Anti-racist Actions in Primary Health Care: Practices for Confronting Institutional Racism

Abstract

Institutional racism constitutes one of the main determinants of health inequities in Brazil. Brazil’s Unified Health System (SUS – acronym in Portuguese), while ensuring universal and equitable access to health actions and services, faces significant challenges in guaranteeing equity for historically marginalized groups, such as the Black population. By incorporating the confrontation of institutional racism into its management, care, and monitoring strategies, the Secretariat of Primary Health Care (Saps – acronym in Portuguese) reaffirms the Ministry of Health’s commitment to building a more inclusive and equitable SUS, dedicated to safeguarding the right to health. In this context, this descriptive study conducts a critical analysis of the persistence of racial health inequities within the SUS, as well as the challenges related to the effective operationalization of racial equity policies within the scope of Primary Health Care (PHC). The analysis of the intersectionality among care practices, the principles of the SUS, the National Policy for Comprehensive Health of the Black Population (PNSIPN), and the National Primary Care Policy (PNAB) suggests that consolidating antiracist practices in PHC and in the SUS requires a structural transformation of care, management, and knowledge production, incorporating racial equity as a structuring principle.

Keywords:
Equity; Racism; Primary Health Care

Resumo

O racismo institucional configura-se como um dos principais determinantes das iniquidades em saúde no Brasil. O Sistema Único de Saúde (SUS), ao assegurar o acesso universal e igualitário às ações e serviços de saúde, possui desafios para garantir equidade a grupos historicamente marginalizados, como a população negra. Ao integrar o enfrentamento do racismo institucional às suas estratégias de gestão, cuidado e monitoramento, a Secretaria de Atenção Primária à Saúde (Saps) reafirma o compromisso do Ministério da Saúde (MS) com a construção de um SUS mais inclusivo e equitativo, comprometido com a garantia do direito à saúde. Nesse contexto, este estudo descritivo realiza uma análise crítica acerca da persistência das iniquidades raciais em saúde no contexto do SUS, bem como dos desafios relacionados à efetiva operacionalização das políticas de equidade racial no âmbito da Atenção Primária à Saúde (APS). A análise da interseccionalidade entre as práticas de cuidado e os princípios do SUS, da Política Nacional de Saúde Integral da População Negra (PNSIPN) e da Política Nacional de Atenção Básica (PNAB) sugere que a consolidação de práticas antirracistas na APS e no SUS requer transformação estrutural do cuidado, da gestão e da produção de conhecimento, com a equidade racial como princípio estruturante.

Palavras-chave:
Equidade; Racismo; Atenção Primária

Introduction

Institutional racism constitutes one of the main determinants of health inequities in Brazil, expressing itself through norms, practices, routines, and organizational arrangements that produce systematic inequalities in access, quality of care, and health outcomes among Black, quilombola, Indigenous, and other historically vulnerable groups. Within the Brazilian National Health System (SUS), these inequalities challenge the principles of universality, comprehensiveness, and equity, demanding structured, intersectoral, and continuous responses from the Brazilian state (Silva; Lima, 2021). In this context, by ensuring universal access to health actions and services and promoting equity in care, SUS recognizes that historically marginalized groups face specific barriers in access to and delivery of health care, among whom the Black population stands out.

The Ministry of Health is the national manager of SUS and is the body responsible for formulating, coordinating, inducing, and evaluating national public health policies, guiding the work of the federative entities, and promoting equity in access to and delivery of health care (Brazil, 2024). In this context, confronting institutional racism and promoting racial equity are configured as cross-cutting commitments of health policies, requiring the incorporation of this perspective at different management levels (Brazil, 2025a).

The National Primary Care Policy (PNAB) provides guidance for adopting person-centered care, community participation, and an approach focused on the social determinants of health, directing actions toward curbing inequities (Brazil, 2017b). In this regard, Primary Health Care is as the first space of bonding, continuous care, and territorial action, and has strong potential to transform institutional practices and promote social justice. This is because it is within the territory, through longitudinal bonds with individuals and communities, and through the organization of the work processes of health teams that both inequalities and opportunities to transform care practices take shape most directly (Cunha; Giovanella, 2011).

