A letter from Brazil

No not football, but QOF. The Brazilians have introduced a pay for performance scheme for primary care. As a nation they are strikingly positive and ambitious. A decade or so ago they decided they needed universal healthcare coverage, so instituted Primary Care Units which cover geographically defined populations across the whole of Brazil. Each consists of one GP, one nurse and three or four healthcare assistants. The healthcare assistants are drawn from and live in the local community and have a very strong emphasis on health promotion. Sometimes there’s a dentist included too. Each Primary Care Unit is responsible for around 3500 patients. I visited one of these PCUs and was really impressed with their strong community focus. Their information systems are simple, only partly electronic, but, for example, they have maps of their households showing just where their diabetics and hypertensives lived. I was also very impressed with the strong sense of teamwork. At this PCU (I suspect unusual), team members met for a half day every week to plan and review their care.

The reason for my visit was to meet with the Brazilian Ministry of Health to review their QOF. Again, not lacking in ambition, they’ve developed a pay for performance scheme with over 1400 indicators and teams of inspectors have assessed all 20,000 Primary Care Units. They had three overseas experts to advise over two days – me, James Macinko (New York University) and Maria Augusta Nicoli (Bologna University). Each hour long presentation was followed by two hours of vigorous debate, all simultaneously translated between English, Portuguese and Italian. I don’t know how simultaneous translaters do their job, but they were incredibly good. Anyhow, the Brazilians were very receptive to robust criticism of their QOF from their foreign visitors and I think we stimulated some good discussion.

Two years ago I visited China on a similar ministry-advising trip. What a contrast with Brazil. In comparison, the Chinese were reserved, taking it all in, but not giving much away. The Brazilians were much more like you’d imagine them to be – loud, colourful, exuberant. This is a country where democracy rules OK with all it’s warts, and the meeting was lively with internal criticism and debate.

Oh, and Rio is all it’s cracked up to be.

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