M. West Fall 2015 ISP

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Organization and Personal Philosophy of Community Health Worker
Program in Maracanaú
West, Madison
Academic Director: Calhoun, Bill
Project Advisor: Sousa, Petha
University of Denver
International Studies
Brazil, Maracanau
1. Submitted in partial fulfillment of the requirements for Brazil: Social Justice and
Sustainability, SIT Study Abroad, Fall 2015

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Abstract
Brazil is home to a large, complex, and decentralized health system that has made great
health advancements for Brazilians. Although programs such as the community health agents are
effective in providing primary health care, shortage of supplies and funding can make this job
difficult. This research analyzes the community health agent program from three different levels
of inquiry. The first level is how the community health clinic coordinates with the Municipal
Director for Health, the second is how the health clinic manages, coordinates, and organizes
staff, and the third is exploring the personal philosophy of the community health workers and
their experience in their positions.
Although health agents gather first hand demographic information on health needs the
population, they are largely removed from communication with the larger health structure. A
lack of communication between health agents, who encourage treatment, and health facilities,
with long lines and lack of resources, means that community members often become discouraged
from seeking care. In order to more effectively reach the community, private public partnerships
should be made with the strong industrial sector in Maracanaú to provide health seminars at
places of employment. In addition better technology, access to re-training, and new hires of
health agents are needed to give support to an over burdened program.

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Table of Contents
Introduction 5
Methods 12
Results and Recommendations 14
Conclusions 23
Appendix 24
Sources 25

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Acknowledgements
I would like to thank SIT Brazil for giving me the amazing opportunity to learn about
Brazil and pushing myself in new ways I could have never imagined. My time here has been
difficult but very educating and fulfilling. I would like to thank Bill Calhoun for always
providing extensive articles and e-mails to help support our learning process. Thank you for
providing us access to beautiful communities that are working to make people’s lives better.
Thank you to Oelito for driving me to Maracanaú and always making sure I got to my meetings
safely, you are truly the dad for all of us on this program.
The biggest thank you to Petha Sousa, my advisor and friend, for being the multi-tasking
informant without which my research would have been impossible to complete. I appreciate
learning about your life and our friendship. Thank you to you Petha, Nielia, and Nielson for
allowing me into your home, getting to know your community, and being a small part of your
lives, while eating your entire supply of guava jam. Thank you to the other health agents and
health team members for being very gracious and welcoming me to learn about your roles and
views.

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Introduction
The global health society is recognizing the need for sustainable community health
policies. With greater frequency, community leaders are acknowledging that more emphasis
needs to be placed on organizations that can serve the health needs of people over longer periods
of time and with more stable sources of funding. In International Relations, and specifically
within the development and health field, there is a big push to consider the sustainability and
longevity of health projects. Following the boom of Non- Governmental Organizations (NGOs)
during the 1990s, academics and professionals are now considering how feasible it is for an
organization to expect long-term goals with short-term commitments. Can an NGO found a
health clinic in a disadvantaged area, when their funding for the project is unstable and they may
leave within a few years? During my service learning in Mozambique, I saw the fragility of
many NGO run programs and their heavy grant dependence (Field Journal, pg.60).
The seemingly obvious solution to this issue is for the government of these countries to
fund and administer these projects, so that they have a more permanent place within the
community. Brazil recognized these challenges and implemented a system of national health that
has produced results, especially in the northern state of Ceará. Community health workers have
been identified as having special potential to gain the trust of their patients in an area as personal
and important as providing care, especially to low income neighborhoods. The program enlists
workers from local communities to check up on people in their homes concerning their health.
However, with Brazil’s low funds and bureaucratic entanglement, how sustainable is the
program? Brazil’s health system is comprehensive in concept, but its implementation has many
structural problems. Does the structural inefficiencies prohibit community health workers from
realizing health improvements with the residents in their areas?

