Date Published: July 27, 2017
Author(s): Louis S. Jenkins, Marcos A. Goldraich.
Brazil and South Africa share many sociodemographic and health features that provide many learning opportunities. Brazil’s national health system, the Sistema Único de Saúde (SUS) prioritises primary health care since 1994, the year democracy came to South Africa. Two family physicians from these countries met in Rocinha favela in Rio de Janeiro, a densely populated area where poverty, danger, drugs, tuberculosis and mental illness are the focus of the health system.
Central to the SUS are the Family Health Teams, consisting of community health workers, nurses, doctors and allied health workers. This clinic in Rocinha has 11 teams, caring for 2700 people each, all visited monthly, preventing illness and promoting health. Patients with mental illness are cared for in a therapeutic residency, with an onsite psychiatrist, psychologist and social worker. The relationships between the health carers and the clinic and the community are collegial and equal, sharing care. Larger than life photos of patients from the community line the walls.
A culture of learning is evident, with 18 family medicine residents, student nurses, a small library and a learning centre at the clinic. Local authorities compensate trainees in family medicine more than traditional specialties.
Brazil has made massive progress in providing universal health coverage over the last 20 years. South Africa, with not too dissimilar challenges, is embarking on this road more recently. The lessons learnt at clinic and community level in this inner-city clinic could be very useful for similar settings in South Africa and other countries.
South Africa and Brazil share many sociodemographic and health features that provide many learning opportunities. Following the 21st World Conference of Family Doctors held in November 2016 in Rio de Janeiro, the authors, fellow family physicians on either side of the Atlantic Ocean, reconnected. Dr Goldraich is the descendent of German–Polish immigrants during the Second World War. He lives with his wife, also a family doctor and mother of their 1½-year-old daughter, in the city of Rio de Janeiro. He has worked as a clinician and family physician supervisor for the last six years in Rocinha, the largest favela in Rio city, and invited his South African counterpart (first author) to visit the clinic where he works. With a reminder that not all clinics in Brazil look alike, the work happening at this clinic that opened nearly seven years ago is remarkable and needs to be shared with a wider audience (Figure 1).
Brazil’s national health system, the Sistema Único de Saúde (SUS) was introduced in 1994, the year South Africa inaugurated its first democratically elected president, Mr Nelson Mandela. The SUS provides universal health coverage to more than 70% of the country with the world’s fifth largest population.1,2 Health expenditure in Brazil amounts to 9.3% of GDP, with out of pocket (private insurance) health expenditure amounting to 57.8% of health expenditure.2 South Africa spends 8.6% of the GDP on health, with 60% spent in the private sector for only 16% of the population.3,4 In Brazil, 28.9% of the population have private insurance.5
This PHC clinic is the largest of the three that serve the community of Rocinha. The clinic is spacious, light, colourful, well ventilated, with larger than life pictures of patients from the community displayed on the walls as portraits of art. It creates a sense of ownership or agency, and turns the clinic into a kind of home. Adjacent to the clinic is a 24-h walk-in Emergency Department, known as Unidade de Pronto Atendimento (UPA). It has an overnight ward with six short-stay beds, 24-h X-ray facilities, a sonography room (four times a week) and a small onsite laboratory (although most blood tests are processed off site). Patients with surgical and orthopaedic conditions that need specialist care are referred. Patients with the usual conditions that would fall into the ambit of Internal Medicine, like cardiac, renal or neurological disease, are mostly managed locally in the clinic. For example, patients with myocardial infarcts receive alteplase in the clinic and sometimes stay for one to a few days, awaiting transfer to a hospital bed. Patients with diabetic keto-acidosis are mostly managed in the clinic, staying for a few days. This is not necessarily the norm everywhere in Brazil.
Primary health care vocational training is taken very seriously by the city’s health department. This clinic is a big training centre, with 18 family medicine registrars, 8 PHC nursing students and medical students from different stages of training all working here. Brazil is serious about training doctors and especially family physicians for PHC, which is reflected in their massive improvements in the health outcomes for the country over the last 20 years.21 The population of about 200 million people is served by over 200 medical schools, with another 60 in the pipeline, of which half will be rurally situated.22 South Africa’s 50 million people are served by nine medical schools, with the 10th medical school opening soon. However, it remains difficult to attract doctors into PHC and family medicine – only 1.2% of the 400 000 doctors in Brazil are trained in Family Medicine.23 Despite an increase in the number of training sites each year (total of about 3000 per year), students are not attracted into Family Medicine, with about a 30% occupation rate. For this reason, trainees in Family Medicine are paid more than trainees in traditional specialist training programmes, an initiative governed by various district authorities, such as in Rio de Janeiro. With this incentive, the occupation rate for Family Medicine training in the city is almost 100%. A key driver is high salaries, which will probably become unaffordable in the future, especially with the country’s new austere economic agenda.24
Initially, when the clinic was first opened, the health team was overwhelmed with people with massive health needs and struggled to get through the day. But over time, as the FHT worked in the community, the burden on the clinic lifted. Now it is a very good place to work, with a fine balance of working with and in the community. What was striking is the mutual respect that exists between health cadres in the health team, with the nurses, doctors and security staff all sharing the care of patients, even as they share lunch together (Figure 4). The healthy relationship between the health team and the designated families in the community was very evident in the way the team interacted with young and old, pregnant women, the dying and the mentally ill. Lastly, the integrated way that learning was part and parcel of PHC work, with the many nursing trainees and family medicine registrars in one clinic, and the government incentives to attract trainees to PHC were very enviable. South Africa can do well if political priority is given to PHC as a preferred place for patients and health personnel to find themselves, sharing responsibility for health and learning from each other in community. Being a clinic or community doctor or nurse should become a proud vocation once again.