Cufino Svitone E, Garfield R, Vasconcelos M I, Araujo Craveiro V
UNICEF Fortaleza, Brazil.
Rev Panam Salud Publica. 2000 May;7(5):293-302. doi: 10.1590/s1020-49892000000500002.
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.
以市场为主导的经济改革通常被视为与政府推动的弱势群体社会经济发展相冲突。然而，巴西东北部的贫困州塞阿拉自1987年以来同时推行了这两种策略。该方法的一部分是一项由护士指导辅助卫生工作者的计划，服务约500万人——几乎是首都以外的所有人以及首都一半的人口。该系统要求被称为“健康代理人”（agentes de saúde）的辅助人员居住在他们服务的当地社区。健康代理人每月走访每户家庭一次，开展少量优先健康活动。虽然健康代理人岗位需求很高，但代理人领取的最低工资仅占该州预算的一小部分。该系统的一个关键方面是及时和全面的信息，这些信息基于代理人的走访，并由经过培训的护士管理。自健康代理人系统启动以来，婴儿死亡率迅速下降，免疫接种率迅速上升，识别出限制其他医疗资源利用的瓶颈，并在危机时刻及时进行干预。在选举民主化时期，健康代理人系统将行政分权与财政集权结合起来。即使以市场为导向的变革减少了政府的整体作用，该系统也加强了塞阿拉对初级保健的承诺。塞阿拉计划正在巴西东北部和其他地区推广。护士在塞阿拉计划中组织和领导贫困社区和农村地区基本初级保健系统方面所发挥的关键作用，可能为其他国家提供有益的经验教训。此外，塞阿拉没有其他成功投资于初级卫生保健的国家所具备的许多有利特征。因此，塞阿拉为其他国家提供了一个更可行的模式，这些国家像巴西一样，收入、教育水平和土地保有权公平性都有限。
