The NHS is close to collapse – could a radical scheme from Brazil’s favelas save it?

Entering the outskirts of Rio de Janeiro, the taxi driver’s warning is stark: “Some of the favelas are so dangerous, even the police won’t go there.”

His words hang in the air, despite a glittering welcome from a city enjoying the last hoorahs of Carnival. On Copacabana, even the bin men are dancing.

But Rio is a city of contrasts – and danger is never far away.

This proves little obstacle to an army of community health agents, who are determined to access all areas.

The workers are central to the Family Health Strategy devised in Brazil in the 1990s, which aimed to bring care out of hospitals into communities and was created as part of a response to the first major outbreak of cholera in a century.

Under the model, the agents – who receive training but have no minimum qualifications – go from door to door, providing a listening ear as well as health advice, education and links to health services.

The strategy has been linked to dramatic improvements in health outcomes – including a 34 per cent drop in deaths from heart problems in areas with a full roll-out of the scheme.

Some agents provide help on the spot, dispensing vaccinations, prescriptions and blood pressure checks. In other cases they help the vulnerable to navigate health systems, for example by fixing up appointments with hospital specialists, GPs and dentists.

They also provide something less tangible.

In a country battling a host of social ills, in particular drugs, crime and unemployment, the agents take on a deeper long-term role, learning the secrets that divide families and helping some of the most vulnerable to get back on their feet.

Trust is key to the success of the scheme, especially in areas where a knock on the door can prove unwelcome.

So, crucially, a community health agent (Agente Comunitario de Saude) is always recruited from the areas they serve, even living on the very street where they work.

The programme, which began in the most deprived areas, has been rolled out across 75 per cent of Brazil – even in the heart of the Amazon.

It is a model which is attracting the interest of other countries – including Britain – which are struggling to cope with an inexorable rise in demand for healthcare services, leaving hospitals overwhelmed.

In June, Wes Streeting, the Health Secretary, will publish a 10-year plan for the NHS, which aims to make a fundamental shift in the way healthcare is delivered – with far greater focus on prevention of ill-health and in moving far more services from hospitals to the community.

To this end, officials are taking a close interest in the Brazil model, with a pilot in Pimlico – a mile away from the political decision-makers – followed by a roll-out to 25 areas of England.

Within months of winning the election, the Labour Government was sufficiently interested in the Brazilian Family Health Strategy that it sent a health minister to Rio to sign a letter of intent on UK-Brazil health co-operation.

Last month, Mr Streeting invited Brazilian health experts to take part in round-table discussions about neighbourhood health in order to inform the NHS 10-year plan.

And I went to Brazil, to find out more about the national “door-knocking” programme which has been linked to a dramatic improvement in health outcomes.

‘They tell us what they won’t tell a doctor’

The Barbara Mosley de Souza Clinica de Familia is in Jacarepagua in Anil, in the western zone of Rio.

It is by no means one of the most deprived favelas, but piles of rubbish and shacks line the canal facing the clinic, while young children play in the dirt.

The building is a busy hub and, after a whistle-stop tour, I met Bernardo Xavier, one of more than 90 agents based at the clinic.

The law graduate originally intended to become a lawyer, but followed his mother in becoming a health agent after getting involved in health during the Covid vaccination campaign.

“I began to have a passion for it,” he says. “It’s not just a job, it’s a life-changing job: it helps to save so many lives.”

Visiting people in their own homes is critical, he says, providing agents with clues about the difficulties residents face, from broken heating to suicidal thoughts.

“We see how they live; we hear the whole story. If it is in my power to do something, I will do it, or I will find them help,” he says.

“We are the intervention between the services and the people. This is the magic of it: they tell us what they won’t tell the doctor.”

His simple but eloquent pitch could be music to the ears of any health secretary seeking to lift pressures on overloaded NHS hospitals.

Bernardo adds: “We can resolve 75 per cent of problems that come to us; this is the way to empty hospitals so they can do what they need to do.”

