Officials working in public health in Brazil haven’t always felt rooted in their communities. Dr Hugo Coelho Barbosa Tomassini, a former municipal health secretary, told the WHO that in his city of Niterói, the local government employed a full-time “death secretary” to lead its approach to funerals, but had only one health centre for citizens.
In 1988, the country took a step forward, enshrining healthcare as a human right in its constitution. But it wasn’t until the national introduction of its community agent program in 1994 that things began to change on the ground.
Small, locally-trained teams have proven to be a crucial part of the process. The country has found that an integrated, trusted pillar of the community can break down barriers to accessing health in a way that no outsider could, no matter how qualified.
Community care in Brazil
The Community Health Agent Program (O Programa dos Agentes Comunitários de Saúde) relies on a network of small teams of “healthcare agents” drawn from each neighbourhood.
Agents are healthcare advisers, primarily employed as conduits between doctor and patient. “They’re an essential part of the healthcare infrastructure in Brazil,” said Professor Patty Kostkova, Professor in Digital Health at University College London, who has worked with public health agents in the country fighting the spread of the Zika virus. “They’re filling a gap in the healthcare system.”
They work alongside primary care clinicians to build trust in the community, improve healthcare efficiency and keep costs down. Crucially, formal medical education is not required, just a knowledge of the local community and a desire to help.
How agents help
In public health teams, small healthcare “family” teams of ten to twelve agents are drawn up, working alongside an existing primary care team of a doctor, a nurse and even a dentist. Psychologists, social wellbeing assistants and physical education specialists are also available for extra support.
Public health agents, who usually have no previous specialist knowledge or skills, are trained and assigned to around 150 households which they then visit monthly, carrying out a range of tasks. In one house they may schedule an appointment with the doctor; in another, they check whether medication is being taken regularly.
“It works because the agents are seen as an authority”
They identify potential warning signs of further problems: violence, neglect, truancy, or drug use. The agent provides a warm, local face — someone to be trusted — to check in and report back to the medically trained staff.
In environmental health teams, agents are employed to visit properties to check for health hazards, such as in Kostkova’s case, examining stagnant water patches to stop Zika or dengue fever. They’re trained to remove at-risk or contaminated water and then report their findings back to senior agents. Their superiors then step in to double-check that the premises are now safe for human habitation.
Environmental health agents also have an educational role within their local communities, focusing on reducing the spread of water-based diseases. “It works because they’re seen as an authority,” said Kostkova.
Regardless of specialism, each agent is drawn from the community they then work within, using their knowledge of local issues and existing relationships to provide medical support and advice to residents. But different provinces have their own healthcare infrastructure, so coverage can vary and there are regional variations in how agents are deployed.
Reporting forms a vital part of their work, with regular meetings with the clinicians or senior agents in their team. This feedback loop provides an opportunity for the team to regularly reflect on the service being provided, with agent contributions informing workshops on how to improve services for at-risk groups.
Brazil’s health challenge
With over 50 million Brazilians below the poverty line, patients and healthcare professionals are contending with little capital and a lack of infrastructure. Five million residents have no access to clean water, leaving patients at risk of infectious diseases like dengue fever.
While poverty and environmental health challenges persist, patients are just as much at risk from the indiscriminate chronic conditions that challenge higher-income countries too, like cancer.
Tackling both types of disease at the same time presents a significant policy challenge. The presence of both environmental health and public health agents reflect this dual need for support.
Although starting in 1994, the concept has evolved beyond where it was in the nineties. In 2014, the number of environmental health agents increased, in order to work to prevent the looming Zika threat on the population.
The strategy has been recognised internationally as a best practice. In the UK, for example, the Royal Society of Medicine has argued that systematic deployment of community health workers into the country’s National Health Service (NHS) has the potential to address problems in the system, like fragmentation and inefficiency.
Agents have persisted because they get results. Patients see better health outcomes, including reductions in infant mortality and improved detection of neglected tropical diseases.
The scheme is also designed to keep costs down. For public health agents, keeping would-be patients at home, away from hospitals, and instead flagging and treating them in their local community reduces high-cost treatment bills. For environmental health agents, the cost of treating Zika is more than the cost of preventing it.
“I have to be inserted within the mindset of my patients. The agents help me do that.”
Not only do patients benefit, but the medical staff also feel supported. Dr Rui de Gouveia Soares Neto, family physician and coordinator of Primary and Psychosocial Care Networks of the Municipal Secretariat of Health for the city of Fortaleza, values the contribution they make to his work and wellbeing.
“The agents help me to be certain making decisions within my own local community,” said de Gouveia Soares Neto. “I have to be inserted within the mindset of my patients. The agents help me do that.”
Physicians can also use agents to spread the word about local public health campaigns, and community events. “The agent lives in the community and understands the dynamics of the community,” said de Gouveia Soares Neto.
On top of this, physicians like de Gouveia Soares Neto can then use the information gathered from their agents to advise larger government agencies on how to best shape public health policy in their respective neighbourhoods and cities.
Their feedback is then looped into the city’s public health strategy, meaning policies are more plugged into what’s happening on the ground.
But not only does the agent system report back its findings to improve policy, but it also roots its healthcare professionals into local needs, improving its public face.
If the saying goes that it takes a village to raise a child, then the healthcare teams in Brazil have shown it takes a villager to understand its health context and needs. — Emma Sisk