Re-imagining community health

Daniel Becker *

Brazil has taken a unique path with respect to health. The country’s experience could serve as a positive influence on the reconstruction of Haitian society.

Brazil passed through what amounts to a silent revolution in the health sector during the 1990s. In the wake of the 1988 Constitution and the ‘United Health System’ (Sistema Único de Saúde), a new model was needed. The earlier model based on hospital assistance and curative care was a disaster in all respects. It lacked effectiveness, efficiency of care, and generated widespread dissatisfaction amongst users, professionals and the public alike.

This network of health posts were poor and had comparatively little prestige. As a result, the population often sought emergency attention for routine problems resulting in a wastage of resources and undermining health care services across the board. What is more, people in need of special care continued to be attended by unknown professionals, and often returned to the same behaviour and symptoms that contributed to their illnesses in the first place. In many instances citizens who fell ill anew were forced to the back of the queue.

In the beginning of the 1990s a new model appeared. It was based on the Cuban and English approach to family medicine with an emphasis on local community health agents. This model was especially successful at reducing infant mortality in the Northeast of the country and led to the creation of the Family Health Programme (PSF)– which emerged as a national public policy by 1994.

What is extraordinary about the Brazilian experience over the past 16 years is how it rescued the concept of Comprehensive Primary Healthcare (CPH) first presented at a WHO Conference in Alma Ata in 1978. The CPH approach had been abandoned owing to structural adjustment policies favoured by international financial institutions. As front line policies and focused on the poorest of the poor, they were unable to withstand the cost-saving measures imposed by the World Bank and the International Monetary Fund. Brazil, however, resisted these tendencies and constructed a system with surprising tenacity and resilience.

The “secret” of the Brazilian experience resides in the territorial and community-based approach adopted by health teams. The programmes include teams formed by a General Practitioner, a nurse, technicians, and agents with specialisation in community health and development. These teams were all designated to specific community areas. The Family Health Programme (PSF) is designed to generate mutual responsibilities and accountability between the team and communities in which they work. Using simple technologies and operating in specific municipalities, these teams generate a nucleus of support that extends out to other health professionals (including specialised doctors, physical health specialists, nutritionists, physiotherapists and psychologists). The programme is credited with resolving roughly 80 per cent of the health challenges facing communities.

And the pogramme does much more than prevent illness. With professionals and reisdents working and living together, these interventions are able to isolate local factors contributing to poor health and generate conditions for more healthy living. A range of innovative local solutions emerged using local resources including: actions in schools, theatre and arts for sensitisation, sport and recreation programmes with youth and children, community therapy, and even cultural initiatives and local employment such as income generation projects.

In this way the programme has improved conventional indicators of health. Today the programme is a shining example of an inter-sectoral model featuring participatory management and a holistic approach to enhancing overall quality of life. By recruiting locally, the programme also generates employment in communities where it is established. Moreover, the programme reduces excessive duties on hospitals and the formal health sector and ensures that serious injuries and emergencies are given due attention.

Today more than 100 million Brazilians are covered by the Family Health Strategy. In order to function appropriately, it is critical that the initiative does not operate autonomously but rather is inserted into the health system at multiple levels. A family doctor should be able to refer his patients to specialists with appropriate exames and hospital care. The system must be managed in such a way that it is attentive to emergencies and patients who require continued care.

New communications technologies are also necessary to support primary care in rural and remote areas where medical attention is logistically challenging. With transmissions of images and sounds via cellular phone, or the use of cellular applications issuing professional and technical instruction for health care professionals, it is possible to multiply efforts for the worse-off. The potential for reducing costs and increasing health access can thus be dramatically increased.

It is important not to repeat the errors of the past in the reconstruction of Haitian society and its health systems. It is time to turn a page from the time when services were distant from the population, where accountability was so dispersed as to be non-existent, and where access was determined by the price a patient was able to pay. It is vital to learn from successful experiences and take advantage of newly available technologies that can reduce costs and improve access and outcomes.

In thinking about new possibilities for public health in Haiti, there is a critical opportunity to intensify the role of young Haitians – who make up a majority of the population – in family health programmes. It might be possible to offer them a central role in the reconstruction of the country and a crucial mission. Imbued with values of solidarity, their involvement in health delivery could be a first step to the rebirth of a nation.

* Daniel Becker is a pediatrician trained in Brazil and France and holds a Masters in Public Health. His main areas of expertise are health promotion, primary health care and community development. He founded CEDAPS in 1993. The organization is a national and international reference center in research and intervention in community health. He is a consultant for different organizations, including today the Dreyfus Health Foundation.