Organization and Personal Philosophy of Community Health Worker

Program in Maracanaú

West, Madison

Academic Director: Calhoun, Bill

Project Advisor: Sousa, Petha

University of Denver

International Studies

Brazil, Maracanau

1. Submitted in partial fulfillment of the requirements for Brazil: Social Justice and

Sustainability, SIT Study Abroad, Fall 2015

1

Abstract

Brazil is home to a large, complex, and decentralized health system that has made great

health advancements for Brazilians. Although programs such as the community health agents are

effective in providing primary health care, shortage of supplies and funding can make this job

difficult. This research analyzes the community health agent program from three different levels

of inquiry. The first level is how the community health clinic coordinates with the Municipal

Director for Health, the second is how the health clinic manages, coordinates, and organizes

staff, and the third is exploring the personal philosophy of the community health workers and

their experience in their positions.

Although health agents gather first hand demographic information on health needs the

population, they are largely removed from communication with the larger health structure. A

lack of communication between health agents, who encourage treatment, and health facilities,

with long lines and lack of resources, means that community members often become discouraged

from seeking care. In order to more effectively reach the community, private public partnerships

should be made with the strong industrial sector in Maracanaú to provide health seminars at

places of employment. In addition better technology, access to re-training, and new hires of

health agents are needed to give support to an over burdened program.

2

Table of Contents

Introduction 5

Methods 12

Results and Recommendations 14

Conclusions 23

Appendix 24

Sources 25

3

Acknowledgements

I would like to thank SIT Brazil for giving me the amazing opportunity to learn about

Brazil and pushing myself in new ways I could have never imagined. My time here has been

difficult but very educating and fulfilling. I would like to thank Bill Calhoun for always

providing extensive articles and e-mails to help support our learning process. Thank you for

providing us access to beautiful communities that are working to make people’s lives better.

Thank you to Oelito for driving me to Maracanaú and always making sure I got to my meetings

safely, you are truly the dad for all of us on this program.

The biggest thank you to Petha Sousa, my advisor and friend, for being the multi-tasking

informant without which my research would have been impossible to complete. I appreciate

learning about your life and our friendship. Thank you to you Petha, Nielia, and Nielson for

allowing me into your home, getting to know your community, and being a small part of your

lives, while eating your entire supply of guava jam. Thank you to the other health agents and

health team members for being very gracious and welcoming me to learn about your roles and

views.

4

Introduction

The global health society is recognizing the need for sustainable community health

policies. With greater frequency, community leaders are acknowledging that more emphasis

needs to be placed on organizations that can serve the health needs of people over longer periods

of time and with more stable sources of funding. In International Relations, and specifically

within the development and health field, there is a big push to consider the sustainability and

longevity of health projects. Following the boom of Non- Governmental Organizations (NGOs)

during the 1990s, academics and professionals are now considering how feasible it is for an

organization to expect long-term goals with short-term commitments. Can an NGO found a

health clinic in a disadvantaged area, when their funding for the project is unstable and they may

leave within a few years? During my service learning in Mozambique, I saw the fragility of

many NGO run programs and their heavy grant dependence (Field Journal, pg.60).

The seemingly obvious solution to this issue is for the government of these countries to

fund and administer these projects, so that they have a more permanent place within the

community. Brazil recognized these challenges and implemented a system of national health that

has produced results, especially in the northern state of Ceará. Community health workers have

been identified as having special potential to gain the trust of their patients in an area as personal

and important as providing care, especially to low income neighborhoods. The program enlists

workers from local communities to check up on people in their homes concerning their health.

However, with Brazil’s low funds and bureaucratic entanglement, how sustainable is the

program? Brazil’s health system is comprehensive in concept, but its implementation has many

structural problems. Does the structural inefficiencies prohibit community health workers from

realizing health improvements with the residents in their areas?

5

I Maracanaú, Ceará

Brazil is categorized by five large state groupings: the south, southeast, central west or

interior, north, and northeast. Generally, strong developmental inequalities differentiate the north

from the south of Brazil, with most of the wealth concentrated in the south and southeast regions

of the country. Maracanaú is located within the northeastern state of Ceará, in close proximity to

the capital of the state, Fortaleza. Maracanaú means “drink of the Maracanas,” which is a bird

that drank from the lake located in the central area of the city (T. Vieira, personal

communication, November 12, 2015). The municipality was founded in 1962 but with the

military dictatorship in 1964, they eliminated all municipalities created after 1962 (Estatísticas,

2009). The city officially gained its rightful status as a municipality in 1984 (Estatísticas, 2009).

