Family Practice Vol. 19, No. 4, 410-415
© Oxford University Press 2002
Five years of family health care in São José
Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
Professor Walter W Rosser, Department of Family and Community Medicine, University of Toronto, 620 University Avenue, Suite 801, Toronto, Ontario M5G 2C1, Canada; E-mail: w.rosser{at}utoronto.ca
Sant'Ana AM, Rosser WW and Talbot Y. Five years of family health care in São José. Family Practice 2002; 19: 410–415.
Received 14 February 2001; Revised 2 October 2001; Accepted 11 March 2002.
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Abstract |
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In 1994, the Federal Government of Brazil enacted legislation to share the costs with municipalities of establishing or remodelling up to 20 000 health clinics, covering a population of 69 million people. São José clinic was established with family physicians in 1993 in a community of 3000 in the City of Curitiba. The clinic was functioning by 1995 when the Canadian four principles of Family Medicine were introduced to clinic staff. The impact of the clinic's work has measured improvements in perinatal mortality and child nutrition, reduced hepatitis A infection and produced dramatic improvements in delivery of preventive services. The presence of the clinic has empowered a poor community to demand improved municipal services that have helped to improve overall health. The introduction of Family Health Clinics in Brazil, and assistance provided by Canada, has achieved the objectives of the national Government in one sample site.
Keywords. Family medicine, general practice, international health, prevention, primary health care.
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Introduction |
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In 1994, the Federal Government of Brazil, a country of >160 million people, proclaimed a strategy to provide health care clinics to serve the country's population.1 It was estimated that to achieve this goal, 20 000 Programa Saude da Familia (PSF) clinics would be required by 2002. Each of the proposed clinics would have a human resource grouping for the average clinic serving 4000 persons, comprising one physician, one nurse practitioner and one health care worker (an individual who had received an 18 month training course following graduation from high school). In Curitiba, some clinics included dentists and social workers on their staff. Many clinics would also recruit a contingent of health agents. Health agents live in the community and are paid to work with the clinic to develop dissemination strategies to improve the health of the community as well as to provide those in the clinic with information about what is happening in the community.
The City of Curitiba provided demonstration models for the national plan having established >80 traditional clinics staffed by paediatricians, gynaecologists and internists to serve the population prior to the federal declaration. São José was opened in Curitiba on 28 May 1993, as the first clinic staffed by family physicians. The clinic served a population of 2928, representing three socio-economic groupings. On top of the hills that surround the clinic are unpaved streets and middle class families who live in detached homes. On the hillsides leading down to the river are favillas (shacks not usually served by sewers or water) that are occupied by squatters who have emigrated from rural areas over the past 10–15 years. The third group in the population is made up of descendants of Italian farmers who were immigrants in the 19th century. These families worked on small plots of land in the clinic catchment area.
The age/sex ratio of the population served by São José clinic is illustrated in Table 1
. Table 2 demonstrates the average family income in a country where the costs of food and services are similar to those of developed countries. The average family income is US$ 2500 per year, with the poorest population having a monthly family income of between US$ 65 and 85. The population has an illiteracy rate of 9.3%. There is an average of 65 births per year in the area served by the clinic. Table 3 lists the number of episodes of notifiable diseases in the population served by the São José clinic between 1993 and 1998.
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The environment provided by the São José clinic provides a model on which to assess the impact of implementing the four Canadian principles of Family Medicine on the health of a population (Table 4
).2 Tables 5, 6 and 7 describe changes in the health status of the population that occurred between 1993 and 1998 as a result of programmes promoted by the São José clinic. Since the clinic's baseline health status in 1993 was better than the Brazilian average, potential benefits seen in São José may be less than the benefits to be found in poorer areas of Brazil.
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Health status of the population of São José |
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When the City of Curitiba established the health clinics in the early 1990s, the health department maintained city-wide statistics about the health status of the population. They required formal reporting of morbidity and mortality in populations served by each of the clinics. At São José, the staff maintained much more rigorous statistics providing the base for this report (Table 8
).
