Making disease prevention work in Brazil's district health authorities

Health care in Latin America is largely based around hospital care and tends to focus on curing the sick rather than preventing disease. Many suggest that health systems are effective when they focus on the prevention of disease and the promotion of good health. How are Brazilian health authorities coping with a shift towards disease prevention? 

Encouraginga decentralised health system to prioritise a focus on disease prevention isextremely difficult. The UK's University of Manchester together with the Schoolof Public Health, Ceara, Brazil, compared two localhealth authorities in the Brazilian state of Ceara tofind out why one was more successful than the other at adopting new policiesfor disease prevention.

Thetwo districts chosen in Ceara State, one of thepoorest regions of the country, are similar in many ways. Both are largelyrural and very young: much of the population rely on subsistence farming, whilstover half are under the age of 24. These districts lack basic infrastructure suchas a proper water supply, sewage and waste collection. They are typical of manydistricts in northeast Brazil. The main health problems aresimilar to many low income countries. Common health conditions include diarrhoea,respiratory diseases, malnutrition, hepatitis and meningitis. Many of theseconditions benefit from low cost interventions, such as vaccination and antenatalcare, which have the potential to significantly reduce mortality rates.

Thestudy found that Pedra Branca,the more decentralised health authority, paid greater attention to preventingdisease and promoting good health than the Tauahealth authority. The health system in Pedra Branca:

• was much more committedto the health reforms
• could make its owndecisions and control its own funding, whereas in Tauadecisions and funding were controlled by the local government 
• had fewer hospital inpatientsand referred more people to its family health programme or communityhealth workers
• had made a largeinvestment in environmental projects, whereas Tauahad done little in this area
• had developed stronglinks with the state's education and social work departments as well aswith local churches
• listened to the views of localpeople while Taua had not encouraged localpeople to participate in its health council.

Between1996 and 1998, Pedra Brancawas more successful in a number of basic areas of health care. The districtprovided more women with antenatal care, encouraged more women to breast feedand vaccinated more babies than Taua. Monitoring thegrowth of babies in both districts fell a little. However, it is not only thelevel of decentralisation and resources that makes the difference between thetwo districts: Taua lacks PedraBranca's political will for change.

Inorder to change the focus in the health service from curing disease topromoting wellbeing and preventing disease it is necessary to target not only theactivities of local health staff but also the expectations of the localpopulation and the attitudes of local government.