With the lection of mayor Roberto Pessoa in 2004, the city focused on becoming an

industrial power and is now home to the second largest economy and municipal exporter of

Ceará (Estatísticas, 2009) Some of the largest industrial employers in the city include Girado,

steel, Hidracor, ink, Vicunha, textiles, and Coca Cola (T. Vieria, personal communication,

November 12, 2015). As of 2010 Maracanaú had a population of 209, 748, but within the past

five years the municipality experienced a population boom and the current population is

estimated to be closer to 220,000-250,000 (T. Vieira, personal communication, November 12,

2015). The boom is associated with the growth of industrial based jobs and the growing expense

of living in Fortaleza, leading people to move to more affordable cities (Estatísticas, 2009).

Maracanaú is representative of the health issues that many regions in Brazil are facing,

primarily a shift from infectious diseases to now also dealing with chronic health issues.

Maracanaú has a high population of people with hypertension, diabetes, cardiological problems,

and sedentary lifestyles that largely translate into high rates of obesity (L. Fatima, personal

6

correspondence, November 11, 2015). For example Petha Sousa, a local community health

agent, said when she first began working 18 years ago more children in the community were

malnourished, but now there are more issues of childhood obesity (Field Journal, pg. 15).

Infectious diseases such as tuberculosis and dengue fever continue to be issues; drug use is also

prevalent in the city (Field Journal, pg. 10).

II. Overview of SUS

The Sistema Único de Saudé (SUS) was officially implemented with the new national

Constitution in 1988 that promised health as a human right for all Brazilians. Knowing the

characteristics of Brazilian politics and society during the military dictatorship is important to

understanding the founding characteristics of SUS. During the military dictatorship that ruled

Brazil from 1964-1984 decision making for all sectors of the government was “done without

public involvement… and centralized in large bureaucracies,” (Paim et al, 2005). While the

private health care system flourished, especially in urban centers, the social welfare system

coverage was fractured along occupational posts and inadequate (Paim et al, 2005). Beginning in

the 1970s, social and political groups began to lobby for more complete and universal health

coverage. With the renewal of Brazilian democracy in 1984, these activists seized the

opportunity to re-write the constitution and deliver a comprehensive and decentralized health

system that is now SUS (Paim et al., 2005).

As a health structure, SUS has an interesting combination of private and public care

models, each interacting and affecting each other. The public and family health portion of SUS,

largely referred to as Programa Saúde de Familia (PSF) is financed by taxes from the federal,

state, and municipal level (Paim et al, 2005). The private portion is composed of private

7

insurance plans, mainly provided by employers, and private health care clinics (Paim et al,

2005). Although technically every Brazilian can access both the private and public portions, low

income and working populations are more dependent on PSF while many wealthier Brazilians

opt to use the private system to avoid the characteristic long lines and scarce resources.

The public sector has significantly raised health and living standards for all Brazilians,

and especially working class families. In an analysis of health outcomes from James Macinko,

Frederico Gunais, and Maria Souza, infant mortality rate (IMR) was used as an indicator to

assess the effectiveness and progress of the Programa Saúde de Familia from pre- PSF

implementation, early PSF implementation, and late PSF expansion. The research showed that

PSF was critical to raising health standards; child deaths from diarrhea in 2002 were one third of

the 1990 rates, and deaths from acute respiratory infections (ARI) in 2002 were half of what they

were in 1990 (Macinko, Gunais, Souza, 2006). However “average annual income fluctuated each

year,” and did not significantly rise through out the thirteen years of analysis, which may prove

that people’s increased health was not due to more dispensable income to spend on health care

(Macinko, Gunais, Souza, 2006). Interestingly, an increase in nurses and doctors was not a

substantial indicator in reducing the infant mortality rate, suggesting that community health

workers may be the employees reaching families to educate them on causes of infant mortality

(Macinko, Gunais, Souza, 2006).

