Overview: This Exemplar narrative sought to address the following research question: What are the key factors that enabled the expansion and effectiveness of Brazil’s CHW program? Two frameworks were used to broadly organize the research and analysis: WHO ExpandNet1 and Primary Health Care Performance Initiative (PHCPI).2 The WHO ExpandNet framework guided a systematic exploration of the scaling up process of Brazil’s CHW program. The PHCPI framework organized the inquiry of program design and the health system along the lines of governance and leadership, health care workforce, health financing, facility infrastructure, and service delivery. Contextual factors that influenced CHW program expansion, including political, social and economic, were considered throughout this process.
Advisory Panel: Last Mile Health assembled a seven-member Technical Advisory Panel of global community health and primary health experts. The Panel selected Exemplar countries and advised on the research methods described below and the country narrative content.
Research Partner: In Brazil, Last Mile Health partnered with Fiocruz-Oswaldo Cruz Foundation- who supported the identification of key documents and stakeholders and provided critical input to the country narratives.Note: This research was conducted in 2017 and 2018 by Last Mile Health, in collaboration with Fiocruz, and focused on how the system was established and functioning at that time. Since then, especially with the creation of the Primary Health Care Secretariat, the primary health care system, financing and policies related to community health have been under revision. Some information in this case study, therefore, may not exactly reflect the most recent (present) situation, due to an ongoing process of revisions. Nevertheless, the experiences of Brazil present valuable learnings for the rest of the world.
Literature Review: To answer our research question, Last Mile Health conducted a review of more than 100 documents to develop this country narrative. Documents selected focused on the design and impact of the program and contextual factors which influenced program expansion. Documents included peer-reviewed journal articles, published reports, impact evaluations, government and NGO strategy and policy documents, meeting presentations, and other public and private documentation shared by stakeholders who participated in the CHW program design and implementation process. Last Mile Health also analyzed publicly available health financing, coverage, and outcome data from Demographic and Health Surveys, annual government reporting, and other globally recognized data sets from sources such as the Institute for Health Metrics Evaluation, World Bank, and WHO.
Interviews: Last Mile Health conducted semi-structured interviews with stakeholders in Brazil to obtain additional context regarding the evolution of the community health efforts. Findings from the literature review informed the development of interview guides. The guides included questions about the following topics: program inception, program evolution, success factors, outstanding challenges, and future vision. Furthermore, the guide was tailored to the local context as required. Interviewees were selected through purposive and snowball sampling and included both current and former Ministry of Health leaders and professional associations, research institutions, international and domestic nongovernmental organizations, and multilateral and bilateral institutions. Many of the interviewees played a leadership role in the evolution of Brazil’s CHW program. When possible, interviews were recorded and transcribed.
Analysis: Last Mile Health’s research team analyzed the transcripts using a thematic approach and in alignment with the topical areas included in the interview guides. Findings from the interviews were supplemented with additional literature review. Using inductive reasoning, Last Mile Health explored key factors that contributed to the successful scale-up and implementation of Brazil’s CHW program. Last Mile Health followed up with many of the original interviewees to ensure accuracy of the analysis and validity of the findings.
World Health Organization, ExpandNet. Nine steps for developing a scaling-up strategy. World Health Organization, 2010.http://www.expandnet.net/PDFs/ExpandNet-WHO%20Nine%20Step%20Guide%20published.pdf. Accessed 17 December 2018. Primary Health Care Performance Initiative (PHCPI) Methodology Note, PHCPI.
Primary Health Care Performance Initiative (PHCPI) Methodology Note, PHCPI. https://phcperformanceinitiative.org/sites/default/files/PHCPI%20Methodology%20Note_0.pdf. Updated September 2015. Accessed 17 December 2018.