How did Brazil implement?

Brazil’s CHW program reflects the country’s aspirations as it ended military rule and began its journey toward a more egalitarian and democratic governance and economic system. Civil society leaders led this transition and pushed for a CHW program capable of realizing their vision – a universal health care system delivering essential care to all Brazilians. A few key strategies helped the program achieve and sustain its remarkable scale and impact: innovative financing, decentralization, community ownership, piloting, and monitoring and evaluation. We will discuss each of these tools in this section.

To expedite the implementation of the Family Health Strategy and ensure a steady revenue stream for participating municipalities, Brazil adopted three innovative funding mechanisms: thresholds for health care spending, financial incentives for municipalities to adopt the Family Health Strategy and benefit the poorest municipalities, and a pay-for-performance program to improve quality.

First, Brazil adopted a constitutional amendment in 2000 that established minimum thresholds for state and municipal funding of health care. Brazil requires state and municipal governments to spend at least 12 percent and 15 percent, respectively, of their budget on health.

These minimum thresholds, in addition to robust GDP growth, which increased by 94 percent between 1995 and 2015, contributed to increased health expenditures. During this period, total per capita health care spending (which includes government, out-of-pocket, donor funding, and prepaid private insurance spending) increased by 60 percent, and government per capita health care spending increased by nearly 80 percent. During this time frame, Brazil received little funding from donors.

In Brazilian reals (R$), federal funding for primary health care increased nearly fivefold from 2000 to 2015, from R$17 to R$76. These funds paid for, among other items, new primary health care facilities, equipment, and increased staffing.

Brazil then adopted the Piso de Atenção Básica (Primary Care Salary Floor; PAB), which incentivized municipalities to adopt the Family Health Strategy program, accelerating its expansion. The formula included a fixed per capita payment to municipalities and a variable payment based on their ability to meet certain targets, like increased coverage and reaching high-risk groups.

Then, to improve the quality of care, in 2010, Brazil adapted the PAB formula and created one of the world’s largest pay-for-performance programs, the Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (National Program for Access and Quality Improvement in Primary Care). Under this financing formula, municipalities with poor health indicators could receive more funding if they launched or improved their Family Health Strategy program. Funding was contingent on measured improvements in the management of health services, technical quality of care, and user satisfaction.

These mechanisms helped increase federal funding for CHWs exponentially from 1998 to 2014. In 1998, federal transfers to municipalities for CHWs totaled just over R$98 million, or less than R$1 per capita. By 2014, federal transfers to municipalities for CHWs totaled R$3.2 billion, or R$15.6 per capita. Austerity policies introduced by the government in 2015, however, have led to major cuts in the health and education budgets, and the health budget is projected to decrease by almost 10 percent per capita.

Despite this, by 2018 nearly all (98 percent, or 5,475 of 5,570) municipalities had implemented the Family Health Strategy, transforming Brazil’s health system into a proactive and responsive system focused on health education, provision of preventive and promotive services, a strong referral system, and the use of data to broadly improve quality of life. An army of CHWs served at the front line to ensure the success of this system.

In 2017, approximately 238,000 CHWs in Brazil worked within 43,000 local health teams, covering approximately 60 percent of the population.

Brazil’s decentralization efforts were sparked by a desire to reduce regional inequities and free local governments, financially and politically, to develop and implement policies and programs appropriate to their needs. Nowhere was this desire stronger than in the health sector. As a result, the health sector was the only sector that Brazil fully decentralized.

Decentralization of the health sector in Brazil did not just transfer power to municipalities. It also established new rules and administrative reforms that fundamentally changed decision-making processes and roles at each level of government.

Decentralization gave more independence to municipalities, but it also expanded federal oversight, specifically by the Ministry of Health. Responsibilities at the national, state, and municipal levels of government are outlined as follows:

Federal Ministry of Health

Under Brazil’s decentralized health system, the federal Ministry of Health is the national manager of the Unified Health System and provides high-level guidance to municipalities as they implement the Family Health Strategy. The Ministry of Health is responsible for establishing national guidelines, goals, and technical standards, funding the efforts of states and municipalities to implement the strategy, determining allocation formulas, coordinating monitoring and evaluation, and regulating private health care providers.

At the federal level, a committee – including representatives from municipal and state health authorities as well as representatives from the Ministry of Health – negotiates processes and standards, arriving at decisions by consensus.

States

State governments are responsible for coordinating, co-funding, and monitoring the Family Health Strategy implemented by municipalities. State-level committees – which include representatives from municipal and state health authorities – negotiate processes and standards within each state, arriving at decisions by consensus.

Municipalities

Municipalities have the freedom to decide which programs they should implement  to benefit their constituents. Municipalities can use federal block grants (which started in 2006) for broad line items such as primary care. Municipalities that implement the Family Health Strategy manage contracting, training, supervising, and paying for health worker salaries, supplies, and infrastructure. Decentralization was meant to strengthen the capacity of local authorities to manage these responsibilities and was accompanied by some funds and mechanisms for increasing capacity. Not all municipalities, however, were able to take on these responsibilities. Poorer municipalities, which need the Family Health Strategy program most, are often least equipped to successfully implement it (see  section).