Although the public system is comprehensive and has produced results, in an equity

analysis by Uga et al. the system places a higher burden of tax on lower income earners through

direct and indirect taxes (Uga et al., 2007). Out of pocket medical expenses for the lowest

economic decile of families are estimated to take up 6.8% of income, while it only takes up 3.1%

for the highest economic decile (Uga et al. 2007). In addition, in an analysis with comparative

8

health systems, such as Great Britain in which the government takes responsibility for 80% of

funding, the Brazilian government only finances 44% of the system (Uga et al., 2007). The

combination of these factors, along with the subpar service in some health posts, can dissuade

community members from accessing the posts (Field Journal, pg.52).

When residents do seek medical care from the public health posts there is varying quality

of treatment. A Terra de Souza conducted a qualitative research study about community

interactions with health posts and the “influence of healthcare system factors,” in the role of

infant mortality rates in Ceará (Souza et al., 1982). The researchers asked women living in the

state of Cearaá, who had lost infants in the last 12 months, about their experiences with the

health system. Souza identified three main themes that characterized the women’s experiences

including delay in “seeking medical care, delay in ‘receiving’ medical care, and ineffective

health care,” (Souza et al., 1982). Delays in seeking medical care were defined as mothers not

recognizing the severity of the illness, while delays in receiving medical care were defined as the

hospital not having adequate consultation times or medications, and ineffective health care

included the mothers’ perceptions that the child continued to be sick even after seeking treatment

or poor communication with medical staff (Souza et al., 1982). Experiences that were also

classified inside the delay in seeking care was mothers who decided to seek treatment from

traditional healers, (Souza et al. 1982) which suggests that SUS did not understand the cultural

importance that traditional medicines still play in many communities. Outside of the

physiological reasons for the infant’s mortality, the researchers recognized the socio-cultural

factors that influence family health outcomes. They recommended that health professionals that

have community knowledge be utilized to reach residents that have a lack of education or are

suspicious of accessing the health system.

9

III Structure of ACS

In response to critiques from academics and health professionals, the Brazilian

government implemented the Agentes Comunitarios de Saúde (ACS) program in order to help

community members navigate the PSF program and to promote preventative care. The ACS,

commonly referred to as health agents, is employed in a door-to-door health check for each

family within their designated area (Field Journal, pg.7). The health agents primarily are born

and raised in the same community they serve and approximately 90% are women (Field Journal,

pg. 19). The ACS works in a health team composed of a doctor, nurse, technical nurse, and

between 4-10 community health agents (Field Journal, pg. 20). The nurse of the team is the

direct supervisor of the ACS and performs the job of directing and reviewing the health agents

(Field Journal, pg. 20).

Petha Sousa, a health agent of 18 years, described her responsibilities as needing to

“accompany children from 0-5 years of age, accompany pregnant women, carriers of hyper

tensions, diabetics, tuberculosis, and carriers of leprosy. These are our priorities. We cannot

afford to not visit one of these people. And the agents accompany families in general with basic

health education, with proper nutrition.” (P. Sousa, personal communication, November 19,

2015). The ACS program also places child vaccinations as a high priority, with each child having

a booklet that keep tracks of their vaccination records; health agents are required to check the

cards at each visit (Field Journal, pg. 7). Community health agents are assigned an area of 150

families but because of a lack of staff may accompany up to 200 families (P. Sousa, personal

communication, 19 November, 2015). In addition, the health agents link the community

members to the local health post; the agents often helping residents obtain specialized

10

appointments and navigate the health bureaucracy (Field Journal, pg. 6). Health agents become

trusted sources of information and confidants for community members to express concerns about

their health and personal lives (Field Journal, pg. 6).

The community health agents have proven their effectiveness in several targeted health

campaigns and general coverage of Brazilians. The amount of the population that is covered by

community health workers progressed from 29.6% in 1998 to 60.4% in 2008 (Paim et al., 2011)

Coverage due to the community workers has increased services to roughly 98 million people in

85% of municipalities in Brazil (Paim et al, 2011). In a 2005 study, researchers sought to

understand the value of community health workers in promoting breast-feeding with recent

Brazilian mothers living in Fortaleza, Ceará (Leite et al., 2005). The counselors were mothers

themselves who also had experience with breast feeding their own children, and were assigned to

assess the health of the infant, the home environment and interview mothers based on their

experiences (Leite et al., 2005). For the intervention group compared to the control group, there

was a 9% increase in the rates of exclusive maternal breast-feeding, defined as infants only

receiving breast milk for the first four months of life (Leite et al, 2005). The researchers saw that

one of the most beneficial components of the community counselors was that they were able to

provide psychosocial support to the mothers who wanted to reverse cultural trends and

breastfeed more. The counselors, who came from the same communities as the women in the

study, provided effective support to those participants and effectively delayed the complete

replacement of breast milk with bottle-feeding (Leite et al, 2005).