The Secretariat of Primary Health Care (SAPS) plays a strategic role in formulating and monitoring policies, programs, and actions aimed at strengthening PHC as the coordinator of the Health Care Network (RAS) and the main gateway to SUS. Structured into strategic departments, SAPS works in defining guidelines, supporting local management, improving the work processes of teams, and inducing equity-oriented practices in order to reduce health inequities in the territories (Brazil, 2025b).

In this context, since 2003, SAPS has coordinated actions aimed at confronting institutional racism in PHC, and in 2009, the National Policy for the Comprehensive Health of the Black Population (PNSIPN) was implemented (Brazil, 2017a). Thus, in 2023, the Coordination for Care of the Black Population (CAPN) was established within the then Department of Community Health Strategies and Policies (DESCO) of the Ministry of Health. Later, through Decree N°11.798 of November 28, 2025, CAPN became part of the Department of Prevention and Health Promotion (DEPROS). Subsequently, with the publication of Decree N°12.702 of October 31, 2025, CAPN was incorporated into the Department of Family Health (DESF) and restructured as the General Coordination for Care of the Black Population (CGAPN). Since its creation, its work has been cross-cutting and has focused on strengthening antiracist practices, promoting care, improving management, and producing and using health information that highlights racial inequalities and contributes to achieve better public policies.

Furthermore, the PNSIPN (Brazil, 2017a) explicitly addresses the specific needs of the Black population in order to promote equity, recognizing that race, gender, social class, and other social markers exacerbate vulnerabilities and condition different experiences of access to and delivery of health care. Thus, confronting health inequalities is grounded in the principles of universality, equity, comprehensiveness, and social participation, establishing an intersectional dialogue between the foundations of SUS and the guidelines of the PNSIPN and the PNAB.

By integrating the confrontation of institutional racism into its management, care, and monitoring strategies, SAPS reaffirms the Ministry of Health’s commitment to building a more inclusive and equitable SUS. This alignment strengthens the guarantee of the right to health and recognizes racial equity as a central element in improving care and reducing the historical inequalities that mark Brazilian society.

In this regard, this article seeks, from a descriptive perspective, to critically present the historical, normative, and operational construction of policies, actions, and strategies aimed at the health of the Black population within SUS, emphasizing PHC and SAPS’s work. To this end, the integration between the principles of SUS, the PNSIPN, and the PNAB was analyzed, problematizing receptive practices, comprehensive care, and the promotion of equity in care for the Black population.

Thus, the article presents institutional strategies for confronting structural and institutional racism in health services, initiatives for antiracist education in training and professional practice in PHC, communication and health education actions directed at the Black population, as well as the role of health information systems in monitoring racial inequalities, which support SAPS’s work. Based on this approach, the text is organized into thematic axes that problematize advances, challenges, and perspectives, culminating in a critical reflection on possible paths toward strengthening antiracist practices in PHC.

Historical contextualization: recognition of racism and the establishment of affirmative actions to promote racial equality in health

The recognition of racism as a structural and institutional process in Brazil results from a history marked by social mobilization, critical academic production, and the progressive incorporation of the issue into the governmental agenda. The lack of inclusion policies in the post-abolition period contributed to persistent racial inequalities that are systematically expressed in the social determinants of health, such as income, schooling, housing conditions, and access to services (Nascimento, 2002).

In this regard, the 1988 Federal Constitution (Brazil, 1988) represented a milestone by establishing the principle of substantive equality and by recognizing racism as a non-bailable and imprescriptible crime, thereby creating the normative foundations for the formulation of equity-oriented public policies (Werneck, 2000).