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I Maracanaú, Ceará
Brazil is categorized by five large state groupings: the south, southeast, central west or
interior, north, and northeast. Generally, strong developmental inequalities differentiate the north
from the south of Brazil, with most of the wealth concentrated in the south and southeast regions
of the country. Maracanaú is located within the northeastern state of Ceará, in close proximity to
the capital of the state, Fortaleza. Maracanaú means “drink of the Maracanas,” which is a bird
that drank from the lake located in the central area of the city (T. Vieira, personal
communication, November 12, 2015). The municipality was founded in 1962 but with the
military dictatorship in 1964, they eliminated all municipalities created after 1962 (Estatísticas,
2009). The city officially gained its rightful status as a municipality in 1984 (Estatísticas, 2009).
With the lection of mayor Roberto Pessoa in 2004, the city focused on becoming an
industrial power and is now home to the second largest economy and municipal exporter of
Ceará (Estatísticas, 2009) Some of the largest industrial employers in the city include Girado,
steel, Hidracor, ink, Vicunha, textiles, and Coca Cola (T. Vieria, personal communication,
November 12, 2015). As of 2010 Maracanaú had a population of 209, 748, but within the past
five years the municipality experienced a population boom and the current population is
estimated to be closer to 220,000-250,000 (T. Vieira, personal communication, November 12,
2015). The boom is associated with the growth of industrial based jobs and the growing expense
of living in Fortaleza, leading people to move to more affordable cities (Estatísticas, 2009).
Maracanaú is representative of the health issues that many regions in Brazil are facing,
primarily a shift from infectious diseases to now also dealing with chronic health issues.
Maracanaú has a high population of people with hypertension, diabetes, cardiological problems,
and sedentary lifestyles that largely translate into high rates of obesity (L. Fatima, personal

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correspondence, November 11, 2015). For example Petha Sousa, a local community health
agent, said when she first began working 18 years ago more children in the community were
malnourished, but now there are more issues of childhood obesity (Field Journal, pg. 15).
Infectious diseases such as tuberculosis and dengue fever continue to be issues; drug use is also
prevalent in the city (Field Journal, pg. 10).
II. Overview of SUS
The Sistema Único de Saudé (SUS) was officially implemented with the new national
Constitution in 1988 that promised health as a human right for all Brazilians. Knowing the
characteristics of Brazilian politics and society during the military dictatorship is important to
understanding the founding characteristics of SUS. During the military dictatorship that ruled
Brazil from 1964-1984 decision making for all sectors of the government was “done without
public involvement… and centralized in large bureaucracies,” (Paim et al, 2005). While the
private health care system flourished, especially in urban centers, the social welfare system
coverage was fractured along occupational posts and inadequate (Paim et al, 2005). Beginning in
the 1970s, social and political groups began to lobby for more complete and universal health
coverage. With the renewal of Brazilian democracy in 1984, these activists seized the
opportunity to re-write the constitution and deliver a comprehensive and decentralized health
system that is now SUS (Paim et al., 2005).
As a health structure, SUS has an interesting combination of private and public care
models, each interacting and affecting each other. The public and family health portion of SUS,
largely referred to as Programa Saúde de Familia (PSF) is financed by taxes from the federal,
state, and municipal level (Paim et al, 2005). The private portion is composed of private

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insurance plans, mainly provided by employers, and private health care clinics (Paim et al,
2005). Although technically every Brazilian can access both the private and public portions, low
income and working populations are more dependent on PSF while many wealthier Brazilians
opt to use the private system to avoid the characteristic long lines and scarce resources.
The public sector has significantly raised health and living standards for all Brazilians,
and especially working class families. In an analysis of health outcomes from James Macinko,
Frederico Gunais, and Maria Souza, infant mortality rate (IMR) was used as an indicator to
assess the effectiveness and progress of the Programa Saúde de Familia from pre- PSF
implementation, early PSF implementation, and late PSF expansion. The research showed that
PSF was critical to raising health standards; child deaths from diarrhea in 2002 were one third of
the 1990 rates, and deaths from acute respiratory infections (ARI) in 2002 were half of what they
were in 1990 (Macinko, Gunais, Souza, 2006). However “average annual income fluctuated each
year,” and did not significantly rise through out the thirteen years of analysis, which may prove
that people’s increased health was not due to more dispensable income to spend on health care
(Macinko, Gunais, Souza, 2006). Interestingly, an increase in nurses and doctors was not a
substantial indicator in reducing the infant mortality rate, suggesting that community health
workers may be the employees reaching families to educate them on causes of infant mortality
(Macinko, Gunais, Souza, 2006).
Although the public system is comprehensive and has produced results, in an equity
analysis by Uga et al. the system places a higher burden of tax on lower income earners through
direct and indirect taxes (Uga et al., 2007). Out of pocket medical expenses for the lowest
economic decile of families are estimated to take up 6.8% of income, while it only takes up 3.1%
for the highest economic decile (Uga et al. 2007). In addition, in an analysis with comparative