With its successes, the ACS program also has structural issues that burden the community

health agents. The entire SUS program is chronically over stressed and under financed, with too

few resources for the amount of people served and low workplace moral (Field Journal, pg. 52).

11

Hospitals and health clinics regularly have shortages of supplies and medicines (Macinko,

Gunais, Souza, 2006). In an analysis of the human resource issues with SUS, researchers found a

lack of structured career growth, large differences in salaries between regions, and uneven

distribution of medical staff (Victora et al, 2011). Since Brazilian government workers can only

be hired through an intense competitive process that can take months, many health workers are

on special contracts, which does not guarantee the same job benefits, and usually leads to lower

job satisfaction compared to other government employees (Victora et al, 2011). With special

consideration to community health agents, many of them develop health problems from working

outside, including skin cancer, deteriorating vision, and back pains (L. Fatima, personal

communication, November 11, 2015).

Methods

With these issues in mind, I sought to explore the issues of bureaucratic negotiation

affecting the effectiveness of the ACS program. I utilized a top down approach focusing on the

municipal government policies that regulates the health post in the city, the policies implemented

at the level of the health clinic, and finally how the community health workers feel about the

health policies. Specifically, I focused these levels of analyses for the community health worker

program. I worked with my advisor and key informant Petha Sousa to become familiar with the

health worker community, to schedule interviews, and become acquainted with Maracanaú as a

city.

As my first tier of analysis, I focused on the health policies of the municipality by

speaking with the Secretary of Health for the municipality of Maracanaú, Mr. Vieira. I

interviewed Mr. Vieira concerning the municipality’s history, why the city developed the

12

community health worker program, how it receives its funding, and the effectiveness of the

program. I then asked what the main difficulties of the community health worker program are

and what he hoped for the future of health for Maracanaú.

As my second tier of analysis, I mainly worked with Petha Sousa to understand her

experiences of interacting with the municipal government as a community health agent. I was

able to live with Ms. Sousa for one week, in which time I developed a personal relationship with

her and used many formal and informal interviews to learn about her understanding of the ACS

system and the Maracanaú community. In conjunction with these interviews, Ms. Sousa provided

me with training and educational materials aimed at SUS health workers and community health

agents. I analyzed these booklets and pamphlets to understand how they were educating health

workers about their responsibilities. Finally, I observed a staff meeting at the health post where

health teams evaluated their performances.

As my final level of analysis, I sought to understand how the stresses of bureaucratic

health navigation could affect the personal philosophy of healthcare implementation for the

community workers. In order to accomplish this goal, I used formal and informal interviews to

create a relationship with the workers and managers at the health clinic. I employed formal

interviews and shadowed at home health visits to understand how they interact with residents,

how they organize visits in the community, and what type of profile they have gathered

regarding the overall health of the city. I developed a close relationship with a few health agents

and I used informal interviews to understand their responsibilities, their ideas to improve the

program, and their relationship with the community.

13

Results & Discussion

The PSF system is effective, but not without its flaws. Although community health agents

provide important services for their residents, they are not connected enough to the other sectors

of the health system. A lack of community knowledge and resources to fund health initiatives

also makes the agents’ jobs more difficult. The recommendations from this section are ideas

from community health workers and include corporate partnerships for health seminars, increase

in the amount of health agents and technology in the ACS program, and more cohesion and

education about the SUS structure for health professionals and community members.

I. Communication in the Health System

The Sistema Único de Saúde is by design a decentralized health structure that allows

different areas in Brazil to adapt their health posts based on the needs of their communities.

Although this system has generally worked well, it can also create a lack of cohesion within the

same municipality or even the same health post between different sectors. The basis for this lack

of communication is a deficiency of education about the structure of SUS as a whole. For

example, in a visit to Petha’s assigned Maracanaú health post, a nurse said she did not recognize

that the SUS was not a global health system (Field Journal, pg. 18). In an interview with health

agent Maria Marcos about the difference between Brazil and my native country the United

States, Maria says, “My vision that I have of health in your country is that everything is great,”

(M. Marcos, personal communication, 19 November, 2015).

