Observing emergency clinics during the middle of the night in Rocinha. Interviewing patients at the UPA 24 hrs in Manguinhos about their experiences in the emergency room. Learning about how the municipality of Rio de Janeiro tracks the spread of disease at the Prefeitura. These are just some of the experiences of VER-SUS—a project initiated by the Ministry of Health and the Municipality of Rio de Janeiro to provide university students with a more tangible understanding of the Sistema Unico de Saude (SUS), the public health system of Brazil.
Over the course of two weeks in January, I visited and learned about the various aspects of the public health system in Brazil. Unlike the United States, Brazil has a universal health care system that is mandated to provide care and access to all the country’s residents. Compared to other global health citizens, SUS is a relatively new system. It was in part developed by the National School of Public Health at Fiocruz, but has roots in European and North American ideologies about health. SUS is more that a system to deliver healthcare—it is an ideological approach to health, guided by principles such as universality, equity, social control, and regionalization.
The core of SUS is its decentralized structure. The system distributes responsibility and authority of healthcare to the federal, state, and municipal level. Because of this organization, municipal governments have had the freedom to create innovative and successful programs (namely, Programa Saude da Familia) that have become fundamental components of the public health system in Brazil. As a participant in VER-SUS, I saw how the municipal government of Rio de Janeiro provides health care to its residents.
I visited several Clinicas da Programa Saude da Familia during VER-SUS. These visits were effective at helping me understand the philosophies of public health in Brazil and how they are represented within the structure of the system, as well as the differences between health care in Brazil and in the United States. Because SUS is a holistic system—treating social and environmental factors affecting health just as important as disease itself, activities and resources are provided for residents to improve their quality of life. I saw artwork on the walls on the clinics from activities that the clinic offered. Elderly residents were using the exercise stations to improve their cardiovascular health. Members of the community came to learn about dental health at a free lecture given in one of the classrooms in the clinic. In the United States, healthcare primarily works to treat—rather than to prevent and promote. Within the health units such as clinics and hospitals, there are very few opportunities to promote healthcare. However, unlike in Brazil, the United States places a strict emphasis on teaching about healthcare within the public education system. Courses on sexual education, lectures offered to parents and children about menstruation, and family planning units are found in most public schools. In addition, physical education is a required component of all school schedules until college. Thus, you can still find ways in which the United States promotes health, just not in the same atmosphere as Brazil.
One component of VER-SUS that participants were not allowed to see was how the community health agents—the watchdogs of the Programa Saude da Familia—function. Community health agents are integral to the success of PSF, and I would have liked to learn how their days work, how they observe their micro-areas, and the ways they compartmentalize and disseminate this information. In university, the students of VER-SUS learn about how the healthcare system is structured, from the highest level (the federal government) to the lowest level (the community health agents). See how the foundation works would help piece together the weaknesses and strengths of PSF. In addition, this is a very unique component of the healthcare system that is unique to Brazil. This type of system does not exist in the United States.
Other highlights of VER-SUS included a site visit to the Center for Psychosocial Care, CAPS, in Rocinha, and visits to the UPA-24 hour units (emergency clinics set up in low-income neighborhoods). CAPS house people with mental disabilities, and provide support and care with the intention of helping patients reintroduce themselves into society. The program reminded me of care homes and domestic abuse centers that are in the United States (which are usually not publically funded), but usually in high-risk areas. I was especially impressed with the UPA-24 hour units, which seemed to be well equipped (though perhaps under-staffed. What struck me the most were the types of problems the centers deal with. Brazil is undergoing an epidemiological transition with the double burden of infectious diseases and increased risk of chronic diseases in the aging population. The health system must care for a population at risk from violence related trauma, vector-borne communicable disease such as dengue and malaria as well as high levels of diabetes and high blood pressure. In addition to this, regions like Rio de Janeiro, deal with health consequences from drug trafficking within the low-income neighborhoods, domestic violence, and neighborhood violence, more common to these regions.
One of the other events that I found interesting was the visit to the Epi Info center at the Prefeitura. Similar to the Center for Disease Protection in the United States, the Prefeitura has a department that serves to monitor the progress of spread of cases of diseases. The CDP in the US functions in a similar role, and I later found out that the Oswaldo Cruz Institute has a center that research and tracks this information. I found it interesting that even though the systems are quite different; they seem to use similar tracking devices.
After my two weeks at VER-SUS, I’ve got a better look at the way the system functions, on the surface. I was able to understand the order and structure of the programs within the municipality of Rio, on a very tactile level. I’m still left with questions on the cost-effectiveness of this system, and I wasn’t able to understand the obstacles that SUS has to deal with—something that I found find important for a public health student in Brazil to understand, especially if they can see it on a municipal level.
In the United States, I’ve had plenty of experience observing surgeries, sitting in on physician-patient consultations, and shadowing doctors. My experiences are not so rare in the US, where many high school and college students choose to spend their afternoons and weekends volunteering in hospitals and clinics, but after VER-SUS, I seemed to get the sense that this sort of practical experience is rare in Brazil. Apart from the students that spent the night in the CAPS center. The experiences I gained, as an American, during VER-SUS, were unparalleled to what I could have observed had I tried finding these opportunities on my own. But I’ve had much more experience of this nature in the United States, and it struck me interesting that most of these students had never worked inside a SUS operated clinic. For example, through my experiences in the United States, I was better able to understand the disorganization and weak infrastructure of the hospitals in rural areas, find out how physicians treat their patients—and what needs to change during their training in medical school, and see how doctors interact with administration.
Projects like VER-SUS need to be implemented on a permanent level within the infrastructure of the educational system in Brazil. It’s important to offer students these opportunities at the high school, if not college level, to help them better understand the field they are entering. I gained a lot of insight about the public health system in Brazil during VER-SUS, but I hope that my peers in Brazil learn these things much earlier during their educational trajectory.
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