By: Rose Zulliger
Case Studies of Large-Scale Community Health Worker Programs was derived from Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policymakers, edited by Henry Perry, Lauren Crigler, and Steve Hodgins.
Originally published in May 2014 by USAID’s flagship Maternal and Child Health Integrated Program (MCHIP), it was created in response to the rapid increase in and expansion of CHW programs in low- and middle-income countries over the past decade. In January 2017, a companion document was prepared to provide guidance on 13 case studies, including Afghanistan, Bangladesh, Brazil, Ethiopia, Niger, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia, and Zimbabwe. CHW Central is serializing the case studies over time. We will be releasing each case study bi-weekly on CHW Central.
This next case is on Brazil.
The Programa Saúde da Família (Family Health Program, now called the Family Health Strategy and abbreviated PSF) was launched in 1994, building upon several previous decades of experience in rural underserved areas with Community Health Agents (CHAs), who were legally recognized as professional in 2002. Currently, Brazil has 236,000 CHAs working as part of 33,000 family health care teams (Equipos de Saúde Familiar).
Originally, CHAs provided vertical (centrally directed) MCH services (such as immunizations and FP) in isolated rural areas where services were limited, but have evolved into the cornerstone of the national PHC program that reaches virtually the entire population of the country. CHAs operate as members of the family health care teams that are managed by municipalities. With usually 4–6 CHAs on each team (but sometimes more), each CHA is responsible for 150 families (ranging from 75 to 200 households). Some teams also include a dentist, an assistant dentist, a dental hygienist, and a social worker.
The CHAs are often selected by local health committees, and they must be literate adults who work in the community where they reside. The training of CHAs is conducted at the national Ministry of Health (MOH), but the training curriculum is approved by the Ministry of Education. Nurses provide 8 weeks of formal didactic training at regional health schools.Following this, CHAs receive 4 weeks of supervised field training. CHAs also receive monthly and quarterly ongoing training.
The scope of work for the health care teams varies with geographic distribution, but most teams provide comprehensive care through promotive, preventive, recuperative, and rehabilitative services. CHAs register the households in the areas where they work and are also expected to empower their communities and link them to the formal health system.
CHAs are full-time salaried workers earning in the range of $100 to $228 per month.
CHAs are supervised by nurses and physicians from the local clinics. Supervisory nurses spend 50% of their time in these supervisory roles and the rest of the time working in the local clinic.
Brazil has experienced dramatic improvements in a broad range of national health indicators over the past 3 decades, and much of this progress is attributable to the strength of its PHC program and the critical role played by CHAs.
What is the historical context of Brazil’s Community Health Worker Program?
The Brazilian health system dates back to large-scale vaccination and other public health campaigns that were implemented by sanitary police in the late 1800s and early 1900s. The history of the health system is well-characterized by Paim and colleagues in the recent Lancet Series on Brazil.1 Briefly, the health system was shaped by the country’s tumultuous history. Public health was institutionalized under the Vargas dictatorship in the 1930s and 1940s, and the first MOH was later formed in 1953. A strong private health care system also developed in the 1950s; it continued to expand with the support of the federal government, as did PHC programs. In the 1980s, the country transitioned from dictatorship to democracy, and 1985 marked the start of the New Republic. The Eighth National Health Conference in 1968 established the notion that health is “a citizen’s right and the state’s duty.”