Although these conversations are not indicative of everyone in SUS, it is suggestive of

the lack of information that many health professionals have about experiences outside of their

own job post. If workers had a more complete knowledge of the system, they may understand

14

how the entire structure is interrelated and increase communication between colleagues. In

addition, understanding the mission of SUS and how it sharply differs from many less

progressive systems may help work moral by understanding the access to care they are providing

all Brazilians (Field Journal, pg. 19).

During an initial review of the SUS health structure from existing literature sources, there

seemed to be a contrast between how community health agents were able to help residents

achieve better states of wellbeing with the chronic shortages in both the SUS health posts and

hospitals (Macinko et al., 2006). Although this could partly be attributed to the fact the health

agents promote preventative care and therefore decrease the need for health interventions at the

level of the hospital, many Brazilians still access hospital services. How could the health agents

and the hospitals be experiencing such different health environments and how does this affect the

community? From observations of Maracanaú, there is no communication between the health

agents and the hospital (M. Marcos, personal communication, November 19,2015). If health

agents could have more access to the workings of the hospital, they would be able to help their

residents navigate the health bureaucracy with more ease. Petha Sousa, a veteran health agent

from Maracanaú, stated “at the health post I arrange consultations, I make it easier to resolve a

problem by telling them talk to this doctor or this nurse. I can direct the solutions. If I had this

access in the hospital as well it would be easier. But we don’t have any contact. We don’t have

it,” (P. Sousa, personal communication, November 19,2015).

With a lack of communication between health agents and higher levels of the SUS

system, the burden falls to the community members to navigate the bureaucracy. For example, a

health agent might suggest to a resident of their area to seek treatment from the hospital or to

make a special consultation. Consultations require special appointments that are often moved or

15

changed without notification to the patient or health agent that made the recommendation; this

results in community members being frustrated and feeling their time is being wasted. Loucia,

another veteran health agent, described her experiences with appointment changes: “There are

certain things the community knows and the agents will find out afterwards because they don’t

tell us and there is a lack of communication,” (L. Fatima, personal communication, November

11, 2015). Many times this lack of communication causes the health agent to look unprepared

and discourages residents from trying to obtain appointments in the future (Field Journal, pg.

55).

The actions of other health professionals affect the reputation and connection the health

agent has with their community. For example, health professionals that are assigned to the same

health post often do not have the same level community interaction training. Petha Sousa

described that one of the most difficult parts of being a health agent was “not with the

community, but with ill prepared professionals in the health unit,” (P.Sousa, personal

communication, November 19, 2015). Petha previously described working with the mental

health unit CAPS (Centroa de Atenção Psicossocial) in a joint outreach session with elderly

people for mental health consultations. During the consultations, Petha observed many of the

psychologists from CAPS treated the elderly people “like children,” and many community

members later confided in Petha saying they felt belittled and were not motived to use CAPS

services in the future (Field Journal, pg. 10). If community health agents could give training or

tips to other SUS professionals on effective community outreach strategies, perhaps health

agents would be blamed less for the incompetency of other staff.

16

II. Health Agent Experience

Community health agents are frequently the link between the community and PSF, which

is a difficult role to navigate. ACS often receives discrimination from the health professional

community and hears constant complaints from their residents about accessing care. Several

health agents I spoke to felt they were discriminated against as a health agent because within the

community of SUS workers. Some staff does not consider health agents to be “real health

professionals” because the core of their work is social outreach and most do not have a university

level education (Field Journal, pg. 15). In addition, it is common to find residents that do not

understand that despite the health system’s long lines and shortage of medicines, they have the

constitutional right to free health care. In a conversation with a woman from Maracanaú, she

expressed surprise at learning there was poor people in the United States and that, while there is

a small but growing public health sector, most people have to pay for all of their health care

needs (Field Journal, pg. 12). Many Brazilians do not understand that despite its shortcomings, it

is a privilege to have a public health system such as SUS.

Health agents are responsible for educating their community members about how to

maintain their health and prevent major issues from developing. However, re-training efforts for

health agents are largely sub-par in quality. When asked how she would like to change the ACS

program, Loucia Fatima says she wants more “permanent education which has not happened.

Sometimes the trainings are only shallow; there should be classes for people to be better trained

and better educated and up to date. Because sicknesses are changing every day, they take new

forms,” (Personal communication, November 11,2015).