At the international level, Brazil’s adherence to human rights treaties and its participation in the Third World Conference against Racism, a fundamental landmark in the global antiracist struggle, reinforced state recognition of racism as a determinant of social and health inequities, driving the institutionalization of specific governmental responses. This process materialized in the creation of institutional structures and legal frameworks aimed at promoting racial equality, consolidating the understanding that universal policies are insufficient to confront racially structured inequalities and require the adoption of affirmative action as a complementary strategy for reducing inequities (Batista, 2012).

In Collective Health, this understanding underpins the incorporation of racism as a social determinant of health and guides the formulation of public policies to promote equity and social justice and reduce avoidable and socially produced inequalities. In this context, affirmative actions and racial equality promotion policies are configured as central elements both for mitigating health inequities and for institutionalizing antiracist policies, consolidating equity-oriented legal frameworks, and adopting strategic participatory management. This approach is grounded in respect for religious freedom, diversity, and gender and racial equality, in order to humanize care and guarantee rights to the largest Black population outside the African continent (Brazil, 2009).

The protagonism of Black social movements in exercising social control has been fundamental to strengthening strategic and participatory management of public policies to confront racism. A relevant milestone was Brazil’s participation in the Third World Conference against Racism, Racial Discrimination, Xenophobia, and Related Intolerance, held in Durban, South Africa, in 2001. Brazil had one of the largest delegations at the event, composed of government and civil society representatives, and was among the countries that signed the document reaffirming that declaration, thereby consolidating its commitment to the guidelines established at the international level, as recorded in the Durban Declaration and Program of Action (2001).

In 2003, the Special Secretariat for Policies to Promote Racial Equality (SEPPIR) was established as an innovative initiative among the African diasporas, with a commitment grounded in social control. In 2010, the National Congress approved the Racial Equality Statute – through Law N°12.288/2010 – which aims to guarantee the fight against discrimination and all forms of ethnic-racial intolerance in order to confront racism.

The health status of the Black population reflects the historical construction of discrimination. Racism affects health care and health practices by contributing to an epidemiological profile marked by profound inequalities and social injustice. Such inequities are expressed in earlier deaths, high maternal and infant mortality rates, greater prevalence of chronic and infectious diseases, and high urban violence levels affecting especially young Black men, as evidenced in the Epidemiological Bulletins published by the Ministry of Health in 2025.

Given the diversity that characterizes Brazilian society in its ethnic, racial, and cultural composition, the challenge of formulating and implementing public policies to promote the population’s social well-being becomes clear. In this context, it is essential to recognize racism as a structuring element of social and health inequalities in the country, directly influencing the living and health conditions of the Black population.

Racism: a social and political concept recognized as a social determinant of health

According to Camara Jones (2000), in order to understand the association between race and the social determinants of health, it is necessary to understand how three racism levels operate. This approach contributes to building proposals aimed at health equity, with effective actions and targets to curb the huge differences observed between Black and non-Black populations. The three proposed levels are:

• Institutionalized racism: mediated by interpersonal relations, institutionalized racism refers to differential access to goods, services, and opportunities. It is normative, often legalized, and frequently manifests itself as naturalized disadvantage. Its structural nature stems from the fact that it is historically encoded in norms, customs, and laws, without the need for an identifiable perpetrator.

• Interpersonal racism: defined as prejudice and discrimination, in which prejudice means assumptions about abilities, motives, and intentions according to racial belonging. Discrimination refers to discriminatory acts based on racial criteria. It may be intentional or unintentional and includes both actions and omissions.

• Internalized racism: understood as the incorporation by members of stigmatized groups of negative messages about their abilities and intrinsic worth.

According to Collins (2020), intersecting identities are social markers that render the Black population vulnerable. In this regard, Crenshaw (2002), in conceptualizing intersectionality, highlights how racism, patriarchy, class oppression, and other systems of discrimination are coordinated, producing naturalized inequalities that structure the relative position of women, racial and ethnic groups, social classes, and geographic conditions.

On the other hand, Aníbal Quijano’s (2005) contributions on the coloniality of power emphasize the idea of race as one of its fundamental axes, understood as a social construction that expresses the experience of colonial domination and permeates central dimensions of power on a global scale. This concept contributes to understanding the complex processes of deconstructing racism and promoting racial equality.