The Sistema Único de Saúde (SUS, or Unified System of Health) was instituted as part of the constitution in 1988. The system has its origins in the struggle for democracy within the country. Government responsibilities for health are defined broadly as encompassing social and political realities along with traditional medical services.1 This includes the support of efforts to provide free access to health care services as well as social protection, social mobilization, and expansion of social rights to facilitate “community participation, integration, shared financing among the different levels of government, and complementary participation by the private sector.”2-4 States and municipalities were given taxation authority, and federal guidelines mandated that 10% of this revenue be allocated to health (since then this minimum has been raised to 12% for states and 15% for municipalities).5
CHW programs have been implemented in Brazil for decades, including the successful Visitadora Sanitaria (health visitor) program in which CHWs provided immunizations, information, and various other MCH interventions.6 The CHA program was initiated in the 1980s as a pilot program in Ceará, one of the poorest areas of Brazil. Its success influenced subsequent PHC programs.7
The CHA program started during a drought and followed several successful pilot projects, including a project that trained 6,000 women in 112 municipalities. The women received 2 weeks of training to promote breastfeeding, the use of ORS, and immunization uptake.5 In 1989, 1,500 of these original 6,000 CHWs were incorporated into a new CHA system, supervised by local nurses. These CHAs provided mostly health promotion and health education services in clearly defined geographic areas near their homes. This program was highly successful and served as a model for subsequent CHA programs.5 It did, however, face formal resistance from nurses for a variety of reasons, including unclear roles and overlap of CHA work with that of auxiliary nurses.8 The first national CHA program was developed in 1991 and implemented as part of Brazil’s first national PHC program; later, it was integrated into the PSF.9
The PSF was launched in 1994 to expand health care access to the poorest Brazilians.4 CHAs in programs like the Ceará one were integrated into the PSF.5 In 1996, the federal government transferred control of the management and financing of health care services to the PSF and in 2002 CHAs were officially recognized as professionals by Law No. 10.507/2002.10,11 CHAs originally provided vertical MCH services, but have evolved into the cornerstone of PHC services.1
Brazil has made important advances in other areas of health care. It was one of the first middle- income countries to provide free antiretroviral medication for patients with HIV/AIDS. It has developed legislation supporting the use of generic drugs, and it has strong government regulation of private health plans.
What are Brazil’s health needs?
Brazil has undergone a demographic, epidemiological, and nutritional transition since the 1970s. During this transition, fertility, infant mortality, and illiteracy have all decreased as life expectancy and urbanization have increased.1 For example, the infant mortality rate (IMR) has declined from 114 deaths per 1,000 live births in 1975 to 19 deaths per 1,000 live births in 2007. Life expectancy has increased from 52 years in 1970 to 73 years in 2008.1 The country also has a strong HIV/AIDS program; has completely eliminated polio; and has almost eliminated measles, diphtheria, and Chagas disease.12
Despite these positive advancements, the country is plagued by increasing levels of non- communicable diseases, including very high levels of hypertension and diabetes.1 Other persistent health challenges include overuse of health care services and medications, and challenges in the field of reproductive health such as high levels of utilization of unsafe abortion services, high rates of adolescent pregnancy, and high rates of mother-to-child transmission of sexually transmitted infections.4 There is also a large burden of homicide and traffic-related deaths, and dengue and visceral leishmaniasis remain important problems.12
What is the existing health infrastructure?
There are three levels of health care provided in Brazil, but the country strongly emphasizes the first level—basic PHC. This level is the entry point to more advanced care and includes promotive and preventive components. Family health care teams are the main service providers and comprise one doctor, one nurse, one auxiliary (assistant) nurse, and a minimum of four CHAs.1,3 Secondary care, consisting of community-level hospitals, has many challenges, including its high reliance upon the private sector.1 Tertiary care is provided at specialty referral hospitals, mostly by the private sector and public teaching hospitals, leading to high costs among other challenges.1
The current health system consists of the SUS, a private subsector, and a private health insurance subsector. The private sector is regulated by the National Supplementary Health Agency (Agência Nacional de Saúde Suplementar).10 Private providers are often subcontracted by the SUS to provide a range of services at the secondary and tertiary levels. Coordinating the mix of public and private services remains a challenge for Brazil’s health system.13 The private subsector has grown substantially with state support, while the public subsector of PHC services remains often underfunded, which potentially compromises its ability to guarantee quality of and access to PHC.1 Additionally, private health insurance is disproportionately used in the southeast and south regions of Brazil. Overall, 75% of Brazilians are dependent solely on the SUS for health care.14
CHAs employed by the PSF are hired through special contracts in order to expedite hiring and provide more competitive salaries than is legislated for civil servants in Brazil. This has many benefits, but it means that CHAs lack job security and fringe benefits afforded to other civil servants, leading to higher staff turnover.12
Finally, a central feature of the Brazilian health system is the engagement of civil society in decisions about government health programs. This is structured by the formation of councils at the federal, state, and municipal levels, along with the periodic use of health conferences.2
What type of program has been implemented?