The quality of re-training on health, social issues, and new guidelines was analyzed in a

review of three training booklets and a health journal for SUS workers. Although the quality

17

varied between publications, overall the booklets did not relay any new information to workers

and left out key material on safety. For example, two similar booklets concerning tuberculosis

and leprosy aimed to “erase doubts,” and help health agents in their “day-to-day routine,”

(Minestério de Saúde, 2001, Minestério de Saúde 2002) to identify and manage these two

diseases. Even though the booklet mentions the standard routines vaccinations and medication

schedules, and needing to accompany families to the health clinic, there is no mention of how the

health agents keep themselves safe while working with possible infectious community members

(Field Journal, pg. 60). Since most health agents already have an established relationship with

their community before beginning their jobs, a majority of them already know how to interact

with the populations and need to be informed of new dangers a disease can pose to themselves or

their people. For example in a dengue control pamphlet, agents were advised to be cautious of

environmental factors that can contribute to dengue such as littering, holes in water tanks, and

keeping plants in sand basins instead of water plates (Minestério de Saúde, 2009).

Health agents should be instructed in educational materials on how to take on more

specific roles in addressing community health issues; as of now pragmatic support strategies are

missing from available ACS literature. In an analysis of a SUS produced magazine on violence

in Brazil, each of the editor’s letters described how violence has a social cost and is a public

health concern (Minestério de Saúde, 2008). Although the articles described violence, how the

public sector disproportionately treats victims of violence, and the special vulnerability of Black

Brazilians and women, there are no specific recommendations for any health professional on

how to combat these issues (Minestério de Saúde, 2008). Especially since 63% of all violence

against adults takes place in the home, (Minestério de Saúde, 2008) community health agents

seem to be in a distinctive position to combat domestic violence with their regular access into

18

people’s domestic lives. However, there is no training on how to safely and preventatively care

for victims of domestic violence.

In addition to a lack of continual education opportunities, community health agents are

largely overworked due to the exploding population of Maracanaú. In an interview with the

Secretary of Health for the city, Mr. Vieira confirmed that the municipality has not been able to

keep up with the population growth by providing the correct amount of health agents. Currently

there are 312 health agents in Maracanaú, and each health agent is ideally supposed to

accompany 150 families (Field Journal, pg. 6). However, Maracanaú’s population is now closer

to 250,000 which means that “each team mas micro areas that are 170,180, 190 families and then

about 750 or 800 people for each health agent. So you multiply it by 300 health workers and then

you reache 80-90 % of the population…” (T. Vieira, personal communication, November 12,

2015). Health agents are being over extended by at least 20 families in the best scenarios. In

some areas, there are no health agents because the municipality has not been able to process

health teams’ requests for more health agents (Field Journal, pg.18).

Even though health agents are currently visiting more people past their responsiblities,

better technology is not available to help them keep up with their duties. The Sistema de

Informação de Atenção Basica (SIAB) is a new computer system that should digitize all SUS

users’ medical records according to their SUS card number and keep track of information more

efficiently (Field Journal, pg. 15). However, Maracanaú still does not have this system, and

health agents have to input the written records into the outdated system (Field Journal, pg.15).

When speaking with Jessica, the director for health agents in the municipality, one of her biggest

hopes for the future was to bring more technology to make record keeping easier for agents

(Jessica, personal communication, November 12, 2015).

19

III. Community Experience

A lack of health agents and resources ultimately affects the health outcomes of

community members. Several health agents described their experience of dealing with taboo

health issues with a lack of resources. For example, Petha Sousa describes how she does not

question or counsel drug users “because I don’t have the support to give them to tell them stop

doing drugs. We don’t have a clinic to direct this person to. We have the system of CAPS, we

have CAPS AD, which is drugs and alcohol. But it’s very bad. To get a consultation is very hard

and users have embarrassment, and people will say oh those are users and they don’t want to do

that. So it’s difficult,” (P. Sousa, personal communication, 19 November, 2015).

Mental health or psychological abuse are also difficult to combat; while shadowing a

domestic health visit a woman confided how her husband restricts her choices and movements in

a controlling relationship (Field Journal, pg. 7). The woman has hypertension and her

environment only exacerbates her condition; Petha has counseled her previously about therapy

options but the woman has so far not utilized them. The first step to combating embarrassing

conditions is preparing counseling centers for the amount of people seeking care, or else

community health counseling will be useless.