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In 1993, one infant death was caused by malnutrition and pneumonia. In 1994, two infant deaths are recorded including a sudden infant death (SID; 6 months) and a severe staphylococcal infection of the skin secondary to scabies. In 1995, two deaths were recorded, one from congenital rubella syndrome and the other from a premature delivery of an unmarried adolescent who was hiding her pregnancy. The baby was born at 24 weeks of gestation. Since 1995, there have been no infant deaths reported.
The Brazilian perinatal mortality rate is 40:1000 live births according to the Ministry of Health and 51:1000 according to UNICEF. Both use estimated data. Paraná State, of which Curitiba is the capital, has an estimated perinatal mortality rate of 30:1000 and that in Curitiba City is estimated as 23:1000. During this 5-year period, a number of obligatory notifiable diseases occurred in São José including three cases of TB, two cases of leptospirosis, one case of AIDS, two cases of meningococal meningitis and a high rate of hepatitis A.
Hepatitis A was determined to be due to children walking and playing in open sewers. A school education programme was implemented in 1995 to inform children about the dangers of playing in this water, and since that time there have been no new cases of hepatitis A reported. These rates are similar to diseases reported for the City of Curitiba and the rest of Brazil (Table 3
).
Table 5 demonstrates the effects of improved pre-natal care that occurred between 1994 and 1997. Trends of the past 3 years demonstrate a decline in adolescent mothers from 58 to 26%, an increase in the overall number of pregnancies and an increase in the percentage of planned pregnancies from 31 to 41% between 1995 and 1998.
Most encouraging for the São José clinic is that the City of Curitiba's perinatal mortality rate in a 6-year period was 19.5:1000 live births while São José's rate in a 6-year period was 16:1000 live births. This rate is well below the national perinatal mortality rate, which is near 40:1000 live births.
Table 6 lists the causes of death in the São José area, which are similar to those published for the City of Curitiba. Accidental deaths are the most common cause of mortality, relating to the young age of the population. Hypertension, diabetes, anxiety and dermatitis are the most common adult problems presenting to the São José clinic.
Since the São José clinic has been established, a number of preventive programmes have been implemented. When the clinic first opened in 1993, there was almost a complete absence of preventive programmes. Fewer than 10% of the population had their blood pressure measured in the preceding 2 or 3 years, fewer than 5% of women had ever had a PAP smear, and children under 1 year of age rarely had well child examinations. Table 7 demonstrates the implementation of preventive programmes in 1994 recording the number of people receiving the programmes each year.
By 1997, almost all the neonates had received preventive screening at home in the first 7–10 days of life, and ~70% of the infants had at least one visit per month in the first year of life, with 25% of the visits with doctors.
Over 90% of women in the community had had at least one PAP smear in the preceding 4 years, and a substantial proportion of the hypertensive population had had at least six visits to the Health Unit to control their blood pressure and other cardiovascular disease.
The introduction of a programme to care for type II diabetics found ~100 persons in the population with the problem after 2 years. Table 7 also illustrates the decline in the number of infants below the 10th percentile for height and weight during the period 1994–1997. Attached physically to the São José clinic is a nursery operated by the City of Curitiba which caters for children as young as just a few months old up to school age. Here children are stimulated and fed five nutritious meals daily.
There is a close relationship between the medical clinic and the nursery, which has allowed the introduction of effective neonatal and infant preventive programmes. More than 30% of children under 2 years were below the 10th percentile in both height and weight in 1994 when the nursery and clinic began to function. The impact of the identification of poorly nourished children and the supplementing of their diet reduced the number of children below the 10th percentile to fewer than 10% in 1997.
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Discussion |
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TopAbstractIntroductionHealth status of the...DiscussionConclusionReferences |
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A sample of the statistics available on the health status of the population of São José demonstrates that the establishment of a family health clinic and nursery in the community has resulted in a significant improvement in the health status of the community. Both Canadian visitors and the physicians and nurses working in the clinic observed change occurring as the result of members of the community feeling empowered to improve their situation.
The community took steps, with the assistance and support of the health clinic, to clean up the garbage that littered much of the favillas area. Educating children in the community of the risk inherent in playing in open sewers resulted in the elimination of hepatitis A. Educating members of the community about the importance of sewage services has resulted in a successful campaign with city politicians to provide the favilla areas with sewers, and these were installed in 1998.