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health systems, such as Great Britain in which the government takes responsibility for 80% of
funding, the Brazilian government only finances 44% of the system (Uga et al., 2007). The
combination of these factors, along with the subpar service in some health posts, can dissuade
community members from accessing the posts (Field Journal, pg.52).
When residents do seek medical care from the public health posts there is varying quality
of treatment. A Terra de Souza conducted a qualitative research study about community
interactions with health posts and the “influence of healthcare system factors,” in the role of
infant mortality rates in Ceará (Souza et al., 1982). The researchers asked women living in the
state of Cearaá, who had lost infants in the last 12 months, about their experiences with the
health system. Souza identified three main themes that characterized the women’s experiences
including delay in “seeking medical care, delay in ‘receiving’ medical care, and ineffective
health care,” (Souza et al., 1982). Delays in seeking medical care were defined as mothers not
recognizing the severity of the illness, while delays in receiving medical care were defined as the
hospital not having adequate consultation times or medications, and ineffective health care
included the mothers’ perceptions that the child continued to be sick even after seeking treatment
or poor communication with medical staff (Souza et al., 1982). Experiences that were also
classified inside the delay in seeking care was mothers who decided to seek treatment from
traditional healers, (Souza et al. 1982) which suggests that SUS did not understand the cultural
importance that traditional medicines still play in many communities. Outside of the
physiological reasons for the infant’s mortality, the researchers recognized the socio-cultural
factors that influence family health outcomes. They recommended that health professionals that
have community knowledge be utilized to reach residents that have a lack of education or are
suspicious of accessing the health system.

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III Structure of ACS
In response to critiques from academics and health professionals, the Brazilian
government implemented the Agentes Comunitarios de Saúde (ACS) program in order to help
community members navigate the PSF program and to promote preventative care. The ACS,
commonly referred to as health agents, is employed in a door-to-door health check for each
family within their designated area (Field Journal, pg.7). The health agents primarily are born
and raised in the same community they serve and approximately 90% are women (Field Journal,
pg. 19). The ACS works in a health team composed of a doctor, nurse, technical nurse, and
between 4-10 community health agents (Field Journal, pg. 20). The nurse of the team is the
direct supervisor of the ACS and performs the job of directing and reviewing the health agents
(Field Journal, pg. 20).
Petha Sousa, a health agent of 18 years, described her responsibilities as needing to
“accompany children from 0-5 years of age, accompany pregnant women, carriers of hyper
tensions, diabetics, tuberculosis, and carriers of leprosy. These are our priorities. We cannot
afford to not visit one of these people. And the agents accompany families in general with basic
health education, with proper nutrition.” (P. Sousa, personal communication, November 19,
2015). The ACS program also places child vaccinations as a high priority, with each child having
a booklet that keep tracks of their vaccination records; health agents are required to check the
cards at each visit (Field Journal, pg. 7). Community health agents are assigned an area of 150
families but because of a lack of staff may accompany up to 200 families (P. Sousa, personal
communication, 19 November, 2015). In addition, the health agents link the community
members to the local health post; the agents often helping residents obtain specialized

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appointments and navigate the health bureaucracy (Field Journal, pg. 6). Health agents become
trusted sources of information and confidants for community members to express concerns about
their health and personal lives (Field Journal, pg. 6).
The community health agents have proven their effectiveness in several targeted health
campaigns and general coverage of Brazilians. The amount of the population that is covered by
community health workers progressed from 29.6% in 1998 to 60.4% in 2008 (Paim et al., 2011)
Coverage due to the community workers has increased services to roughly 98 million people in
85% of municipalities in Brazil (Paim et al, 2011). In a 2005 study, researchers sought to
understand the value of community health workers in promoting breast-feeding with recent
Brazilian mothers living in Fortaleza, Ceará (Leite et al., 2005). The counselors were mothers
themselves who also had experience with breast feeding their own children, and were assigned to
assess the health of the infant, the home environment and interview mothers based on their
experiences (Leite et al., 2005). For the intervention group compared to the control group, there
was a 9% increase in the rates of exclusive maternal breast-feeding, defined as infants only
receiving breast milk for the first four months of life (Leite et al, 2005). The researchers saw that
one of the most beneficial components of the community counselors was that they were able to
provide psychosocial support to the mothers who wanted to reverse cultural trends and
breastfeed more. The counselors, who came from the same communities as the women in the
study, provided effective support to those participants and effectively delayed the complete
replacement of breast milk with bottle-feeding (Leite et al, 2005).
With its successes, the ACS program also has structural issues that burden the community
health agents. The entire SUS program is chronically over stressed and under financed, with too
few resources for the amount of people served and low workplace moral (Field Journal, pg. 52).

