Primary health care lessons from the northeast of Brazil: the Agentes de Saúde Program

Market-led economic reforms are usually viewed as being in conflict with government-stimulated socioeconomic development for disadvantaged groups. Nevertheless, Ceará, a poor state in the Northeast of Brazil, has since 1987 pursued both of those strategies simultaneously. One part of that approach has been a program of nurse-directed auxiliary health workers serving about 5 million people--almost all the persons outside the capital city and half of those in the capital. The system requires that the auxiliaries, called agentes de saúde, live in the local communities that they serve. The health agents visit each home once a month to carry out a small number of priority health activities. While health agent positions are in high demand, the minimum-wage salary that the agents receive makes up only a small portion of the state budget. A key aspect of the system is timely and comprehensive information, which is based on agent visits and is managed by trained nurses. Since the health agents system was launched, there has been a rapid decline in infant mortality, a rapid rise in immunization, identification of bottlenecks limiting the utilization of other medical resources, and timely interventions in times of crisis. The health agents system has combined administrative decentralization with financial centralization during a period of electoral democratization. The system has strengthened Ceará's commitment to primary care even as market-oriented changes have reduced the overall role of government. The Ceará program is being copied throughout the Northeast and other regions of Brazil. The key role that nurses play in the Ceará program in organizing and leading a system of basic primary care in poor neighborhoods and rural areas may provide useful lessons for other countries. In addition, Ceará does not have many of the favorable characteristics of other countries that have successfully invested in primary health care. Ceará thus represents a more achievable model for other countries, where, like Brazil, income, educational levels, and land tenure equity are limited.