CHAs are closely integrated into formal health services.5 They operate as members of the family health care teams described above that are managed by municipalities.7 Throughout Brazil’s population of approximately 200 million people, there are 236,000 CHAs working in 33,000 family health care teams.1 These teams are based within PSF clinics and provide services to usually 600–1,000 families (1,500–3,000 people), but they occasionally serve as many as 4,500 people.1 With 4–6 CHAs on each team normally, each CHA is responsible for 150 families (ranging from 75 to 200 households). Some teams also include a dentist, an assistant dentist, a dental hygienist, and a social worker.14,15 CHAs are part of the team that primarily operates outside of the health facility to provide health education promotion and linkage to referral services.3 One study of CHAs in Araçatuba, a city in São Paulo state, found that 83% of CHAs reported good communication within the teams, although some CHAs felt that physicians undermined their work.8 Unfortunately, there are no structured opportunities for career advancement for CHAs.14
The scope of work for the health care teams varies with geographic distribution, but most teams provide comprehensive care through promotive, preventive, recuperative, and rehabilitative services. Key services provided by CHAs include the promotion of breastfeeding; the provision of prenatal, neonatal, and child care; the provision of immunizations; and participation in the management of infectious diseases, such as screening for and providing treatment for HIV/AIDs and TB.16,17 CHAs register the households in the areas where they work and also are expected to empower their communities and link them to the formal health system.14 However, not all CHAs receive training on community mobilization and not all are engaged in this activity.8,14
In the 1990s, CHAs were trained to provide integrated management of childhood illness (IMCI) in the home, including providing prescription antibiotics for children suspected of having pneumonia. Unfortunately, this stopped in 2002 following pressure from medical societies.f Nurses have also pressed against allowing CHAs to administer injections.12
Other significant cadres of CHWs in Brazil include those trained and supported by the Catholic NGO Pastorate of the Child. This NGO has a network of 260,000 volunteer CHWs who promote child survival through low-technology interventions such as the administration of ORS for childhood diarrhea.4
What about the community’s role?
One of the goals of the PSF program is to “promote the organization of the community” and to analyze the community’s needs.18 Thus, CHAs are expected to serve as the link between family health care teams and the communities served by the teams.9 The community is also involved in the organization and budget of the health system, and some municipalities and states have developed a system in which the public is able to vote on the proportion of the municipal budget allocated to health.
In 1993, health councils were functioning in 84% of the rural municipalities of the state of Ceará in northeastern Brazil. These councils were responsible for conducting assessments and making recommendations on health priorities and collection and disbursement of funding, among other roles.5 A 2001 review of CHAs in the city of Araçatuba, São Paulo, found that municipal health councils—comprising representatives from government, health services, and the community—were responsible for the allocation of financial resources for health. They also developed health strategies and mobilized communities’ involvement in health.
There are now health councils operating at a national, state, and municipal level with over 5,500 municipal councils throughout the country. Council membership is allocated as follows: 50% are users, 25% are health workers, and 25% are health managers and service providers. Health conferences are also held every 4 years to “propose directives for health policies.”12
How does Brazil select, train, and retain Community Health Agents?
The CHAs in the early Ceará program were selected by local health committees. There were two selection criteria: (1) they had to come from and reside in the area where they would be working and (2) they had to be literate.16,17 At the outset, priority was given to recruiting CHAs in households most affected by the drought as well as on their responses to hypothetical community problems presented during the selection process.5,14,19
CHA training is conducted in regional health schools operated by the national MOH using curricula approved by the Ministry of Education.14,19 CHAs receive 8 weeks of training from local nurses, followed by 4 weeks of supervised fieldwork. This includes training on home visits and how to conduct a family census, and then on specific priority health care interventions.
CHAs receive monthly and quarterly ongoing education training during meetings5,14 Those who teach CHAs receive an 80-hour training module.14,20
CHAs are salaried, full-time workers. In 2006, CHAs in Araçatuba earned a monthly salary of 500 Brazilian reals (US$228), representing 22.3% of the total family health care team’s salary costs. However, the Araçatuba CHAs had higher education levels than most CHAs in the national program, where the monthly salary is 40% to 50% lower.8,14
How does Brazil supervise its Community Health Agents?
