Health in Brazil

In the 1980s the socioeconomic indicators in Ceará, a state of about 7 million people in northeast Brazil, were among the worst in the country. The infant mortality rate was around 100 per 1,000 live births. Fewer than 30 percent of municipalities had a nurse. And essential health services reached only 20–40 percent of the population. In 1986 the state government began a massive effort to reduce infant deaths. It succeeded: by 2001 infant mortality was down to 25 per 1,000 live births. By 2001 more than 170,000 community health agents covered 80 million Brazilians. Socioeconomic inequalities in coverage were also reduced, and the greatest improvements were made among the poorest of the population.

To encourage municipalities to participate, Ceará state officials tried to create a strong “image” program. Citizens were informed of its benefits, and they lobbied mayors to join the program. Implementation was phased in, beginning with municipalities that demonstrated interest and readiness, stimulating competition among municipalities.

This new Health Agent Programme required the recruitment of 7,300 new basic community health workers (mainly women) and 235 nurse-supervisors to carry out infant vaccinations and child preventive health campaigns. Recruitment of these non-tenured, low-skill field workers from the same communities in which they were to work was conducted centrally by the office of the state governor. This bypassed the patronage systems of the local mayor, and even the control of the health department. The state lavished an unusual amount of publicity on the large local recruitment process, thereby ensuring that considerable public prestige was given to attainment of the job on merit. This was the first step in building the state-citizen sense of joint purpose which has sustained the programme. Unsuccessful applicants and community members were encouraged from the start to act as unofficial monitors of the programme and to report both poor performance and success stories.

The three months’ training was more than tenured public sector workers normally received.

Health agents were immediately noticed and welcomed by local communities, thanks to their ‘uniform’ of a white T-shirt emblazoned with the programme’s name, blue backpacks filled with supplies, and their substantial presence – between 30 and 150 – in the locality. The enormous publicity given to the ‘noble’ mission of improving local health also endeared workers to the local community, something that contributed to their job satisfaction. Together, these elements produced an unusual sense of ‘calling’ in the health agents, which became an informal accountability mechanism, producing self-monitored responsiveness in service delivery.

New standards of care evolved as a result of close interactions between individual health workers and their clients, mothers receiving health agents in the privacy of their homes. The need to establish trust with clients prompted an expansion of the job into simple curative interventions such as removing stitches, treating wounds, taking sick children to hospital, as well as a range of socially supportive tasks such as cutting children’s hair, helping with childcare, or assisting with cooking or cleaning.

Accountability systems relied in part upon building tremendous publicity and public interest in the program, resulting in exposure of any poor performance. The ‘self-expanding’ nature of the work, the way the job evolved into a mothers’ support system, created new public expectations from public sector workers. In other words, health agents came to be held to account for new standards of care, including the demonstration of empathy, responsiveness and integrity.

Accountability also relied in rewards (public prizes and celebrations) for successes. Community organizations were involved in the assessments for the Municipal Seal of Approval—a program to give incentives to municipalities to improve outcomes. This Seal required that municipalities have better-than-average health indicators for the group in which the municipality was classified, based on socioeconomic criteria. Color-coded maps and scorecards facilitated monitoring and recorded the evolution of indicators.

Using matching funds to motivate municipalities to implement new programs, Ceará state policymakers struck a balance between decentralizing responsibilities to the municipalities and keeping a results focus through state control over key aspects of the program. Strategies were also developed to strengthen community leverage over health providers and to strengthen community voice.

Source: The world development report 2004; Tendler & Freedheim, in: Goetz & Jenkins, 2001.