Community Care Workers Symposium “Exploring Alternatives” Johannesburg, 20th,30th April and 1st May 2010 Community Health Workers: the PHC backbone in Brazil Raphael Aguiar

Basic Facts about Brazil 53% of South America Population:190,000,000 States: Federal District Municipalities: 5,563 40% of the population in metropolitan areas Multiple Contexts

Brazilian National Health System Health as a political issue and a universal right (since 1988) The National Health System benchmarks are: Universality Equity Comprehensiveness Decentralization Empowerment and social accountability

Chronic diseases: Hypertension, diabetes... Cancer External Injuries (Violence, car accidents etc) Social inequalities OUR MAIN HEALTH ISSUES:

HIV prevalence in the 15 to 49 age group in 2008: 0.61% (females: 0.41%, and males: 0.82%) Mother ‐ to ‐ child transmission rate: 8.5% (2004) AIDS incidence rate: 18.2 per 100,000 inhabitants (2008) AIDS mortality coefficient: 6.1 per 100,000 inhabitants (2008) Source: Some information about HIV/AIDS in Brazil

466.5 million condoms were distributed in 2009; 2.06 million female condoms were distributed in 2009; 2.17 million units of lubricant gel were distributed in 2009; Massive campaigns on radio, newspapers and TV; Some general counselling activities usually take place in PHC facilities. Source: Some governamental actions regarding HIV/AIDS:

The modern community health agent came up in 1991, in a poor Brazilian state (Ceará) Objectives: to reduce infant mortality and to provide some income to local families Their work (based on simple actions) decreased infant mortality up to 30% in some areas This outcome contributed to their definitive insertion in the National Health System as a national cadre Basic facts about Brazilian Community Health Agents

Their success stimulated the expansion of the CHA's program in other states; In 1994 the “Familiy Health” program (a kind of upgrade) was launched based on those outcomes; Since then, CHA's have been steadily incorporated to Family Health teams. In 2002, the profession was recognized by a federal law This law establishes minimum requirements for becoming a CHA as well as their scope of practice Basic facts about Brazilian Community Health Agents

a) They are usually composed by:  A physician ;  A registered nurse  1-2 nursing assistants  4-6 CHA’s  Many teams have also a dentist and 1-2 dentistry technicians (Oral health team) b) Each team is responsible for delivering health care to about 4,000 citizens Basic facts about Brazilian Family Health Teams

c) Each PHC facility may have1-4 Family Health Teams depending on its size and population. d) Since 2006 many Family Health Teams are being assisted by a multidisciplinary health team (physioterapists, psychologists, nutritionists etc) Basic facts about Brazilian Family Health Teams

Number of CHA's in Brazil – 1994 / 2009

Number of FH teams in Brazil – 1994 / 2009

% of the population covered by health family teams – Brazil, 1998 –2009 0%0 a 25%25 a 50%50 a 75%75 a 100% FONTE: SIAB - Sistema de Informação da Atenção Básica PHC rate coverage

PHC scenario in Brazil (2009)

As of March There were 236,399 CHA’s and 30,782 Family Health Teams in Brazil There are only 86 municipalities with CHA’s and no Family Health Teams

PHC plays a major role in social equity (BLUMENTHAL, 1995; SHI et al., 2003; STARFIELD et al., 2005) In Brazil, Family Health Teams use to be first implemented in most vulnerable areas.

What are the requirements to become a CHA?

As of 2009, a Brazilian CHA must: a)Have at least 18 years old; b)Have concluded primary school; c) Have leadership skills and awareness of their reality; d)Live in the area they will serve by the time of selection; e)Be trained after being hired.

CHA Training Before professionalization: in-service supervision and short term courses offered by regional joint initiatives composed by universities and regional health schools; After professionalization (2002): -They are trained mainly by the Technical Schools of the National Health System; -Once they are hired they receive: - Introductory Training (80 hours); - CHW Training Course (400 hours) - financed by the MoH

CHA Training The CHW Training Course is part of a complete professionalizing course (1200 working hours) offered by technical schools of National Health System; Although it is not mandatory, concluding this course is highly desirable; However, there are no incentives to conclude it. Since 2005, 127,701 CHW have conclude the mandatory part

CHA Recruitment and supervision Municipalities are in charge of selecting and hiring CHA as well as the entire Family Health Team Their activities are supervised by the professionals with higher education (physicians and nurses).

Scope of practices a)General actions aiming disease prevention and health promotion, including counseling activities (major role in treatment adherence as well as in “translating”medical Recommendations); b) Monthly visits to user's houses to follow up and assess risk situations; c) Fulfillment of questionnaires for social and demographic Analysis;

Scope of practices d) Fulfillment of records regarding births, deaths, illnesses and other relevant situations (only for planning purposes) e) Promotion of social accountability and citizens' participation on health policies; f) Engagement in local, intersectoral actions

Important: a Brazilian CHA is not allowed to perform any direct Procedures in patients

Evidences of effectiveness Observation: all the studies take into consideration the entire PHC team rather than only CHA’s.

Evidences of effectiveness Chronic diseases

Evidences of effectiveness General decrease in Hospital admissions in Brazil (2000/2005) a)By conditions which may be influenced by PHC: 15,8% b)By conditions which are not influenced by PHC: 10,1% (Alfradique et al., 2009)

Evidences of effectiveness Hypertension Control: A comparison before and after the establishment of a FH team in a health facility has shown that 56% of its patients with hypertension had their BP controlled in six months (Lemos et al., 2006)

Evidences of effectiveness Hospital admissions by stroke (per 100,000, more than 40 yrs) according to PHC coverage rate (Ministry of Health, 2006)

Evidences of effectiveness Decrease in hospital admissions by stroke (per 100,000, more than 40 yrs) according to PHC coverage rate (Ministry of Health, 2006)

Evidences of effectiveness a)Home care for elders in need: In conventional units: 2,9% In FHT units: 13,3% (p<0,05) (Facchini et al, 2006) b) Consultancies for adults with hypertension in the last 6 months: In conventional units: 31,4% In FHT units: 46,5% (p<0,05) (Facchini et al, 2006)

Evidences of effectiveness c) Consultancies for elders with hypertension in the last 6 months: In conventional units: 34,9% In FHT units: 52,6% (p<0,05) (Facchini et al, 2006)

Evidences of effectiveness d) Consultancies for adults with Diabetes Mellitus in the last 6 months: In conventional units: 39,3% In FHT units: 57,6% (p<0,05) (Facchini et al, 2006) e) Consultancies for elders with Diabetes Mellitus in the last 6 months: In conventional units: 38,8% In FHT units: 52,7% (p<0,05) (Facchini et al, 2006)

Thank you