CHAs are supervised by nurses and physicians from the local clinics.20 Supervisory nurses spend 50% of their time in these supervisory roles and the rest of the time staffing the local clinic. The role of the nurse as a supervisor is clearly defined, and nurses have protected time to perform their supervisory role. Strong supervision of CHAs has been identified as one of the important contributors to the program’s success.21
Brazil also has strong referral systems. CHAs report any ill person within their catchment area to a nurse and the CHA may, at times, escort the person to the local health facility. Upon the patient’s release, the CHA is expected to maintain the continuum of care and follow up with the patient. This role performed by CHAs helps to ensure accountability of the health system to local health needs.14
The PSF has an information system that utilizes data collected by CHAs.14 This has helped to strengthen vital statistics reporting, rapid identification of problems, and implementation of locally relevant solutions.1,5
How is the Programa Saúde da Família financed?
The recent health advancements in Brazil have occurred alongside an evolving health system and increased investment in health. Between 1990 and 2010, the proportion of the gross domestic product (GDP) spent on health increased from 6.7% to 8.4%. Out-of-pocket expenditures have increased steadily as have other expenditures in the private sector such that now, 57% of health-related expenditures are from the private sector. The growth of funding from the public sector has been more constrained.1
The financing of the health system in Brazil is decentralized and arises from a variety of funding sources, including taxes, social contributions, out-of-pocket expenditures, and employer health insurance purchases.1 The PSF provides services free of charge to recipients, and the program is financed on a capitation basis with incentives for municipalities to increase coverage.7 Since 1996, states and municipalities have been responsible for the management and financing of health care. Now, states must allocate at least 12% of their total budget to health; municipal governments are required to spend 15% of their total budget on health—a requirement met by 98% of municipalities.
In 2006, the Brazilian government health expenditure was $252 per person, which is less than in neighboring countries such as Argentina ($336) and Uruguay ($431). An estimated additional
$100 per person is spent each year in order to achieve universal health coverage in Brazil.10
What are the program’s demonstrated impact and continuing challenges?
Brazil has experienced dramatic improvements in a broad range of national health indicators over the past 3 decades. This includes marked increases in access to MCH interventions and marked reductions in maternal, infant, and child mortality as well as marked reductions in childhood stunting. There have also been reductions in the health disparities within the country. The Millennium Development Goal (MDG) 1 indicator of a 50% reduction in the percentage of underweight children and the MDG 4 indicator of a two-thirds reduction in under- 5 mortality between 1990 and 2015 have already been met.4,12
A variety of factors such as socioeconomic development, social improvements, and conditional cash transfers have facilitated this progress, but the PSF and various health interventions have been critical components in the improved health indicators.4 Victora and colleagues used vital statistics, United Nations model life tables, and census data to compare infant mortality in areas with different levels of PSF coverage. They found that while infant mortality was highest within poor communities irrespective of level of PSF coverage, when PSF coverage was higher, the mortality differences between poor and rich communities were less.4
Macinko and colleagues used public data from each state to determine the impact of the program on infant mortality from the pre-intervention period (1990 to 1994) to the period from 1999 to 2002, when PSF expansion had occurred.8 During this time period, the IMR decreased from 49.7 per 1,000 live births to 28.9 and PSF national coverage increased by 36.1%. The authors found a significant and temporal relationship between coverage by PSF and decreased IMR. A 10% increase in PSF coverage was associated with a 4.6% decrease in the IMR, holding all other variables constant. A different analysis found that the program was associated with a 13% to 22% reduction in the IMR, depending on the level of PSF coverage.17 Additional analyses of municipal-level data found that exposure to the PSF program was associated with a reduction in mortality, with the greatest impact on under-5 mortality. The programmatic impact was largest in the poorest municipalities as well as in the more rural regions in the country with worse baseline health indicators.17,18
Current challenges within the Brazilian health system include a high turnover of the PHC workforce, lack of integration between different primary health clinics, lack of investment in linkages and integration between PHC and other levels of care, and management challenges. The competing interests of the health system subsectors also require a reconsideration of the most appropriate roles of the public and private sectors.1 Additionally, patients are provided very different levels of care by private providers depending on whether their care is funded by the SUS or by private health insurance, and there are concerns related to low quality of care provided for patients whose care is funded by the SUS. There are perverse incentives for private providers to provide more services (such as cesarean sections) since they are reimbursed by fee- for-service (as in much of the United States). There are also rising costs for private health care, and the SUS remains underfunded.1,12 Progress has been made toward reducing socioeconomic and regional gaps in service access and in health indicators, but gaps remain and there are some charges of insufficient commitment by the federal government to the SUS.10,12
- Starfield B. Primary Care: Concept, Evaluation, and Policy. New York, NY: Oxford University Press; 1992.