Thus, the challenge of effective management of the PNSIPN incorporates cross-cutting action as a guiding principle. We underscore central points among its general guidelines, such as improving data collection with a race/color focus; training and racial literacy for health professionals in antiracist education; budget monitoring; and promoting the recognition of popular health knowledge and practices, including those preserved by African-based religions. These guidelines also reinforce the appreciation and practice of the principles of interculturality set forth in PlanejaSUS and the National Policy on Popular Education in Health.

National Primary Care Policy (PNAB): mission, shared responsibilities in inter-federative management, and commitment to racial equity

Established by the now-revoked Ordinance N°2.436/2017, the PNAB was consolidated by Annex XXII of Consolidation Ordinance N°2/2017 and defines the guidelines for organizing PHC, recognizing it as the network and care coordinator and the main gateway to the SUS. By reaffirming the principles of universality, comprehensiveness, and equity, the PNAB integrates PHC as a strategic space for expanding access and confronting the inequalities that shape territories and care processes.

In addition, the PNAB provides a normative basis for incorporating the racial perspective into the planning and organization of health services in light of the specific needs of different population groups. Territorialization and empanelment, when guided by the social determinants of health, allow us to identify situations of greater vulnerability, favoring interventions that are better suited to inequalities produced by structural racism.

Longitudinality, care coordination, and community participation directly contribute to the promotion of antiracist practices in PHC. Bonding fosters better identification of situations of discrimination and exclusion experienced by the Black population, while social participation strengthens community protagonism and social control in confronting racial inequities.

In this regard, the Family Health Strategy (ESF), one of the guidelines set for thin the PNAB, highlights the expansion and consolidation of PHC and is fundamental for advancing antiracist practices by working in a territorialized, multiprofessional manner oriented toward the specific needs of the population. When coordinated with the PNSIPN guidelines, the ESF strengthens PHC’s capacity to confront institutional racism by promoting care for historically neglected populations and contributing to the reduction of racial health inequalities.

PHC Secretariat actions to confront institutional racism and implement the PNSIPN

Considering the federal government’s guidelines for social inclusion and in response to the historical demands of Black social movements, the PNSIPN was established on May 13, 2009, through GM/ MS Ordinance N°992/2009. This policy proposes overcoming the epidemiological differences observed between Black and non-Black populations and is committed to guaranteeing racial equity in access to health.

In this regard, aligned with the commitment to confront institutional racism and implement the PNSIPN, the Ministry of Health has developed several initiatives aimed at strengthening antiracist practices in SUS. In this context, actions directed at PHC stand out, as well as initiatives aimed at improving management, care, and the production of health information, such as:

I. Antiracist Strategy in the SUS

The Antiracist Strategy in SUS, established by GM/MS Ordinance N°2.198 of December 6, 2023, aims to confront structural racism in health through the implementation of interministerial and intersectoral actions aimed at promoting equity and social justice. The initiative articulates different policies and programs in order to improve health care and curb inequalities affecting historically vulnerable populations. Its guidelines highlight the strengthening of structuring public policies, such as the PNSIPN, as well as the induction of strategic programs, such as:

• Alyne Network: an initiative aimed at reducing maternal mortality, with emphasis on Black women, which establishes as a specific target a 50% reduction in this indicator by 2027.

• Education through Work for Health Program (PET-Saúde Equidade): a work-based education program that selects projects aimed at training SUS professionals in themes such as intersectionality, ethnic-racial equity, and the confrontation of violence.

• Antiracist Strategy for Early Childhood (PIA): established through Memorandum of Understanding N°10 of November 20, 2023, it is configured as an intersectoral cooperation initiative aimed at confronting racism from birth. The strategy is developed in partnership among the Ministry of Health, the Ministry of Education, the Ministry of Racial Equality, the Ministry of Development and Social Assistance, Family and Fight against Hunger, the Ministry of Human Rights and Citizenship, and UNICEF.