In an effort to reach community members through several different avenues, health

agents are also required to hold educational health seminars with different groups (Field Journal,

pg. 18). However, residents are often unwilling to attend these seminars and “the difficult part is

to gather the members of the community…Because people don’t want to leave their house,

people will say oh it’s boring, I don’t know what it is. So that is the difficulty to meet with

people,” (P. Sousa, personal communication, 19 November, 2015). However, residents are

20

missing out on important information that is directed to their specific health needs. For example,

Petha described a health seminar she was meant to perform in November to coincide with the

men’ health campaign. However, she felt the men did not take her seriously and hardly anyone

showed up to the meeting (P.Sousa, personal communication, 19 November, 2015).

IV. Recommendations

The recommendations in this section are specifically targeted to the Maracanaú

community and are drawn from observations and interviews over the span of four weeks. Some

of these suggestions may be applicable to the larger SUS program based on each community’s

needs and context. Many of these proposals on how to improve community health and the ACS

program came from veteran health agents who are important sources of knowledge.

Community health workers are in a special position within to determine early health

trends or new and arising problems. During the door-to-door check in service, they gather first

hand information that builds the health profile for the city and country (Field Journal, pg. 20).

Although this information is relayed to the nurse of the health team, community health agents do

not have direct access to anyone else outside of their health team. Since the SUS program’s

ideological base is built on the idea of prevention, and the main role of ACS is prevention

through health education and counseling, health agents should have more communication and

influence with higher levels of SUS officials.

As Secretary of Health, Mr. Vieira currently describes his role as the “manager [who]

must above all encourage[s] the group. The manager is like a football coach who did not enter

the field because we already have our cast of players,” (T. Vieira, personal communication,

November 12, 2015). Although Mr. Vieira did not describe if he meets personally with other

21

leaders of health sectors from the city, it would be beneficial for Mr. Vieira to take a more

involved role in listening to community health agents. Petha Sousa describes her ideas for a

better relationship with the Secretary; “I think we should have meetings every few months so

that he can listen to the problems of the area, because sometimes I think that people wait to solve

an issue until someone bigger comes along to solve it quicker,” (P. Sousa, personal

communication, 19 November, 2015). Mr. Vieria has the position and responsibility to take a

stronger leadership role for addressing community agent issues and learning about the current

health status in his municipality.

The scarcity of resources within SUS poses interesting challenges on how to fund the

proposed changes. Since Maracanaú has a strong industrial sector, potentially effective

possibilities exist for public private partnerships. Community health agent Loucia believed that

holding health seminars at places of employment would guarantee that people are present for

important information (L. Fatima, personal communication, 11 November, 2015). In addition,

industries should be held to higher levels of corporate responsibility and help fund these

community seminars. As one small example, the Coca Cola Foundation places health as one of

its main priorities for grants and community outreach (Field Journal, pg. 55). Partnerships

between the health agents and the municipality could be constructed to provide better health

outcomes for residents.

22

Conclusions

The community health worker program continues to have great relevance for Brazil and

specifically the city of Maracanaú. By employing workers that are local to the communities they

serve, health agents are easily able to gain the public’s trust for the sensitive topic of health.

Despite threats of violence in the at large society, health agents enter into people’s homes to

become confidants and counselors to resident’s health needs. Although the health agents more

formal roles include monitoring children and people with chronic diseases, they largely serve as

a sounding board for every day well being concerns. Of the health agents I spoke to, they all

listed their favorite part of their job as having a close connection with their community and

taking care of their neighbors.

Health agents deserve the respect of their community and of their fellow health

professionals. Health agents are the link between the community and health services, but often

handle much of the miscommunication and differences between these two groups. If residents

had better education on how their privileges as a SUS cardholder compares to other countries, I

believe they would have a greater appreciation of their system. They may follow the

recommendations of the ACS and incur the long lines to access preventative care. In addition,

health professionals need to respect the groundwork health agents perform to gather data that

benefits the entire health system. Although not explicitly stated in any of my interviews, through

out much of my observations I can hypothesize that health agents are partly discriminated against

because of their lack of university level education and that 90% of health agents are women. The

ideas for increasing technology, private public partnerships, and better community resources all

came from health workers of Maracanaú. If the municipal government had avenues for direct

contact with health agents, they would have already had access to these valuable ideas.