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Hospitals and health clinics regularly have shortages of supplies and medicines (Macinko,
Gunais, Souza, 2006). In an analysis of the human resource issues with SUS, researchers found a
lack of structured career growth, large differences in salaries between regions, and uneven
distribution of medical staff (Victora et al, 2011). Since Brazilian government workers can only
be hired through an intense competitive process that can take months, many health workers are
on special contracts, which does not guarantee the same job benefits, and usually leads to lower
job satisfaction compared to other government employees (Victora et al, 2011). With special
consideration to community health agents, many of them develop health problems from working
outside, including skin cancer, deteriorating vision, and back pains (L. Fatima, personal
communication, November 11, 2015).
Methods
With these issues in mind, I sought to explore the issues of bureaucratic negotiation
affecting the effectiveness of the ACS program. I utilized a top down approach focusing on the
municipal government policies that regulates the health post in the city, the policies implemented
at the level of the health clinic, and finally how the community health workers feel about the
health policies. Specifically, I focused these levels of analyses for the community health worker
program. I worked with my advisor and key informant Petha Sousa to become familiar with the
health worker community, to schedule interviews, and become acquainted with Maracanaú as a
city.
As my first tier of analysis, I focused on the health policies of the municipality by
speaking with the Secretary of Health for the municipality of Maracanaú, Mr. Vieira. I
interviewed Mr. Vieira concerning the municipality’s history, why the city developed the

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community health worker program, how it receives its funding, and the effectiveness of the
program. I then asked what the main difficulties of the community health worker program are
and what he hoped for the future of health for Maracanaú.
As my second tier of analysis, I mainly worked with Petha Sousa to understand her
experiences of interacting with the municipal government as a community health agent. I was
able to live with Ms. Sousa for one week, in which time I developed a personal relationship with
her and used many formal and informal interviews to learn about her understanding of the ACS
system and the Maracanaú community. In conjunction with these interviews, Ms. Sousa provided
me with training and educational materials aimed at SUS health workers and community health
agents. I analyzed these booklets and pamphlets to understand how they were educating health
workers about their responsibilities. Finally, I observed a staff meeting at the health post where
health teams evaluated their performances.
As my final level of analysis, I sought to understand how the stresses of bureaucratic
health navigation could affect the personal philosophy of healthcare implementation for the
community workers. In order to accomplish this goal, I used formal and informal interviews to
create a relationship with the workers and managers at the health clinic. I employed formal
interviews and shadowed at home health visits to understand how they interact with residents,
how they organize visits in the community, and what type of profile they have gathered
regarding the overall health of the city. I developed a close relationship with a few health agents
and I used informal interviews to understand their responsibilities, their ideas to improve the
program, and their relationship with the community.

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Results & Discussion
The PSF system is effective, but not without its flaws. Although community health agents
provide important services for their residents, they are not connected enough to the other sectors
of the health system. A lack of community knowledge and resources to fund health initiatives
also makes the agents’ jobs more difficult. The recommendations from this section are ideas
from community health workers and include corporate partnerships for health seminars, increase
in the amount of health agents and technology in the ACS program, and more cohesion and
education about the SUS structure for health professionals and community members.
I. Communication in the Health System
The Sistema Único de Saúde is by design a decentralized health structure that allows
different areas in Brazil to adapt their health posts based on the needs of their communities.
Although this system has generally worked well, it can also create a lack of cohesion within the
same municipality or even the same health post between different sectors. The basis for this lack
of communication is a deficiency of education about the structure of SUS as a whole. For
example, in a visit to Petha’s assigned Maracanaú health post, a nurse said she did not recognize
that the SUS was not a global health system (Field Journal, pg. 18). In an interview with health
agent Maria Marcos about the difference between Brazil and my native country the United
States, Maria says, “My vision that I have of health in your country is that everything is great,”
(M. Marcos, personal communication, 19 November, 2015).
Although these conversations are not indicative of everyone in SUS, it is suggestive of
the lack of information that many health professionals have about experiences outside of their
own job post. If workers had a more complete knowledge of the system, they may understand