• Improved care: development of specific actions aimed at the care of diseases prevalent in racialized populations, such as sickle cell disease, emphasizing early diagnosis and treatment in children.

• Strengthening care for quilombola communities: expansion of funding for ESF teams working in these territories and increased allocation of professionals through the Mais Médicos program.

• Training and continuing education: offering specialization courses in equity, thematic workshops, and training of equity facilitators for SUS professionals.

• Improved data collection and analysis: inclusion of specific indicators on the quilombola population and other Black populations in health monitoring panels, in order to improve the monitoring of health inequalities.

II. Telehealth Services

With a focus on expanding medical care and reducing inequalities in access to health care, telehealth services in PHC Units (UBSs) provide care to quilombola communities.

III. National Registry of SUS Users (CadSUS)

SUS information systems establish self-declared race/color for all registered users as mandatory, as well as the registration of the “Traditional Peoples and Communities” field, which makes it possible to monitor data aimed at the epidemiological profile and supports the development of prevention protocols directed at populations with specific characteristics.

IV. Training Program for Popular Health Educators (AgPopSUS)

It contributes to the work of popular social movements in defending SUS and the right to health, in order to strengthen popular protagonism, the coordination of knowledge, and popular health education practices in the territories.

V. Bolsa Família Program (PBF)

It is an intersectoral conditional cash-transfer policy that articulates actions in health, education, and social assistance. In health, the program establishes specific conditionalities, operationalized within PHC, such as updating vaccination schedules, monitoring childhood nutritional status, and prenatal care, thereby contributing to expanded access, stronger linkage, and care continuity in the SUS. The program’s beneficiaries are predominantly women, with significant participation of Black women, which gives the PBF strategic relevance in confronting racial inequities in health. By acting on structural social determinants such as income and food security, the program stands out as an instrument for promoting equity, having contributed to overcoming hunger in the country and progressively breaking the intergenerational cycle of poverty.

VI. The School Health Program (PSE)

It is an intersectoral initiative of the Brazilian government that strengthens the articulation between health and education through health promotion actions in the public school environment. The program seeks to improve students’ quality of life and contribute to the comprehensive development of children and adolescents through health promotion and disease prevention actions, encouragement of healthy eating and physical activity, mental health care, prevention of violence, alcohol and other drug use, and sexual and reproductive education. In place in most Brazilian municipalities, the PSE plays a strategic role in reducing health inequities by acting on social determinants from childhood onward and prioritizing historically vulnerable populations, including Black children and adolescents.

VII. Health Information Systems (SIS)

They are central instruments for organizing, monitoring, and evaluating public policies within SUS, including the monitoring of racial inequities in PHC. In this regard, the Health Information System for Primary Care (SISAB), established by GM/MS Ordinance N°1.412 of July 10, 2013 (Brazil, 2013), has become over the last decade a national basis for recording the actions of health teams, supporting financing and adherence to PNAB programs and strategies. More recently, the transition from SISAB to the Primary Health Care Information System (SIAPS) represents an advance in information governance, database integration, and strengthening the analytical capacity of federal, state, and municipal management.

In PHC, information systems are important tools for supporting health surveillance, territorial planning, and the evaluation of care practices from the perspective of racial equity (Coelho Neto; Chioro, 2021). In this context, the publication of Ministry of Health Ordinance N°344 of February 1, 2017 (Brazil, 2017c), represented a milestone in the institutionalization of the race/color variable in SUS health information systems by establishing its mandatory completion in forms and systems, based on IBGE classification and the principle of self-declaration. The regulation explicitly identifies race/color as essential information for monitoring health inequalities and recognizing racism as a social determinant of health (SDH). The disaggregated analysis of these data, articulated with other social markers – such as territory, gender, age, and socioeconomic status – expands the capacity to understand inequities and strengthens the targeting of more contextualized interventions that are sensitive to local specificities, although their effective incorporation into the daily practices of health services remains an ongoing challenge.

