7 November 2019

Training Brazilian community health workers to understand their patients better

PhD in Global Health

Brazilian PhD student César Augusto Paro is on a mission. He wants to improve the training of Brazilian community health workers so that they are able to provide better health care for patients in poorer areas in Brazil. He is currently visiting UCPH’s Global Health Section to work with community-based interventions in the university's research projects.

Cesar and the community health volunteers

Text: Morten Mechlenborg Nørulf

Brazil is a huge complex country, which is also reflected in its health care system. When the federal government puts forward new health guidelines, practices or campaigns to be implemented at local levels, it often results in failure because they are not adjusted to fit local conditions. This is also the case with community health workers in some of Brazil’s poorer areas. Here, training of the health workers is insufficient, which results in general disbelief in the health care system among Brazilians.

César wants to change this with his PhD project. Through community-based interventions, he is mobilising community health workers to better understand and help their patients.  

Community health workers in Brazil

Community health workers are a vital part of the Brazilian health care system. They assist other health professionals such as nurses and general practitioners (GPs) in health promotion, disease prevention and treatment of patients at primary health care (PHC) level. They are the link between the health professional and a certain community and therefore they have to live in the community they serve. For example, if a GP needs to do a home visit at a patient’s house the community health worker will go with the GP. Or if a patient needs to go for a consultation at the clinic the community health worker will schedule the consultation for them.

Normally, each PHC team has five to six community health workers. They normally work 40 hours and are affiliated with one clinic close to their community. Parts of the community territory is divided among the affiliated community health workers and one time per week they meet with other professionals of the PHC team to discuss the cases in their territory.

Part of their work is also to do health prevention promotion but they often have a very strict way of doing this, telling people in their community to do this or to do that. César is hoping that through community-based interventions the community health workers will be less authoritarian in their health prevention methods and include the determinants of health in their approach.

A community health worker identifying health risks relating to the trash management in the community
A community health worker identifying health risks relating to the trash management in the community. Photo: César Augusto Paro.

Although the public health professionals have a lot of expectations towards the community health workers' work and consider them as important elements for a healthy community in a poor area, there are still problems with this system. Some of the community health workers are protestants and unfortunately, sometimes reject to help patients of other religious beliefs. They also have a very low salary compared to other health professionals, which is why their important work and function in the system is not valued enough.

The approach with community health workers has been in place for more than 30 years in some places in Brazil and served as inspiration for when the system was adopted in the entire country with the creation of the Unified Health System in 1988.

The official health care authorities have guidelines for health care in Brazil but these guidelines do not always fit local areas. This is also the case with the training and practices for the community health workers, which is something César is hoping to change through this community-based intervention.

Better education is the way forward

To improve the health care services provided by the community health workers, their training must be improved and tailored to the community in which they work. Now, community health workers only receive one week’s training at the beginning of their contract. They are supposed  to have permanent training throughout their career. However, this training is still rare or is of poor quality.

César's supervisor teaches the community health workers
César's supervisor teaches the community health workers. Photo: César Augusto Paro

For two years, César has been working with educating the community health workers in Complexo do Alemão – a group of favelas in Northern Rio de Janeiro city. Here he worked with 40 community health workers, training them with a participatory methodology that focused on a community-based intervention. Together with the workers he held weekly training workshops on how to improve their practice to better understand their patients. He used the Paulo Freire method, which is about learning and teaching each other through dialogue. It is an epistemological way of making you question your practice. In practice, this means that you need to understand how people interact with each other and their neighbourhood in order to design the interventions. 

The goal of the workshops was to train the community health workers to develop competencies through community engagement for promoting innovative disease prevention and health promotion proposals for the Zika outbreak. Through these workshops, César was trying to make the community health workers re-think their practices and how they think about their patients.

The workshops also made the community health workers reflect on their community territory. In areas with a lot of violence, it is crucial that the health workers know how to navigate the territory. So creating maps and narratives about their territory is an important part of their training.

Workhop: The community health workers make maps of the territory they work in
Workshop: The community health workers make maps of the territory they work in. Photo: César Augusto Paro

For his PhD, César has been collecting data from these workshops (reports, maps, narratives). The data has been analysed and this last year of his PhD project, he will spend finalising reports and writing the actual thesis. Here at UCPH’s Global Health Section he is part of a research team that explores the feasibility of integrating mosquito control subjects and activities into the primary school curriculum in Zanzibar, Tanzania.

Problems with the health care system in Brazil

In Brazil, the public health care system is complex. While the federal and state government takes care of actions and services in secondary (ambulatory) and tertiary (hospitals) care levels, the municipalities are responsible for the primary health care (health promotion and preventive). According to César, although the country has one of the most inclusive and embracing universal health systems in the world on paper, there are a lot of problems in reality.

One of the major problems is the chronic underfinancing since it was created. The health care system has always been receiving fewer resources than needed for implementing all the necessary actions and services. 

Another problem is the disbelief in the public health care system by the middle and especially the upper class. This causes them to use private sector health care providers and by doing so they can claim reimbursement for the treatment they receive in the private sector from the public sector. In other words, they are wasting money on health care services they could have received in the public sector – money that could have been put to good use in the public system.

A third issue is the medias’ depiction of the Brazilian health care system. Often the media run stories on how bad it is and, according to César, they only show the worst sides of the system. This depiction adds to the general disbelief in the system among the population – also the poorer part of the population, who then also thinks that private insurance is the best solution.

Children creating a water-playground from drain water
Complexo do Alemão: Children creating a water-playground from drain water, which could cause health risks. Photo: César Augusto Paro

On paper, everyone is equal in Brazil. However, huge inequalities do exist and people are sometimes directly and indirectly discriminated against in the health care system due to things like sexism, homophobia and structural racism. Often this discrimination is rooted in religious beliefs. Even though a GP or a nurse should be neutral in their profession they often carry their religious beliefs with them into their professions, which may lead to for example homophobic moralisation towards their patients. And as a patient from a poor neighbourhood, if you are not aware of your human rights in such a situation, what can you do?

Furthermore, there are problems with access to secondary and tertiary services in some places, poor coverage of primary health care in some regions in the country, and waiting time can be longer than expected for a lot of specialists.

To César, it would all be much better if people put more trust in the system and started to use it more. Therefore, active participation is one of the principle ways of making the health care system work well. In Brazil there is a saying: “Health is democracy” ("Saúde é democracia" – coined by one of the founding fathers of the Brazilian health care system, Sergio Arouca). If everyone exercised their democratic rights to use the health care system in Brazil, it would automatically become better.


For further information or questions, please contact César Augusto Paro: cesaraugustoparo@iesc.ufrj.br