Brazil: Progress in decentralising health care

Abstract

In 1988 a law was passed to create a unified decentralized health system in which municipalities have a responsibility for developing health care. Secretaries of health from municipalities met with general practitioners public-health specialists administrators and representatives of UNICEF and PAHO to review the progress of decentralization. Progress has been slow as many smaller municipalities lack the money to plan health care and there are few training programs for general practitioners community nurses and managers. In Icapui Ceara inhabited by 14000 people a local health plan was developed in 1989 with health promotion community participation and primary health care. There was a pronounced fall in infant mortality in 1992 compared with 1991 and appropriate referral of patients to specialist facilities also improved. The general practitioner training program based at the Conceicao hospital group and in the surrounding community in Porto Alegre is now well established. In the state of Para health workers employed by a local nongovernment organization go by boat to villages along the banks of the Amazon and Tapajos rivers to deliver basic health care. The base clinic in the city of Santarem accepts referrals from these outlying villages. The Fundacion Carvajal supports innovative intersectoral work in Cali Colombia based on linking health with development by giving training to small local businesses and individuals to improve their performance. There is emphasis on community health care and much surgery has been devolved from the teaching hospital to small community hospitals. Further reforms include a more integrated approach with emphasis on equal access to care community participation and speeding up of decentralization. Other needs are the development of human resources for health care improved financing a system of referral and discharge and improved collaboration between municipalities. Networks are being set up to encourage the training managers general practitioners and other community health workers.