Despite the robust normative framework presented, the implementation of several actions reveals a bottleneck between the formality of ordinances and the capillarity of antiracist practices in the daily routine of delivered services. The implementation of the mandatory race/color field in CadSUS, for example, may be reduced to a bureaucratic act of completion through presumed hetero-identification by the professional, which compromises the reliability of the data and the user’s autonomy. Thus, the transition from regulation to practice requires not only the existence of programs but also a change in organizational culture that prioritizes racial equity as a care quality indicator.

Challenges and perspectives

Despite normative advances and the expansion of intersectoral programs aimed at improving quality of life and health conditions, persistent structural challenges limit their equitable impact, especially for the Black population. These challenges are associated with the reproduction of historical inequalities in access to services, fragmented care networks, insufficient intersectoral coordination, and overloaded PHC services in territories marked by social and racial vulnerabilities (Cobo, 2021).

Improving health information systems is one of the main challenges for PHC. Although these systems have strong potential to support the analysis and monitoring of racial health inequities (Coelho Neto; Chioro, 2021), their effectiveness depends on qualified incorporation and proper completion as part of daily practice in health services (Braz et al., 2013). When properly recorded and analyzed, this variable reveals historically invisible inequalities, highlighting distinct patterns of diagnosis, prognosis, access to health services, and quality of care, which result in different outcomes and limit the State’s capacity to formulate effective and equitable responses (Coelho et al., 2024).

Studies show that Black people face greater challenges in accessing health services, reduced availability of medicines, worse clinical outcomes, and greater exposure to discriminatory practices than the White population, even when they present similar socioeconomic and educational conditions (Williams; Collins, 2001). In the case of Black women, these inequalities are aggravated by the intersection between racism and sexism, resulting in higher maternal mortality rates, less access to care technologies, and the discrediting of their complaints in health services (Crenshaw, 1989; Davis, 2016). In the Brazilian context, authors such as Werneck (2016) and Batista (2017) show that institutional racism in SUS compromises equity, contradicting the constitutional principle of universality, by reproducing racial and gender inequalities in access to and provision of care.

Moreover, although the Alyne Network program seeks to improve maternal care by reducing avoidable deaths, racial inequalities persist, evidenced by lower-quality prenatal care, reduced access to tests, late referrals, and greater exposure to obstetric violence among Black women (Lessa et al., 2022; Leal et al., 2017). These factors reveal persistent institutional racism in health services, operating on a daily basis in clinical decision-making and in the organization of the care network.

Conclusion

Because of its broad capillarity, PHC is essential for implementing health policies, inducing good practices in territories, producing strategic information, promoting continuing team education, improving policies, and guaranteeing universal, comprehensive, and equitable access. In this context, SAPS is strategic in institutionalizing actions aimed at confronting structural racism. The PNSIPN guidelines, in turn, establish clear responsibilities for the three SUS management levels, guiding efforts to promote racial equity, improve care, and curb health inequities, aligned with epidemiological evidence on structural inequalities.

The antiracist actions listed in this text are fundamental to achieving health equity and social justice. However, racial equity depends on individual commitment that recognizes, questions, and transforms discriminatory practices in everyday life, incorporating antiracist attitudes both in health care and in social interactions.

However, antiracist practices require not only the formulation of specific policies and programs, but also the transformation of care practices and of the knowledge production processes that guide system management, so as to integrate racial equity as a structuring principle rather than merely a normative guideline.

Data Avaibility Statement:

The content underlying the research text is contained in the manuscript.

Financial support:

There wasn’t any.

Acknowledgments:

We would like to thank all the contributors who, in one way or another, helped bring this project to fruition.

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Correspondence

Gleiciane Avelar, Email: [e-mail], Esplanada dos Ministérios - Bloco O - Plano Piloto, Brasília, DF, Brazil, Zip code: 70050-000.

Editors:

José Miguel Olivar, Raquel Souzas

Publication Dates

• Publication in this collection
  17 Aug 2026
• Date of issue
  2026

History

• Received
  25 Mar 2026
• Reviewed
  27 Apr 2026
• Accepted
  01 Jan 2026