- Fleury S. Brazil’s health-care reform: social movements and civil society. Lancet. 2011;377(9779):1724-1725.
- Macinko J, Guanais FC, de Fatima M, de Souza M. Evaluation of the impact of the Family Health Program on infant mortality in Brazil, 1990-2002. J Epidemiol Community Health. 2006;60(1):13-19.
- Victora CG, Aquino EM, do Carmo Leal M, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet. 2011;377(9780):1863- 1876.
- Svitone EC, Garfield R, Vasconcelos MI, Craveiro VA. Primary health care lessons from the Northeast of Brazil: the Agentes de Saúde Program. Rev Panam Salud Publica. 2000;7(5):293-302.
- Rice-Marquez N, Baker TD, Fischer C. The community health worker: forty years of experience in an integrated primary rural health care system in Brazil. J Rural Health. 1998;4:87-100.
- Macinko J, Marinho de Souza Mde F, Guanais FC, da Silva Simões CC. Going to scale with community-based primary care: an analysis of the family health program and infant mortality in Brazil, 1999-2004. Soc Sci Med. 2007;65(10):2070-2080.
- Zanchetta MS, McCrae Vander Voet S, et al. Effectiveness of community health agents’ actions in situations of social vulnerability. Health Educ Res. 2009;24(2):330-342.
- Kluthcovsky AC, Takayanagui AM. Community health agent: a literature review. Rev Lat Am Enfermagem. 2006;14(6):957-963.
- Jurberg C, Humphreys G. Brazil’s march towards universal coverage. Bull World Health Organ. 2010;88(9):646-647.
- Government of Brazil. Portal da Saude—SUS. 2013. Available from: http://portal.saude.gov.br/portal/sgtes/visualizar_texto.cfm?idtxt=23176. Accessed 2013.
- Victora CG, Barreto ML, do Carmo Leal M, et al., and the Lancet Brazil Series Working Group. Health conditions and health-policy innovations in Brazil: the way forward. Lancet. 2011;377(9782):2042-2053.
- Kleinert S, Horton R. Brazil: towards sustainability and equity in health. Lancet. 2011;377(9779):1721-1722.
- Bhutta ZA, Lassi ZS, Pariyo GW, Huicho L. Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems. Geneva, Switzerland: WHO and Global Health Workforce Alliance; 2010.
- UNICEF. State of the World’s Children 2009: Maternal and Newborn Health. New York, NY: UNICEF; 2009.
- Prado TN, Wada N, Guidoni LM, Golub JE, Dietze R, Maciel EL. Cost-effectiveness of community health worker versus home-based guardians for directly observed treatment of tuberculosis in Vitoria, Espirito Santo State, Brazil. Cad Saude Publica. 2011;27(5):944- 952.
- Aquino R, de Oliveira NF, Barreto ML. Impact of the family health program on infant mortality in Brazilian municipalities. Am J Public Health. 2009;99(1):87-93.
- Rocha R, Soares RR. Evaluating the Impact of Community-Based Health Interventions: Evidence from Brazil’s Family Health Program. Bonn, Germany: IZA; 2009.
- Celletti F, Wright A, Palen J, et al. Can the deployment of community health workers for the delivery of HIV services represent an effective and sustainable response to health workforce shortages? Results of a multicountry study. AIDS. 2010;24(suppl 1):S45-S57.
- CHW Technical Task Force. One Million Community Health Workers: Technical Task Force Report. New York, NY: The Earth Institute; 2011. Available at: http://www.millenniumvillages.org/uploads/ReportPaper/1mCHW_TechnicalTaskForceRepo rt.pdf.
- Liu A, Sullivan S, Khan M, Sachs S, Singh P. Community health workers in global health: scale and scalability. Mt Sinai J Med. 2011;78(3):419-435.