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how the entire structure is interrelated and increase communication between colleagues. In
addition, understanding the mission of SUS and how it sharply differs from many less
progressive systems may help work moral by understanding the access to care they are providing
all Brazilians (Field Journal, pg. 19).
During an initial review of the SUS health structure from existing literature sources, there
seemed to be a contrast between how community health agents were able to help residents
achieve better states of wellbeing with the chronic shortages in both the SUS health posts and
hospitals (Macinko et al., 2006). Although this could partly be attributed to the fact the health
agents promote preventative care and therefore decrease the need for health interventions at the
level of the hospital, many Brazilians still access hospital services. How could the health agents
and the hospitals be experiencing such different health environments and how does this affect the
community? From observations of Maracanaú, there is no communication between the health
agents and the hospital (M. Marcos, personal communication, November 19,2015). If health
agents could have more access to the workings of the hospital, they would be able to help their
residents navigate the health bureaucracy with more ease. Petha Sousa, a veteran health agent
from Maracanaú, stated “at the health post I arrange consultations, I make it easier to resolve a
problem by telling them talk to this doctor or this nurse. I can direct the solutions. If I had this
access in the hospital as well it would be easier. But we don’t have any contact. We don’t have
it,” (P. Sousa, personal communication, November 19,2015).
With a lack of communication between health agents and higher levels of the SUS
system, the burden falls to the community members to navigate the bureaucracy. For example, a
health agent might suggest to a resident of their area to seek treatment from the hospital or to
make a special consultation. Consultations require special appointments that are often moved or

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changed without notification to the patient or health agent that made the recommendation; this
results in community members being frustrated and feeling their time is being wasted. Loucia,
another veteran health agent, described her experiences with appointment changes: “There are
certain things the community knows and the agents will find out afterwards because they don’t
tell us and there is a lack of communication,” (L. Fatima, personal communication, November
11, 2015). Many times this lack of communication causes the health agent to look unprepared
and discourages residents from trying to obtain appointments in the future (Field Journal, pg.
55).
The actions of other health professionals affect the reputation and connection the health
agent has with their community. For example, health professionals that are assigned to the same
health post often do not have the same level community interaction training. Petha Sousa
described that one of the most difficult parts of being a health agent was “not with the
community, but with ill prepared professionals in the health unit,” (P.Sousa, personal
communication, November 19, 2015). Petha previously described working with the mental
health unit CAPS (Centroa de Atenção Psicossocial) in a joint outreach session with elderly
people for mental health consultations. During the consultations, Petha observed many of the
psychologists from CAPS treated the elderly people “like children,” and many community
members later confided in Petha saying they felt belittled and were not motived to use CAPS
services in the future (Field Journal, pg. 10). If community health agents could give training or
tips to other SUS professionals on effective community outreach strategies, perhaps health
agents would be blamed less for the incompetency of other staff.

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II. Health Agent Experience
Community health agents are frequently the link between the community and PSF, which
is a difficult role to navigate. ACS often receives discrimination from the health professional
community and hears constant complaints from their residents about accessing care. Several
health agents I spoke to felt they were discriminated against as a health agent because within the
community of SUS workers. Some staff does not consider health agents to be “real health
professionals” because the core of their work is social outreach and most do not have a university
level education (Field Journal, pg. 15). In addition, it is common to find residents that do not
understand that despite the health system’s long lines and shortage of medicines, they have the
constitutional right to free health care. In a conversation with a woman from Maracanaú, she
expressed surprise at learning there was poor people in the United States and that, while there is
a small but growing public health sector, most people have to pay for all of their health care
needs (Field Journal, pg. 12). Many Brazilians do not understand that despite its shortcomings, it
is a privilege to have a public health system such as SUS.
Health agents are responsible for educating their community members about how to
maintain their health and prevent major issues from developing. However, re-training efforts for
health agents are largely sub-par in quality. When asked how she would like to change the ACS
program, Loucia Fatima says she wants more “permanent education which has not happened.
Sometimes the trainings are only shallow; there should be classes for people to be better trained
and better educated and up to date. Because sicknesses are changing every day, they take new
forms,” (Personal communication, November 11,2015).
The quality of re-training on health, social issues, and new guidelines was analyzed in a
review of three training booklets and a health journal for SUS workers. Although the quality