Research indicates that municipalities with smaller populations, higher levels of poverty, and a higher proportion of black and mixed-race residents were more likely to implement the Family Health Strategy. Municipalities in wealthy areas, where people are more likely to have private health insurance, were less likely to implement the Family Health Strategy. Poorer states in the Northeast region generally have 75 to 90 percent coverage. Wealthier states in the Southeast region, which see the program as a mismatch with their needs, average 60 to 70 percent coverage rates.

Health councils at the federal, state, and municipal levels reflect Brazil’s commitment to community ownership: 50 percent of council members are ordinary citizens, 25 percent are frontline health workers like CHWs and nurses, and 25 percent are health managers and senior staff. The health councils play a vital role in establishing accountability and transparency by continuously monitoring the program and releasing performance indicators and impact data to the public.

These health councils are considered part of the basic structure of state and municipal health authorities. More than 5,000 municipal health councils and 27 state councils currently exist. These councils participate in developing healthcare strategies and proposals, decisions over resource allocation, infrastructure development and management, and program implementation.

The institutional and budgetary political commitment necessary to achieve the transformation of Brazil’s health sector was achieved through the long-term efforts of civil society activism.

Brazil’s CHW program is the product of a civil society reform movement sparked by public health research in the 1970s and early 1980s. The widely circulated research painted a worrying picture – a wealthy urban elite enjoyed health coverage, while wide swaths of the country went without basic primary care. Those without health coverage suffered from high rates of poverty-related health challenges, including diarrhea and malnutrition.

Public health experts responded by launching the Movimento da Reforma Sanitária (Sanitary Reform Movement). The movement was initially led by medical professionals and public health researchers. Over time, it would expand to include civic organizations, labor unions, progressive elements of the church, neighborhood associations, and left-wing politicians and bureaucrats. The movement maintained a focus on promoting comprehensive whole person primary health care, citizen engagement, and intersectoral collaboration to achieve universal health coverage and equity.

Two civil society organizations led the reform movement: Centro Brasileiro de Estudos de Saúde (Brazilian Health Studies Center; CEBES), a research and advocacy organization; and the Associação Brasileira de Pós-Graduação em Saúde Coletiva (Collective Health Postgraduate Association; ABRASCO), an association of postgraduate programs in public health.

These organization framed health not just as a result of purely biological factors, but also as influenced by social factors, especially poverty. Reformers demanded both the inclusion of civil society in the design and implementation of health care reforms and the state provision of health care to all.

CEBES introduced a magazine, Saúde em Debate (Health in Debate), which became one of the main vehicles for spreading the health care reform movement’s ideas. ABRASCO hosted an annual conference on national health policy, which brought together progressive public health professors, researchers, physicians, grassroots activists, and trade unions. Their first annual conference in 1979 laid out the principles that would later become central to Brazil’s health care system – the need for universal health, the right to health, the role of the state as the primary provider of health care, and the role of the public in guiding government health policy.

CEBES and ABRASCO attracted a range of other civil society groups to support health care reform, including neighborhood associations, the Catholic Church, doctor’s associations, municipal health departments, progressive members of the National Congress of Brazil, and unions.

As two decades of military rule ended, this growing civil society movement seized a window of opportunity. In 1988, reformers and their allies successfully pressed for the inclusion of health as a right provided by the state, in Brazil’s new constitution.

This historic shift created a foundation for three key reforms that transformed the health sector and the health of Brazilians:

• In 1990, Brazil established the Unified Health System, a national health system for the entire population, financed by general taxes.
• Also in 1990, Brazil adopted the Lei Orgânica de Saúde (Organic Health Law 8.080), which defined health not only as an absence of illness, but also as the existence of a certain quality of life, achieved through the reduction of inequalities and the fostering of inclusive economic growth. This new law, which followed a blueprint originally outlined by ABRASCO, formally tied socio-economic conditions to improved health outomes.
• Reformers pressed the government to create a proactive service delivery model through the Programa Saúde da Família (the Family Health Program, later renamed the Estratégia Saúde da Família, or Family Health Strategy), first rolled out in 1994. With the new strategy, proactive, coordinated, and comprehensive health care is delivered by a team (including a nurse, nurse assistant, physician, and four to six CHWs) to 3,500 people in each catchment area.

Brazil’s Family Health Strategy was modeled on a program that began in the low-income state of Ceará, in Brazil’s Northeast region.

In 1986, Ceará state gubernatorial candidate Tasso Jereissati visited a community health program in the municipality of Jucás and met the program’s founders, primary health care activists Carlile and Miria Lavor. The Lavors and a group of physicians offered to support Jereissati’s election if he committed to creating a statewide CHW program upon taking office. As it happened, Jereissati won the election and named Carlile Lavor the new Secretary of Health for Ceará state.

