What did Brazil do?

Brazil’s CHW programming has succeeded in connecting the majority of Brazilians with essential primary health care. The program, which was born out of the country’s democratization and decentralization process in the 1980s, reflects international best practices. These include: embedding CHWs in the health system; a multi-sectoral approach to improving health; proactively providing preventive care; and universal guidelines, training, and supervision for all CHWs. We will explore each of these elements in this section of the case study.

Integration with the formal health system

The centerpiece of Brazil's primary health care system is the Family Health Team, which consists of a nurse, nurse assistant, physician, and four to six CHWs. Each team serves 3,500 people in a defined catchment area. Their goal is to provide proactive and holistic care to all Brazilians.

Brazil embedded CHWs within the Family Health Team to achieve two goals: strengthen the CHW's ability to link communities to a continuum of preventive and curative care provided by the Family Health Team at nearby primary health care facilities, and leverage the deep knowledge of CHWs as community insiders to better serve families. The cultural competence of CHWs benefits both families and the Family Health Team as a whole.

Multisectoral approach

The role of CHWs embodies Brazil's goal to implement decentralized, democratic, and responsive health care that reflects community needs. A CHW serves as equal parts health educator, system navigator, bridge to the health system, and community organizer, with wide latitude to solve whatever challenges they encounter in the families and communities where they work.

	The Multisectoral Approach of a Community Health Worker (CHW)
	HEALTH EDUCATOR CHWs initially assess health risks and provide tailored messages related to those risks, including promoting immunization, good nutrition and healthy lifestyles.They also address less traditional health topics, such as promoting social activities for older people and speaking with families about domestic violence.	FOR EXAMPLE Promote immunization, good nutrition, and healthy lifestyles Promote social activities for older people Speak with families about domestic violence
	SYSTEM NAVIGATOR CHWs help families navigate bureaucracies and get the help they need from school officials, law enforcement, and government social and medical services. This reflects Brazil's priority to address social determinants of health. Research shows that combining primary health care programs like Brazil's Family Health Program with conditional cash transfer programs like Bolsa Familia can improve the health outcomes for poor families.1	FOR EXAMPLE Help enroll a child  in school Help a family obtain government benefits such as conditional cash transfers through Bolsa Familia (in which families receive small cash payments if they keep their children in school and up to date with immunizations).2
	COMMUNITY ORGANIZER CHWs advocate for not only individual families but also entire communities in their catchment areas. CHWs may help secure electricity, sewage, or garbage service for a neighborhood with the goal of reducing key health risks and improving health outcomes.	FOR EXAMPLE Help secure electricity, sewage, or garbage service for a neighborhood with the goal of reducing key health risks and improving health outcomes.

Each of these layers of responsibility enables CHWs to address the social determinants of poor health and reduce inequities. CHWs can leverage an array of government programs and resources to help a family or community improve their quality of life.

Proactive care

CHWs play a pivotal role in connecting patients to the facility-based primary health system. CHWs identify patients in need of services, coordinate healthcare, and troubleshoot challenges. For instance, in some areas CHWs use blood pressure screenings or questionnaires to identify patients with early signs of hypertension. The CHW shares this information with their team, which may recommend that the patient go to a health clinic. The CHW then relays this information to the patient, helps them schedule an appointment, reminds them of the appointment, and may accompany them to the clinic. After the appointment, the CHW helps the patient follow their treatment plan.

CHWs help monitor families from the communities they serve, using systematic reports and indicators. They carry a register of households and different forms that focus on the health status of children, pregnant women, the elderly, and patients with diabetes and hypertension. During home visits, CHWs collect data for disease surveillance, providing an important source of information to supplement facility-based data. CHWs' notes are discussed at weekly team meetings and added to the medical record, which is usually electronic. ³  Aggregate data is entered into a database and updated monthly. The database is available at municipal health offices and is maintained by staff at the federal level for monitoring key health indicators such as the infant mortality rate.⁴ This activity is the bulk of the CHW's work, when visiting 10 to 15 households in their catchment area each day.

CHWs extend the reach of the health care system to individuals and families who may not know they are sick, may not understand what services are available, or may be unfamiliar with the benefits of preventive care. Every household in each CHW's catchment area receives a visit from their CHW roughly once per month, regardless of their health.

Research shows a threefold increase in the number of primary health care visits in Brazil between 1994 and 2014. The number of primary care services per capita also increased from nearly three to nine, annually. Primary care services include consultations and procedures such as simple diagnostic exams, prevention and promotion activities, etc. ⁵

Research also found that child mortality rates were reduced by as much as 22 percent in municipalities with high levels of CHW coverage. The impact was strongest in municipalities with higher baseline child mortality rates and lower human development indices.⁶

Guidelines and training

According to Ministry of Health guidelines, CHWs are required to live in the community in which they work. They must have a minimum of a ninth grade education, although they often have a college degree.^{7 8}  CHWs are usually nominated by their community. Nearly 90 percent are women between the ages of 21 and 49.³ The federal government’s requirements for CHW training includes, at minimum, a two-month residential course followed by four weeks of field work, though municipalities under budgetary or staffing pressure have sometimes provided more limited training. Pay varies by municipality, though federal regulations mandate that CHWs receive above minimum wage.