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varied between publications, overall the booklets did not relay any new information to workers
and left out key material on safety. For example, two similar booklets concerning tuberculosis
and leprosy aimed to “erase doubts,” and help health agents in their “day-to-day routine,”
(Minestério de Saúde, 2001, Minestério de Saúde 2002) to identify and manage these two
diseases. Even though the booklet mentions the standard routines vaccinations and medication
schedules, and needing to accompany families to the health clinic, there is no mention of how the
health agents keep themselves safe while working with possible infectious community members
(Field Journal, pg. 60). Since most health agents already have an established relationship with
their community before beginning their jobs, a majority of them already know how to interact
with the populations and need to be informed of new dangers a disease can pose to themselves or
their people. For example in a dengue control pamphlet, agents were advised to be cautious of
environmental factors that can contribute to dengue such as littering, holes in water tanks, and
keeping plants in sand basins instead of water plates (Minestério de Saúde, 2009).
Health agents should be instructed in educational materials on how to take on more
specific roles in addressing community health issues; as of now pragmatic support strategies are
missing from available ACS literature. In an analysis of a SUS produced magazine on violence
in Brazil, each of the editor’s letters described how violence has a social cost and is a public
health concern (Minestério de Saúde, 2008). Although the articles described violence, how the
public sector disproportionately treats victims of violence, and the special vulnerability of Black
Brazilians and women, there are no specific recommendations for any health professional on
how to combat these issues (Minestério de Saúde, 2008). Especially since 63% of all violence
against adults takes place in the home, (Minestério de Saúde, 2008) community health agents
seem to be in a distinctive position to combat domestic violence with their regular access into

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people’s domestic lives. However, there is no training on how to safely and preventatively care
for victims of domestic violence.
In addition to a lack of continual education opportunities, community health agents are
largely overworked due to the exploding population of Maracanaú. In an interview with the
Secretary of Health for the city, Mr. Vieira confirmed that the municipality has not been able to
keep up with the population growth by providing the correct amount of health agents. Currently
there are 312 health agents in Maracanaú, and each health agent is ideally supposed to
accompany 150 families (Field Journal, pg. 6). However, Maracanaú’s population is now closer
to 250,000 which means that “each team mas micro areas that are 170,180, 190 families and then
about 750 or 800 people for each health agent. So you multiply it by 300 health workers and then
you reache 80-90 % of the population…” (T. Vieira, personal communication, November 12,
2015). Health agents are being over extended by at least 20 families in the best scenarios. In
some areas, there are no health agents because the municipality has not been able to process
health teams’ requests for more health agents (Field Journal, pg.18).
Even though health agents are currently visiting more people past their responsiblities,
better technology is not available to help them keep up with their duties. The Sistema de
Informação de Atenção Basica (SIAB) is a new computer system that should digitize all SUS
users’ medical records according to their SUS card number and keep track of information more
efficiently (Field Journal, pg. 15). However, Maracanaú still does not have this system, and
health agents have to input the written records into the outdated system (Field Journal, pg.15).
When speaking with Jessica, the director for health agents in the municipality, one of her biggest
hopes for the future was to bring more technology to make record keeping easier for agents
(Jessica, personal communication, November 12, 2015).

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III. Community Experience
A lack of health agents and resources ultimately affects the health outcomes of
community members. Several health agents described their experience of dealing with taboo
health issues with a lack of resources. For example, Petha Sousa describes how she does not
question or counsel drug users “because I don’t have the support to give them to tell them stop
doing drugs. We don’t have a clinic to direct this person to. We have the system of CAPS, we
have CAPS AD, which is drugs and alcohol. But it’s very bad. To get a consultation is very hard
and users have embarrassment, and people will say oh those are users and they don’t want to do
that. So it’s difficult,” (P. Sousa, personal communication, 19 November, 2015).
Mental health or psychological abuse are also difficult to combat; while shadowing a
domestic health visit a woman confided how her husband restricts her choices and movements in
a controlling relationship (Field Journal, pg. 7). The woman has hypertension and her
environment only exacerbates her condition; Petha has counseled her previously about therapy
options but the woman has so far not utilized them. The first step to combating embarrassing
conditions is preparing counseling centers for the amount of people seeking care, or else
community health counseling will be useless.
In an effort to reach community members through several different avenues, health
agents are also required to hold educational health seminars with different groups (Field Journal,
pg. 18). However, residents are often unwilling to attend these seminars and “the difficult part is
to gather the members of the community…Because people don’t want to leave their house,
people will say oh it’s boring, I don’t know what it is. So that is the difficulty to meet with
people,” (P. Sousa, personal communication, 19 November, 2015). However, residents are