The clinic itself offers an impressive array of services, rather like the polyclinic model which has been often proposed but seen little roll-out in the UK. Dental services sit side by side with women’s health, sexual health services, vaccination and antenatal checks.

In many cases, agents like Bernardo are providing some of the poorest patients with assurance that the healthcare they thought they had to pay for is free.

About a quarter of the population of Brazil have private health insurance, mainly through their jobs, which is often used to reduce waits for hospital operations.

Each agent is part of a team, usually made up of one doctor, one nurse, two to three nurse technicians and about eight agents, who cover a dedicated area – known as a micro population – going from door to door visiting nearby streets.

Today, Bernardo’s schedule includes a visit to Marie Luisa Da Cunha, aged 102, who appears thrilled to see him.

The grandmother of 12, who lives with her daughter, says she “adores” the visits.

Bernardo normally pops in twice a week, providing medicines for high blood pressure, vaccinations and support during her recovery from cataract surgery.

The pair laugh easily together, with Marie happy to share the secret to her long life (“God gives her health, and dancing does the rest”).

‘The white coat is a shield from danger’

Paula de Castro-Nunes, an epidemiologist based at the respected Fiocruz institute (Fundacao Oswaldo Cruz, a Brazilian public research institute affiliated with the country’s ministry of health) shares Bernardo’s passion for the programme.

“At the start, people didn’t trust the agents; in the favelas it is important to know people before you open the door. There was a lot of concern that personal information could be used against them. But the white coat is like a shield,” says the researcher, suggesting that the high respect for the workers, combined with the fact they are working in their own neighbourhoods, provides them with a level of protection that the police would envy.

“People don’t have trust in the authorities; they have seen interventions become violent,” she adds.

“It’s very difficult to get doctors to work in the favelas. It is a violent community with arms and drug dealers. The fact that [the agents] live in the same communities that they work in, for us, that’s a dream come true.”

The next day, I am in Duque de Caixas, a sprawling industrial city within Rio.

In fact, it is the same area singled out by the taxi driver who on arrival warned me of the dangers in its favelas.

The first stop is Parque Eldorado Unit, a slightly run-down clinic which nonetheless offers a variety of services. I meet a team of health agents, who are about to embark on their visits. They squeeze us into their car, judging that it would not be safe for our unknown vehicle to enter such areas.

Crime and violence are rife in Rio and situations can change rapidly.

A system of “safe access” means that car windows must come down as areas are entered, so all passengers are visible and potential threats assessed.

Our first journey quickly comes to a halt, with a diversion because roadblocks are in place.

If trouble is feared alerts are sent to all agents, who also routinely monitor danger levels, updating colleagues with WhatsApp messages using a traffic light system. Red means that agents should leave the area, amber means all external visits are suspended and green means go ahead.

The diversion is minor and we soon receive a warm welcome from Antonio Lino dos Santos, 75.

Agents Rosilene Correira Pareira Alves and Patricia Andrade de Aranjo clap outside the front door of his home, to attract his attention.

In many areas, particularly those with the thinnest of walls, it’s seen as more polite to clap or call out to announce an arrival, rather than to knock and cause more disturbance.

Antonio greets the pair, who today are accompanied by a doctor, Dr Rafael S Bispo. It’s a regular visit.

The great-grandfather, who has lived in the favela for 45 years – almost as long as he has been married to his wife Maria – has high blood pressure, has undergone treatment for throat cancer and broke his femur climbing a tree.

Patricia, 42, an agent for 20 years, says some patients are more open than others about their health issues.

“It’s easier to talk to people once they are at ease. We get to know people, about their problems, people can be ashamed and fearful about their health problems, it takes time to open up.”

A few streets away, Maria Raimunda da Silva, aged 79, is a case in point.

She lost most of her family, including her husband and two daughters, in a situation she does not want to discuss.

The elderly woman, who lives with her granddaughter, became unable to leave the house alone, suffering panic attacks and anxiety.

But it took some time before she would admit this to agent Sandra Maria Quiorato Grativo, 60, who describes her role as “a bit like being a psychologist”.

