Ethical considerations in decentralizing antivenom treatment in indigenous territories of the Brazilian Amazonia

Snakebite envenoming disproportionately affects Indigenous populations in the Brazilian Amazon, where centralized healthcare systems limit timely access to antivenom. The recently implemented SAVING Program has decentralized antivenom delivery to Indigenous primary healthcare facilities, improving access and clinical outcomes. This article examines the ethical considerations encountered and the approaches adopted to address these challenges. Using the WHO/TDR framework for ethics in implementation research as a starting point, we continuously adapted to ethical issues arising during the planning, implementation, and dissemination of the program. The analysis was informed by focus groups and stakeholder discussions involving Indigenous leaders, patients, healthcare professionals, health managers, policymakers, and representatives of Indigenous governance structures. Key themes included community and stakeholder responsiveness, informed consent, balancing risks and benefits, culturally appropriate standards of care, data governance, sustainability, and benefit sharing. Decentralizing antivenom delivery can improve equitable access to lifesaving treatment while strengthening Indigenous health systems. To date, the program has demonstrated the feasibility of building sustainable partnerships with Indigenous communities, enhancing acceptance and equity. The ethical lessons from the SAVING Program may provide practical guidance for implementing health innovations in Indigenous and other historically underserved communities.