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missing out on important information that is directed to their specific health needs. For example,
Petha described a health seminar she was meant to perform in November to coincide with the
men’ health campaign. However, she felt the men did not take her seriously and hardly anyone
showed up to the meeting (P.Sousa, personal communication, 19 November, 2015).
IV. Recommendations
The recommendations in this section are specifically targeted to the Maracanaú
community and are drawn from observations and interviews over the span of four weeks. Some
of these suggestions may be applicable to the larger SUS program based on each community’s
needs and context. Many of these proposals on how to improve community health and the ACS
program came from veteran health agents who are important sources of knowledge.
Community health workers are in a special position within to determine early health
trends or new and arising problems. During the door-to-door check in service, they gather first
hand information that builds the health profile for the city and country (Field Journal, pg. 20).
Although this information is relayed to the nurse of the health team, community health agents do
not have direct access to anyone else outside of their health team. Since the SUS program’s
ideological base is built on the idea of prevention, and the main role of ACS is prevention
through health education and counseling, health agents should have more communication and
influence with higher levels of SUS officials.
As Secretary of Health, Mr. Vieira currently describes his role as the “manager [who]
must above all encourage[s] the group. The manager is like a football coach who did not enter
the field because we already have our cast of players,” (T. Vieira, personal communication,
November 12, 2015). Although Mr. Vieira did not describe if he meets personally with other

22
leaders of health sectors from the city, it would be beneficial for Mr. Vieira to take a more
involved role in listening to community health agents. Petha Sousa describes her ideas for a
better relationship with the Secretary; “I think we should have meetings every few months so
that he can listen to the problems of the area, because sometimes I think that people wait to solve
an issue until someone bigger comes along to solve it quicker,” (P. Sousa, personal
communication, 19 November, 2015). Mr. Vieria has the position and responsibility to take a
stronger leadership role for addressing community agent issues and learning about the current
health status in his municipality.
The scarcity of resources within SUS poses interesting challenges on how to fund the
proposed changes. Since Maracanaú has a strong industrial sector, potentially effective
possibilities exist for public private partnerships. Community health agent Loucia believed that
holding health seminars at places of employment would guarantee that people are present for
important information (L. Fatima, personal communication, 11 November, 2015). In addition,
industries should be held to higher levels of corporate responsibility and help fund these
community seminars. As one small example, the Coca Cola Foundation places health as one of
its main priorities for grants and community outreach (Field Journal, pg. 55). Partnerships
between the health agents and the municipality could be constructed to provide better health
outcomes for residents.

23
Conclusions
The community health worker program continues to have great relevance for Brazil and
specifically the city of Maracanaú. By employing workers that are local to the communities they
serve, health agents are easily able to gain the public’s trust for the sensitive topic of health.
Despite threats of violence in the at large society, health agents enter into people’s homes to
become confidants and counselors to resident’s health needs. Although the health agents more
formal roles include monitoring children and people with chronic diseases, they largely serve as
a sounding board for every day well being concerns. Of the health agents I spoke to, they all
listed their favorite part of their job as having a close connection with their community and
taking care of their neighbors.
Health agents deserve the respect of their community and of their fellow health
professionals. Health agents are the link between the community and health services, but often
handle much of the miscommunication and differences between these two groups. If residents
had better education on how their privileges as a SUS cardholder compares to other countries, I
believe they would have a greater appreciation of their system. They may follow the
recommendations of the ACS and incur the long lines to access preventative care. In addition,
health professionals need to respect the groundwork health agents perform to gather data that
benefits the entire health system. Although not explicitly stated in any of my interviews, through
out much of my observations I can hypothesize that health agents are partly discriminated against
because of their lack of university level education and that 90% of health agents are women. The
ideas for increasing technology, private public partnerships, and better community resources all
came from health workers of Maracanaú. If the municipal government had avenues for direct
contact with health agents, they would have already had access to these valuable ideas.

24
Appendix
SUS- Sistema Único de Saúde Brazil’s national health program
ACS- Agentes Comunitarios de Saúde Community health agents
CAPS- Centroa de Atenção Psicossocial Mental health unit
CAPS AD- Centroa de Atenção Psicossocial Rehabilitation clinic for drug users
por Álcool e Drogas and alcoholics
PSF- Programa Saúde de Familia Family health program
IMR- Infant Mortality Rate
ARI- Acute Respiratory Infections

25
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