23

Appendix

SUS- Sistema Único de Saúde Brazil’s national health program

ACS- Agentes Comunitarios de Saúde Community health agents

CAPS- Centroa de Atenção Psicossocial Mental health unit

CAPS AD- Centroa de Atenção Psicossocial Rehabilitation clinic for drug users

por Álcool e Drogas and alcoholics

PSF- Programa Saúde de Familia Family health program

IMR- Infant Mortality Rate

ARI- Acute Respiratory Infections

24

Sources

Estatísticas. (2009, May 13). Retrieved November 6, 2015, from

http://www.maracanau.ce.gov.br/estatisticas

Leite, Á, Puccini, R., Atalah, Á, Cunha, A., & Machado, M. (2005). Effectiveness of home-

based peer counselling to promote breastfeeding in the northeast of Brazil: A randomized clinical

trial. Acta Paediatrica, 94(6), 741-746. Retrieved September 29, 2015, from

http://jc3th3db7e.scholar.serialssolutions.com/?sid=google&auinit=ÁJ&aulast=Madeiro

Leite&atitle=Effectiveness of home‐based peer counselling to promote breastfeeding in the

northeast of Brazil: A randomized clinical trial&id=doi:10.1111/j.16

Macinko, J. (2006). Evaluation of the impact of the Family Health Program on infant mortality in

Brazil, 1990-2002.Journal of Epidemiology & Community Health, 60(1), 13-19. Retrieved

October 17, 2015, from http://jc3th3db7e.scholar.serialssolutions.com/?

sid=google&auinit=J&aulast=Macinko&atitle=Evaluation of the impact of the Family Health

Program on infant mortality in Brazil, 1990–2002&id=pmid:16361449

Minestério de Saúde. (2001). Tuberculose: Informações para Agents Comunitarios de Saude (1st

ed.). Brasilia: Minestério de Saúde.

Minestério de Saúde. (2002). Hanseníanse: Informações para Agents Comunitarios de

Saude (1st ed.). Brasilia: Minestério de Saúde.

25

Ministério da Saúde. (2008). Prevenção de Violências e Cultura de Paz. SUS-Painel, 10-50.

Minestério de Saúde. (2009). O Agente Comunitário de Saúde no control da dengue (Vol. 1).

Brasilia: Minestério de Saúde.

Paim, J., Travassos, C., Almeida, C., Bahia, L., & Macinko, J. (2011). The Brazilian health

system: History, advances, and challenges. The Lancet,377(9779), 1778-1797. Retrieved October

15, 2015, from http://jc3th3db7e.scholar.serialssolutions.com/?

genre=article&spage=1778&SS_referer=https://scholar.google.com.br/

&issue=9779&auinit=J&date=2011-05&aulast=Paim&atitle=The Brazilian health system:

history, advances, and challenges&title=Lance

Souza, A., Peterson, K., Andrade, F., Gardner, J., & Ascherio, A. (1982). Circumstances of post-

neonatal deaths in Ceara, Northeast Brazil: Mothers’ health care-seeking behaviors during their

infants’ fatal illness. Social Science & Medicine, 51(11), 1675-1693. Retrieved September 29,

2015, from http://jc3th3db7e.scholar.serialssolutions.com/?sid=google&auinit=ACT&aulast=de

Souza&atitle=Circumstances of post-neonatal deaths in Ceara, Northeast Brazil: mothers’ health

care-seeking behaviors during their infants’ fatal illness&id=do

Uga, M., & Santos, I. (2007). An Analysis Of Equity In Brazilian Health System

Financing. Health Affairs, 26(4), 1017-1028. Retrieved October 14, 2015, from http://0-

content.healthaffairs.org.bianca.penlib.du.edu/content/26/4/1017.full.pdf html

26

Victora, C., Barreto, M., Leal, M., Monteiro, C., Schmidt, M., Paim, J., . . . Barros, F. (2011).

Health conditions and health-policy innovations in Brazil: The way forward. The

Lancet,377(9782), 2042-2053. Retrieved October 17, 2015, from

http://jc3th3db7e.scholar.serialssolutions.com/?genre=article&spage=2042&SS_referer=https://

scholar.google.com.br/&issue=9782&auinit=CG&date=2011-06&aulast=Victora&atitle=Health

conditions and health-policy innovations in Brazil: the way forward

27