“Over time, I have become her friend and helped her cope with what she has been through. I started to notice memory lapses and from that I discovered she had panic attacks and anxiety. She couldn’t cope with the losses,” says Sandra.

“It is the intimacy that gives you the information. The bonds are important, and you have to see where a person is living to see what they need.”

Having been an agent for 23 years, the former saleswoman believes maturity and life experience are of great value in the role.

She adds: “Many people don’t value this job, but it can really change people’s lives.”

Back at the clinic, Dr Talane Loiola sums up: “They are of utmost importance to us, because without them we cannot work; they live within the community, so they know the community better than we do.”

Visits go beyond simple health checks

In Santo Antonio da Serra unit a few miles away, another team of agents has begun to make their visits.

Top of the list is Ysabelle Rocha Da Silva, 26, and her baby, Maste Esther, who is one week old.

She is Ysabelle’s fifth child, and the young mother and her family are living in a one-bedroomed shack.

This pregnancy has proved especially difficult.

Ysabelle’s nine-year-old daughter died of a lung condition shortly before Ysabelle found out about her pregnancy. She was so devastated by the loss that she did not seek antenatal help, but was proactively offered support by the agents.

Today, Larissa Veloso Bueno, a doctor, is taking part in the visit, to check on the newborn and her mother. Both are deemed to be in good health, but Ysabelle is having some problems breastfeeding.

The team is also seeking a psychologist to help with the couple’s five-year-old autistic child, who is non-verbal and in much distress.

The doctor says the role of the agents is particularly crucial for those like Ysabelle who are reluctant to come forward for help.

“It was hard for her to get out of bed, she didn’t have the strength to come to the clinic; we need to come to her,” she says.

Vital healthcare in the jungle

Snake bites and explosions are all in a day’s work for Francisca Carneiro, a 47-year-old nurse working on the water ambulance.

The service is based in Manaus, the capital of the vast state of Amazonas, which stands on the banks of the Negro River. It is the gateway to the Amazon rainforest, serving the most rural and isolated locations.

The nurse works for SAMU Fluvial, a mobile emergency care service, where water ambulances (“ambulanchas”) are at the heart of healthcare.

It is Friday morning, and as we take to the Amazon waters, she is two hours into a 24-hour shift. The durations are long, because the distances between call-outs can be substantial: one round trip can amount to five hours.

Snake and scorpion bites are among the most common reasons for a call out, she says, while boat explosions, drownings and work-related injuries such as falls from trees also feature heavily.

The service links closely with an army of health agents, based in the rural communities.

“Often it is the agent who calls us if it is an emergency; they can give us an account of the medical history so we have all the details,” says Francisca.

Monsoon weather and dry seasons both provide challenges: storms and torrential rain can mean boats are unable to be sent out, while droughts mean journeys can take far longer, or involve helicopters.

Today, the waters are still. The boat, which can manage speeds of up to 40kmph, takes us to the nearest community, Fatima, some 20 minutes away.

Could Britain learn from Brazil?

The Unidade de Saude da Familia Rural Nossa Senhora de Fatima (Rural Family Health Unit of Our Lady of Fatima) is having a busy morning.

We may be deep in the heart of the Amazon, but agent Adna de Oliveira Bastos delivers a masterclass in digital healthcare, describing how she uses an app to schedule up to 10 home visits a day.

Later, colleagues in the heart of Manaus describe how Brazil’s health system connects up all the data, allowing nurses and health agents instant access to crucial information.

In the UK, just before Labour won the general election, Mr Streeting told The Telegraph that his party would “fix the front door to the NHS,” while warning that Britain’s access to GPs stood “on the brink of collapse”.

At the family health unit in the district of Petropolis, director Silvane Aguilar has a simple message about access to healthcare: “The doors are open for everybody: everybody is treated equally.”

She urges Britain to look to the Brazil model, to provide more care closer to home, especially for the most vulnerable.

There are challenges. “It’s an area known for being poor, so people have a lot of needs. There are criminals, drug dealers, but the agents have their credentials and they are known in the community, they are respected so they are safe. And even the families of criminals need help,” says the unit leader, a former social worker.

