compensating for problems in the collection of data. The research results indicate that for the whole country, the actual maternal death rate is 1.62 times higher than what is shown in collected data. (When broken down geographically, different regions of the country have different multipliers: 2.0 for the Southeast, 1.29 for the North, 1.85 for the Northeast, 1.67 for the South and 1.25 for the Center-West region.) | ||||
| • | Antenatal care has expanded from 5.4 million women in 1997 to 10.1 million in 2001. The average number of consultations per woman increased from 2.0 to 4.2 over the same period. | ||||
| • | An agreement between the Ministry of Health (MoH) and municipal health managers included incentives for good care, and established a national information system for monitoring services. | ||||
| • | Long-standing problems of procurement, quality control and distribution of reversible contraceptive methods started to be overcome at the central (MoH) level. Assessments have been made of delivery at local levels. | ||||
| • | Screening for cervical cancer has expanded, reaching out to women who had never had a Pap smear. | ||||
| • | In 1998, the Ministry of Health (despite strong opposition) approved regulations outlining how SUS should respond to women who had suffered gender violence – including women seeking legal abortions after rape or where the woman's life was at risk. Although the law on abortion has remained unchanged, practice has evolved. There are now 245 government-sponsored, public health services addressing gender violence (82 hospitals and 163 clinics). They offer counselling and treatment, including emergency contraception and HIV post-exposure prophylaxis. Of these, 73 services provide abortions on the two grounds permitted by law, and the number of sites is growing rapidly. Another protocol adopted in 2002 requires that all gender-based violence cases seen by the public health system be reported. A large number of health professionals have been trained. | ||||
| • | A national programme was established to provide early detection and treatment of sickle-cell disease, which primarily affects the black population. | ||||
It must be said, however, that the priority given to sexual and reproductive health at the federal level does not always translate into efficiency and quality of care across the system. SUS is a gigantic machinery delivering services to 100 million people in an extremely diverse country. Decentralisation has helped to reduce the gaps between managers, providers and users, and has improved transparency and accountability. But tensions also remain with respect to power relations among the various levels of the system, particularly regarding allocation rules and their effects on the flexibility allowed to municipal managers. With the extreme variation in technical capabilities, human resources and ideologies across the system, federal rules and incentives do not always ensure access or quality of services. Consequently, assessments of progress and gaps may vary widely, depending on where the measurement is made.
In other areas, the experts' appraisals of policy results diverge. In regard to the cervical cancer screening programme, for example, Maria Betânia Ávilla's (Sos Corp Gênero e Cidadania) critique echoes the views expressed by many sectors of the Brazilian women's health movement since the programme's start in 1998:
Implemented as a campaign, the national cervical programme can never become a routine service. Many women who had the examination never got the results. Others who tested positive for cancer had no access to treatment.This should not be a matter of campaigning, but should be part of the routine daily operations of the health system.
In contrast, Dr Tania Lago (formerly National Women's Health Policy) and Margareth Arilha point out that the campaign adopted in 1999 and 2002 reached many women who otherwise would never have had a Pap smear. Still, Dr Lago recognises that the campaign model is not well accepted inside and outside the health system. In her view this is because it often discloses service flaws – for example, in the accuracy of laboratory test results or in access to treatment – that would otherwise remain invisible. When these faults are highlighted, strong criticism of the health services emerges from civil society, and health managers and professionals feel threatened.
The assessment of strategies to reduce maternal mortality has also revealed a critical area in which the gap between decisions taken at the federal level and implementation at municipal level is particularly difficult to resolve.
The Minister of Health has made an effort in the last decade. This is undeniable. But women's health only becomes a priority if the local health managers are committed, or if women's organisations exert pressure for change... If maternal mortality has not decreased it is not because the Ministry of Health was not concerned. At the local level the health system is still problematic: antenatal, childbirth and post-partum care are not of the required quality. This is why maternal mortality is considered a good indicator of how government treats women. (Dr Maria José Araãjo, Women's Health Policy, SP)
The role of policy accountability mechanisms
In Brazil, a web of mechanisms for policy accountability greatly favours the engagement of civil society in monitoring policy. The 1988 Constitution provisions that set forth the Integrated Health System (SUS) included health councils operating at all levels –national, state, and local – and comprising an equal mix of providers and users, government and civil society representatives. As SUS gradually consolidated, the number of these councils grew and they gained political and managerial legitimacy. The National Council of Health meets monthly to monitor MoH policymaking and it may propose resolutions and recommendations that can eventually become policy guidelines. Commissions advise the Council on specific policy areas. In 1996, a Cross-Sectoral Commission on Women's Health was re-activated, and began to play a critical role.