Upon taking office, Jereissati was faced with a devastating drought. Lavor used some of the emergency drought funding to launch a CHW program modeled on the earlier program in Jucás.

To launch the program, Lavor recruited 6,000 CHWs, most of them poor women, and some of whom were illiterate, to work in the same drought-ravaged communities where they lived. They were tasked with promoting infant, child, and maternal health, including immunization, oral rehydration therapy (for treatment of diarrhea), and breastfeeding, following up on antenatal care visits, and referring patients to increase institutional births. Nurses were hired to supervise the CHWs.

Soon, studies began to demonstrate the impact of the Programa de Agentes Comunitários de Saúde (Community Health Services Program).

Between 1987 and 1990, the percentage of children receiving oral rehydration therapy more than doubled, the number of children with four vaccines (through the Expanded Program on Immunization) increased by nearly 20 percent, and children who had visited a doctor in the last three months increased tenfold. During the same period, infant mortality dropped from 100 deaths per 1,000 live births to 68 deaths per 1,000 live births.

Beyond its remarkable impact, the Community Health Services Program in the state of Ceará had another strong selling point: it was a bargain. It cost about US$2 per person served, compared with the existing fragmented and less-proactive health system, for which Brazil spent about US$80 per capita.

This data and an eagerness to address constituents’ needs drove officials to expand the program across all 183 municipalities in Ceará state. By 1992, 7,300 CHWs had been hired, along with 235 half-time nurse supervisors.

The documented impact of the program in the state of Ceará came at precisely the moment when national health care reformers were demanding a more responsive and democratic health system. They seized on the CHW program in Ceará as a model for the nation.

From the outset, data played a large role in Brazil’s health care reforms. In the initial launch of the Family Health Strategy, the federal government used a hunger map to target the program’s rollout to the eight highest-need states in Brazil’s Northeast region, covering 60 million people. The map, developed by the Food and Agriculture Organization of the United Nations, assessed multiple dimensions of malnutrition and ranked municipalities on this indicator. In 2006, the program formally became national policy.

Today, Brazil monitors data from a wide variety of sources, including census data, municipal-level data, and routine health and demographic data collected by the Family Health Team. The country harnesses this data to inform programming, ensuring that households and communities most in need receive tailored programming that addresses their most pressing health challenges.

For example, in 2003, health planners in the large city of Belo Horizonte developed a health vulnerability index, which ranks census tracks within the city, based on sanitation conditions, household characteristics, schooling and income levels, and indicators of early mortality. Based on this information, the city prioritized expanding primary care in medium, high, and very high-risk areas with both limited access to health care and the highest concentration of social vulnerability.

Other cities, such as Rio de Janeiro, use a tool developed by the U.S. Centers for Disease Control and Prevention called the Social Vulnerability Index, to target vulnerable families for services. This index includes 12 household-level indicators such as literacy, whether children have dropped out of school, and availability of electricity, water, and sanitation. The index helps identify families with the greatest need and ensures that CHWs prioritize monitoring them.

In addition, longitudinal health and socioeconomic data collected by CHWs is uploaded to the Sistema de Informação da Atenção Básica (Primary Care Information System). This data can help CHWs, as well as the Ministry of Health and municipalities, identify trends and ensure that care is responsive to individual and community health needs. For example, in the Northeast region, data collected by CHWs indicated a noteworthy increase in infant mortality during the rainy season (January to April). The increase in death rates during these months was found to be associated primarily with an increase in diarrhea. The system identified municipalities where data showed the greatest rise in malnutrition and mortality, and each municipality was supplied with information on how infant death rates in their municipality compared with the statewide target of 50 (later 40) per 1,000. The data prompted municipalities to modify training for CHWs and treatment regimens for clinicians to better identify and more effectively treat diarrhea in children.

A 2016 study indicates that targeting families based on data is working. Families with the lowest education, who are generally at higher risk of poor health, were most likely to receive visits from CHWs. Likewise, families with university education were, in most regions, most likely to never receive a visit.

Brazil coupled investments in CHWs with investments in the entire Family Health Team staff and 40,000 local primary health care facilities (Unidade Básica de Saúde), where the Family Health Teams work. This investment in a national network of physical clinics alongside CHW programming is in line with the emerging global consensus that investments in community-level facilities and CHWs complement one another. As CHWs generate demand for health care, the clinics improve the system’s ability to meet that growing demand.

Brazil doubled the density of outpatient facilities from 1.9 facilities per 10,000 people in 1990, to 3.5 in 2009. Hospital growth was stagnant during the same period, which demonstrates the fundamental shift in the health system toward primary care.

Alongside an increase in primary health facilities, this period also saw a dramatic increase in the number of nurses and midwives per 1,000 people, from less than one to more than seven. Increasing the number of primary health care doctors, however, has proved more challenging (see  section).