The centre has been open for 30 years. To their credit, many of the community health agents have been working there for almost as long, creating tight bonds with residents.

But the agents are getting older and several need help from occupational health to manage their own medical problems.

Our last visit is to Ester Fernandes, aged 93, who has been bedridden for about three years and suffers from diabetes and high blood pressure.

Checks quickly show that her blood sugar and blood pressure levels are too high and a doctor’s visit is booked.

Antonio Sergio, another agent, has a long chat with the elderly woman and her daughter Jancinette, who says her mother is always glad to see the agents and sometimes cries when they leave.

But the agent, 58, who came to the role three years ago, has some other concerns; about the disease risks from the area surrounding her one-room shack.

Dengue fever is on the rise in Brazil, linked to stagnant water, where mosquito larvae breed, and the agent books in a check from local environmental health services.

For Antonio, the career change after many years working in food production has brought fulfilment and a sense of purpose.

He puts it simply. “There is the satisfaction. At the end of a day you go home tired, but you know that you helped someone: in the end, you know that you did a good job,” he says.

The inspiration for a radical approach

I have come to São João e São Paulo, in the city of Camaragibe, in north-east Brazil, to see one of the very first clinics to introduce community health agents.

The programme was born of necessity, in response to the first major cholera outbreak in almost a century.

Health officials quickly realised that their hospital-based system was inadequate to stop the spread of disease among communities.

In 1999, a young British GP called Dr Matthew Harris came to work here. He was so enthused by the model that he brought it back to the UK and is now leading research at Imperial College London, which has backed the roll-out of Britain’s first programme.

Dr Alexina Calle has led the Brazilian clinic for the last five years, working with agents who started out more than 25 years ago, alongside Dr Harris.

Today eight workers – all female – join for a discussion of the programme and the difference it has made to their patients’ lives. The mood quickly becomes reflective.

Lucernita Maria Bezerra, 47, and Socorro Josefa da Silva Santos, 49, recall their desperate efforts, fresh in the job, to save a premature baby, who was being brought up in filthy surroundings by refuse collectors who had little idea how to provide basic hygiene. Today, that baby is 27.

Fellow agent Naura Maria Santiago, 54, thinks of her patient Julio, aged 91, whom she has now been visiting for almost a quarter of a century.

Hers is the only visit that he gets on his birthday. “When he dies, it will be like losing a father,” she says.

During the discussions, agents discuss the difficulties of setting boundaries; while WhatsApp means that agents are easily contactable, the GP insists that they “have to set limits” on days when they are not working.

The GP describes the heavy burden of responsibility felt by the agents, who often carry the secrets of the community, as well as knowing when not to ask too many questions.

Describing the problems of drug dealing and crime in the community, Dr Alexina adds: “We don’t ask, ‘What do you do for work?’”

In many cases, agents can be privy to secrets which divide families – the details of lovers, sexually transmitted diseases and pregnancies.

Perhaps the greatest problem facing the agents is their workloads, the GP says – each agent has about 750 cases on their books, but they are forced to prioritise those most in need.

But Dr Alexina, 59, is a passionate advocate of the model: “This is about opening the door of the clinic for everyone,” she says.

Could this model save the NHS?

It is 33C (91F) in São Paulo as I head to the airport.

The lessons from Brazil’s healthcare strategy appear instructive to any government seeking to make a fundamental shift of care into the community.

I am left with some questions. Brazil’s approach takes advantage of a community spirit which, despite major challenges, appears in strong supply. Workers are hired from the very streets in which they live and appear richly connected to those they help.

It is perhaps less clear if modern Britain has such a sense of community it could harness, or whether a knock on the door would be as welcome.

The Health Secretary has promised radical change to overhaul the health service. Does fixing the NHS mean going further and tackling the social ills of broken Britain?

Mr Streeting believes so. “If we get this right, the prize will be all of us living not just longer lives, but healthier, happier lives; and also the cost to the state of ill-health going down,” he says.

“At the moment, a lot of people in our country are thinking, we’re paying a hell of a lot for failure.”