Also in the second half of the 1990s, a National Commission for Ethical Review of Research on Human Beings was established, the National Commission on Maternal Mortality was re-structured, and a National Commission on Trauma and Violence was created to advise the National Health Council. In addition, since 1992 the National HIV/AIDS Programme has put in place a series of bodies to facilitate consultations and provide accountability in specific policy areas. These include the National AIDS Commission and specific committees on prevention, treatment, women, epidemiological surveillance and research. Women's health and HIV/AIDS activists, along with other members of civil society, have a seat on all these bodies.
Specifically regarding the health councils, it is worth noting that at the local level, in order to receive full financial transfers from the federal government (which make up 65% of public health expenditures), municipalities must comply with some rules, which include the existence of a functioning health council. One council mandate is to review and approve the municipal health budgets. Presently, more than 100,000 people participate in the councils nationwide. In addition to this permanent monitoring of health policies and budgets, periodically (roughly every four years) a National Health Conference is organised, which is preceded by similar events at state and municipal levels. These conferences involve health managers, providers and councillors and their main goal is to appraise policy progresses in health (in the long run) and devise new strategic guidelines.
In the mid-1980s, a National Council on Women's Rights was established; its mandate includes reviewing policies that address gender equality. Similar bodies have mushroomed at the state and municipal levels, creating a network that, while less structured than what is seen in the health policy domain, has been critical in keeping gender equality and gender violence issues on the agenda.
In May 2002, the government created a new National Secretary for Women's Affairs, an office with ministerial status under the Ministry of Justice. In January 2003, the Secretary was placed in the Presidency of the Republic, a step that gives it higher status.
The Cross-Sectoral Commission on Women's Health (CISMU) has promoted conversations among various programmes within the MoH to reactivate the PAISM agenda, and has systematically assessed policy initiatives in women's health, including those concerning obstetric assistance, maternal mortality, cervical cancer, family planning and HIV/AIDS among women. In 1997, under pressure from CISMU, a resolution was approved by the National Council of Health – and later adopted by the MoH – to make maternal mortality cases subject to compulsory reporting.
Conclusion
Despite the gaps and weaknesses in the Brazilian sexual and reproductive policies of the 1990s and early 2000s, real progress has taken place – in part because the agenda was sustained and expanded by civil society and academia. Women's sexual and reproductive rights initiatives were also consolidated in the period. The best illustration is the RedeSaude, which, as Maria José Araãjo reminds us, expanded its affiliations from 45 members in 1991 to more than 150 organisations and individuals in 2002. Another important breakthrough of the last decade was the increasing ability of women's organizations to lead public debate on these issues. This, as underlined by Jacira Mello (Instituto Patrícia Galvão de Comunica§ao e Midia), has directly influenced policy-making and legal reforms, and most notably, has opened a space for a positive engagement with the media. Betânia Ávilla's says that this fresh wave of feminist public discourse signals a new comprehensive approach. Another important aspect of civil society dynamics was the emergence and consolidation of black women's organisations and the incorporation into their agendas of sexual and reproductive health and rights.
During the next decade, as the international development community works toward the UN Millennium Development Goals, we can expect to see continued progress in areas such as gender equity, maternal health and HIV/AIDS prevention around the world. We hope the lessons from Brazil will help inform national and local efforts to promote these goals.
Note
This paper is excerpted from a report to the John D and Catherine T MacArthur Foundation, summarising the lessons learned from the Foundation's grants in population and reproductive health in Brazil from 1990 to 2002. It was originally written and published in Portuguese for a Brazilian audience. Carmen Barroso was Director of MacArthur's Population and Reproductive Health Programme throughout the period covered by the report and spearheaded the Foundation's work in this area. The text is reprinted here with kind permission of the MacArthur Foundation. The complete document can be found at: ⟨http://www.macfound.org/documents/pdfs/gss_population_lessons_learned_01_26_2004.pdf⟩.