The relationship between the health clinic and the community has provided a mechanism to improve the education and understanding of health issues by all members of the community. The provision of knowledge about the importance of environmental issues related to health facilitated political activism within the community, leading to the acquisition of sewers. On Sundays, meetings are held to assess the relationship between the City and the community. It is not unusual on a Sunday afternoon to find hundreds of community members in a church basement discussing the impact of the municipal budget on their community.
Physicians, nurses and dentists working in São José participated in the Canadian Five-Weekend Basico Programme.3 The Basico Programme is based on the four principles of Family Medicine as developed by the College of Family Physicians of Canada. Those participating in the programme were stimulated to measure health outcomes in their community and promoted the use of evidence-based medicine following the Canadian Task Force on the Periodic Health Examination guidelines in their clinical practice. Exercises in the Basico Programme promoted better understanding of ‘problem’ families, leading to improvement in the doctor–patient relationship. Even though the clinical environment in São José is quite different from that in Canada, the principles of Family Medicine apply.
The clinic is very strongly community-based as a number of examples have demonstrated. The physicians have become an excellent resource to their population, providing extensive preventive interventions as well as stimulating the community to become more empowered and environmentally active.
A physician and nurse from São José visited Toronto for 4 weeks during the winter of 1998, to gain a better understanding of the Canadian approach to health care delivery. Since housing and social circumstances are determinants of health, clinic workers promote social activism to assist in improving housing, and social well-being is considered an activity to improve the health status of the population. The excellent links with the community served by the clinic, and the role of physicians and other primary care providers in improving the community environment, provides Canadian family physicians with a model to aspire to for improved health in poor communities. The concept of health agents working with clinic staff is particularly powerful when providing health education that reaches all members of a community in their homes. Use of a similar model to reach elderly and often isolated senior citizens in Canadian communities should be considered. The concept of creating 20 000 of these clinics throughout Brazil with impact on the health status of the population similar to that which was measured in São José has huge potential for improving the health status of the Brazilian people.
The Department of Family and Community Medicine at the University of Toronto has developed several strategies to assist Brazilian physicians in understanding the four principles of Canadian Family Medicine. Since none of the 73 medical schools in Brazil has a Department of Family Medicine, there is a serious lack of family physician leadership to achieve the full potential of health status gains throughout the country.
As of mid-2000, ~3000 physicians, nurses and dentists have completed the University of Toronto Basico Programme founded on the principles of Family Medicine, and another 2000 currently are enrolled in programmes in five Brazilian states. These programmes are now run by Brazilian physicians and it has become a Brazilian programme. The programme is expected to extend to all 23 states within 2 or 3 years. Two new Family Medicine residency programmes have begun in Brazil, in addition to a single programme established for the past 15 years in Porto Allegre. Another interesting characteristic of the Basico Programme is that it is entirely supported by municipalities and states in Brazil with no outside support as of mid-2000.
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Conclusion |
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TopAbstractIntroductionHealth status of the...DiscussionConclusionReferences |
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The introduction of a family health clinic in São José in 1993 has demonstrated a significant improvement in the health status of its population during the 5 years of health education and intervention. The clinic has also served to stimulate social activism, leading to improvements in sanitation in the favillas. The model of proving health care, health education and promoting socio-economic improvement in the community is one that Canadian communities could benefit from emulating.
The challenges of bringing the health benefits of this programme to all 160 million citizens of Brazil will require continuing support. With an economic currency crisis having jeopardized continuing development of Brazilian health clinics, international support for the programme may be sought. Brazilian physicians who have achieved such improvements in the health of their populations will continue to inspire their Canadian colleagues.
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References |
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TopAbstractIntroductionHealth status of the...DiscussionConclusionReferences |
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1 The PSF Program of the Government of Brazil.
2 The College of Family Physicians of Canada. The Four Principles of Family Medicine. First published in 1986.
3 Talbot Y, Lima, Wagner H et al. Aperfectionamento da Practica em Saude da Familia. Revista da Saude da Familia de Contagem. Contagem Brazil, September 2000; 13–17.
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