Lessons from Brazil


The blog below are reflections from a learning tour of key health institutions in Brazil with the TEDxChange Pilot Programme supported by Bill & Melinda Gates Foundation.

In Nigeria, the National Health Bill has been ten years in the making and is currently with Mr President for signing. While the bill still contains some contentious issues, it presents an opportunity to appropriately clarify and delegate responsibility in the sector to different tiers in our complicated Federal structure. This will hopefully lead to the reinvigoration of the sector and usher in a new era.

However, in the frenzy of politicking, it is hard to detect any interest in the bill outside a small group of hard core advocates. Neither the people nor the politicians seem interested. Why is there a lack of interest in health? Have Nigerians completely given up on their government’s ability to provide for their health care?

I recently visited Brazil. Brazil has a lot in common with Nigeria: a large population (200M in Brazil vs. 170M in Nigeria) and a similarly huge gap between the rich and the poor. Over the years, I had heard a lot about Brazil’s progressive policies in public health. Long before universal access to antiretroviral therapy (ART) became accepted, Brazil challenged conventional wisdom and, despite World Bank objections, provided free universal access to ART for all people living with HIV/AIDS since 1996. In addition, Brazil manufactures most of its own vaccines in the famous Fiocruz Institute. So, I jumped at the opportunity enabled by the TEDxChange programme and supported by the Bill & Melinda Gates Foundation, to visit a primary health centre in Rocinha (Rio de Janeiro), one of the largest favelas in Brazil. Its proximity to the homes of the upper class from neighboring districts marks a profound contrast to the urban landscape of the region. It was just as seen in the movies; narrow alleyways ascending steep hills absolutely packed with people. While I felt somewhat uncomfortable about looking around and into their day-to-day reality, I felt privileged to deepen my understanding of the common challenges shared by Rio, Lagos and Johannesburg, two other cities close to my heart.

The Rochina favela in Rio de Janeiro Photo Credit: Pilar Olivares/TED

In the heart of this favela, I found one of the most advanced primary health care centres I have ever seen anywhere in the world. No, I am not just referring to its infrastructure but also to the information management system, the availability of dental surgery and mental health services, its emergency room, family planning services and paediatric unit. We were taken round the centre by Dr. Michael Duncan, who proudly showed us the various services and explained that, despite a well established parallel private health care sector, for many diseases, this clinic provides the best care available in Brazil. The centre is open for 24 hours every day of the year.

A tour round the Primary Health care centre in the Rochina favela Photo Credit: Pilar Olivares/TED

What impressed me the most was not what happens in the clinic but outside. The entire favela has been mapped, and there are “Family Health Teams” responsible for the ongoing care of about 70,000 to 100,000 people. Each sub-team is responsible for 3,000 to 4,000 people and is made up of a doctor, a nurse and about 6 community health workers. Chatting with one of the nurses, she told me that she knew most of her 3,000 patients by name. They are responsible for the on-going care of the people they looked after, including health promotion and prevention to reduce the need for healthcare services wherever possible. Brazil came to the profound recognition that a healthcare system that is built on the best curative services in the world will not make it a healthier country and made a strategic decision to address this.

So, how is this possible? Since returning to democracy in 1985 and with the new 1988 Constitution, quality healthcare has been explicitly identified as a right of citizenship and a responsibility of the government in Brazil. Following sustained pressure from civil society organizations , the Government of Brazil made deliberate and significant investments in the health sector, including initiating a comprehensive healthcare system: the Unified Health System (SUS). This provides free universal care for all Brazilians. Brazil’s Primary Care Strategy (which includes the Family Health Strategy) is a shift from curative hospital-based care to preventive ambulatory care with a strong pro-poor focus. It is organised as a decentralized system with complex patterns of funding and service provision with the Federal, State and Municipal governments involved. Brazil shows that despite having a large population, a large private sector and a federal government structure, it is still possible to deliver a healthcare service that is accessible for most people in the population.

The principle is clear, free access to healthcare at the point of need, even without a social insurance number. Brazil’s Unified Health System is a great example of a fair system in an otherwise unfair society.

Can this model work in Nigeria? This is a question for another day, but the purpose of sharing this story is to show it can work, even in the poorest of neighborhoods. We have learnt not to expect much from our leadership in the health sector; it may be time to change that. There are few opportunities to create the foundation of a country that may one day be great: enabling equitable access to health and education is a starting point.

With some of the staff at the Primary Health care centre in the Rochina favela Photo Credit: Pilar Olivares/TED

The most important lesson for me from this tour was that it is absolutely possible to build a health system that enables equitable access to the population in a developing country. Whether it is funded through a tax based system as in Brazil or through a community health insurance model as in Rwanda, or indeed any other funding model is a decision every country should make on its own. It is one we will have to make in Nigeria.

I could feel Dr Duncan’s pride as he took us round this centre; it is not impossible to achieve the same in Nigeria – if we choose to. But first, let’s ask Mr President to sign that bill.

More pictures from the tour can be found HERE.


Chikwe Ihekweazu is an epidemiologist and consultant public health physician. He is the Editor of Nigeria Health Watch, and the Managing Partner of EpiAfric (www.epiafric.com), which provides expertise in public health research and advisory services, health communication and professional development. He previously held leadership roles at the South African National Institute for Communicable Diseases and the UK's Health Protection Agency. Chikwe has undertaken several short term consultancies for the World Health Organisation, mainly in response to major outbreaks. He is a TED Fellow and co-curator of TEDxEuston.

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