Decentralisation and difference: Indigenous peoples and health system reform in the Brazilian Amazon

In recent decades, Brazil has undergone one of the world's most far-reaching processes of political, fiscal and service decentralisation. In the social policy sectors-and particularly in the health system-this has gone hand in hand with the establishment of a strong institutional framework for service user participation. However, this process has failed to erode the strong correlation between social difference - including gender, race, ethnicity and geographical origin - and differential access to services and health outcomes in Brazil's highly unequal society. This article reviews the experience of a specific subsystem - that responsible for delivering healthcare for indigenous peoples-for which difference is a key consideration. Based on fieldwork in the Rio Negro region in the northwest Amazon, the authors examine the implications for indigenous peoples' movements of institutionalised engagement with the delivery of health services. Far from decentralisation enabling indigenous peoples' participation to transform health system bureaucracy, there is evidence the forms of engagement it has promoted have bureaucratised indigenous movements' approach to securing the health rights of their communities.