The position is considered a good entry-level job. CHWs are highly respected in their communities, so much so that CHWs in dangerous areas report their social standing affords them a level of protection from violence.³

Supervision

Nurse supervisors, who work within the Family Health Team, dedicate half their time to supervising the CHWs on their team and the other half to their work at local health clinics. Nurse supervisors provide critical supervision guided by public health knowledge and best practices. They provide support and mentoring to CHWs and investigate the quality of care provided to patients. CHWs generally stop by the local clinic first thing in the morning and at the end of the day. They regularly meet with nurse supervisors to review their visit records and data gathered from the community. Supervision often focuses on challenges CHWs identify during their home visits. Nurse supervisors will also identify specific focus areas, informed by community health indicators and trends. For example, if indicators show high rates of leishmaniasis, the nurse supervisor and CHW would focus on planning continuing education activities for the community on that topic.⁹ Nurse supervisors sometimes accompany CHWs in their visits to patients that are unable to come to clinics and also make their own independent home visits to ensure that CHWs are visiting the families for which they are responsible.⁴

Defined catchment areas to reduce redundancies

Family Health Teams are organized geographically, with no overlap or gap between catchment areas, eliminating redundancies and helping expand coverage. The Family Health Team maintains a list of all residents in their catchment area to ensure seamless coverage, and enable the delivery and monitoring of care over time.¹⁰ A catchment area generally has between 3,000 and 5,000 people, usually 600 to 800 households. Each CHW attends to 500 to 700 people, or 100 to 150 households.

CHWs register every family in their area, including those who have recently moved in, for both health care services and government social services, with the goal of full coverage.³

CHW SERVICES IN BRAZIL

DISEASE/ INTERVENTION	INDICATORS	ACTIVITIES
Preventing and managing chronic disease/NCDs	Hypertension Diabetes Cancer screening Mental health	Assess current use of alcohol and drugs; eating habits; smoking, etc. Measure blood pressure/glycemia to support the identification of people with hypertension/diabetes. Provide 1:1 counseling on cancer and other NCDs, healthy behaviors, smoking, alcohol and other drugs, etc. Provide 1:1 counseling when signs and symptoms of mental health problems are observed during home visits. Sensitize the community on mental health. Design, organize and deliver group education meetings for individuals with chronic disease. Provide information on services available at UBS and refer as needed. Make appointments, follow up to ensure attendance and support adherence to medication (example: for diabetes)
Addressing social determinants of health	WASH Domestic violence Disability	Identify risk factors in the home. Observe signs of domestic violence (emphasis on children, women and the elderly). Assess eligibility for social services and support application process. Provide 1:1 counselling on water and sanitation, nutrition, etc.
Adolescent health	Sexual behaviors Alcohol and drug use Nutrition disorders	Check for danger signs (obesity, sexual abuse, alcohol and drugs use, etc.) Check immunization status. Provide 1:1 counseling on sexual activity, contraception, prenatal care in case of pregnancy, alcohol and drugs.
Child health	Vaccines Diarrhea ARI	Use Integrated Management of Childhood Illness decision support tool to identify children at risk of serious illness. Check vaccination cards to make sure all vaccinations are up to date and counsel on importance of immunization. Conduct monthly or bimonthly weight measurement in all children less than 2 years of age. Check for signs of violence affecting the child. Provide ORS and home-made ORS promotion (as needed). Refer child to primary care facility if danger signs identified.
Reducing maternal and neonatal mortality	ANC PNC SBA	PREGNANCY Check immunization status Develop individualized pregnancy plans Check for danger signs Design, organize and deliver low-risk pregnancy health education groups Inform about facility for delivery Schedule and remind client of ANC/PNC visits Follow up of women missing ANC/PNC appointments NEWBORN Check that all immunizations and biomarker blood tests have been administered Check hygiene, how frequently diapers are changed, etc. Check overall physical appearance (skin, hair) to ensure normal development Provide one-to-one advice and support for breastfeeding in the household Design, organize and deliver group education meetings for breast-feeding mothers Schedule PHC visits for postnatal care, etc. Measure child weight
Improving SRH	Modern contraception	Check sexual activity status and prior/current use of contraceptives Stimulate the creation of women’s self-help groups to talk about reproductive health, including contraception Provide 1:1 counselling on contraception
Reducing communicable diseases	TB HIV Malaria	TB (AS EXAMPLE): Identify signs and symptoms (3+ weeks of cough), help schedule appointment at PHC facility Contact tracing Monitor TB patients including the collection of data for the health information system Perform DOTS (3 observations per week first 2 months, 2 per week rest of the treatment period) Search for people who have abandoned treatment
Household data collection		Regularly collect and update basic household data on occupancy, demographics, education levels, occupation, deprivation and predominant health issue including smoking and alcohol use of every member in each household.
Community liaison		Link community members to social services (e.g., assistance with civic duties such as voter registration).
Health related administrative tasks		Make appointments with physicians on behalf of clients, reminding clients of scheduled appointments, following up as needed.
Planning and performance		Weekly meetings with nurse supervisor and regular liaising and collaboration with ESF team members.