Honoring Nations: Mary Jo Bane: Preventive Health in Brazil
Bane, Mary Jo. "Preventive Health in Brazil." Honoring Nations symposium. Harvard Project on American Indian Economic Development, John F. Kennedy School of Government, Harvard University. Cambridge, Massachusetts. September 10, 2004. Presentation.
"Well, I'm delighted to be here with you this afternoon. Thank you for having me. What I thought I would do to start off our discussion this afternoon is talk through with you a case that I teach in my course on Strategic Management in the Public Sector. And I like this case because it is a case about a project that should not have succeeded, but it is a project that did succeed and from its success, I think that there are some very important lessons to be learned about program design, but even more importantly about management and about managing in a political environment. So what I'll do is describe the case, talk through some of the ideas about it, make a few general comments as a result of it, and then we'll move on to the other presentations in this session. What I'm going to talk about is a preventive health program that was run in Ceara, Brazil and this program is described by the political scientist Judith Tendler in a book, which I think is very good and if you find this interesting, you may want to look at the book. Her book is called Good Government in the Tropics and it's a set of cases about successful programs run in this part of Brazil and her analysis of why they were successful.
As I said, the interesting thing about this program is that it should not have worked. Any self-respecting management consultant, any self-respecting bureaucrat from the World Bank would have told the State of Ceara that this would never work. Now, why would they have said that this program would never work? This program was a program which hired 7,300 unskilled workers, sent them out into villages to do preventive health work with rather little supervision in a context where there was a history of corruption, where there was a history of clientelism, of patronage, of government workers abusing their power and abusing their authority, and a place in which there was a context of government workers -- shall we say -- not being particularly dedicated to their job. And the World Bank bureaucrat would have said, 'In this kind of a context, you should never...this kind of a program should never work. These people are not likely to perform their jobs; they're likely to get caught up in the patronage system, they're likely to engage in corruption, they're likely to do harm, they're likely to slack off. What you should do is privatize and have some competition in this program and make sure that the jobs of the workers are extremely well defined and that they are extremely well supervised.' That's not how this program worked. It should have failed, but it didn't fail, and it didn't fail according to some pretty important measures.
The program was started because the health situation in this particular part of Brazil was very poor. It continues to be very poor. The health indicators in this part of Brazil were very bad, very high infant mortality rates, very low immunization rates for children, very poor access for the citizens to preventive health programs and to health professionals, but after a couple of years of this program, infant mortality had dropped by 50 percent, immunization rates among children had tripled, and all of the people in this area now had access to doctors and to clinics. So why was it that this program succeeded where the predictions would have been that it should not have succeeded? Judith Tendler gives her own analysis of it in her book. My take on the success of this program is that it succeeded because the program incorporated some very interesting and important and innovative ways of structuring accountability, of building in accountability mechanisms in a way that was very different from the standard way.
Okay, what's the standard accountability paradigm when we think about a government program? How do we think about the mechanisms of accountability? How do we think about making sure that the folks who are employed by government actually do what they are supposed to do? Well, the standard way of thinking about accountability -- I would say -- is a way of thinking about accountability that looks like this: the elected officials instruct the state bureaucrats, the state bureaucrats instruct and oversee the supervisors in the program, the supervisors oversee the workers in the program, and the workers deliver services to the clients. To the extent there is accountability from the citizens in the course of the program, it's a very indirect form of accountability. The standard way we think about accountability in government programs is that the citizens elect the elected officials who then instruct the state bureaucrats who then instruct supervisors, who then instruct the workers, who then deliver the services to the clients. That's the standard way that we think about accountability.
And if you just think about this for a minute in the context of a preventive health program, you can see why you might predict that this kind of a structure wouldn't work. We've got a few state bureaucrats -- we've probably got a lot of state bureaucrats, but relative to the number of workers really, very few state bureaucrats -- who sit in the state capital, have 7,300 unskilled workers who are working basically in the homes of 850,000 citizens. They're basically working in rural villages, they're visiting homes, they're doing things in their villages and they're acting very autonomously because they have to. They're out in the middle of nowhere delivering the services that they're meant to deliver. There are 235 supervisors who are supervising the 7,300 workers and if you think about that and you think about the context, you can understand how supervision could not be close and direct. So that's why people said this is not going to succeed and indeed, one would not expect it to. But it turned out that as the program was being structured, a number of features of the program were developed that modified this accountability paradigm in some very interesting ways.
Now, I have to say when I talk about this case sometimes students ask, "˜Did they really plan this? Did they really think through all these ideas in the way they designed the program?' And the honest answer to that question is no. Some of these things they did for political reasons, they did because it seemed like a good idea at the time, but it turned out working in a very interesting way and let me explain two pieces of it.
One way in which this program ended up modifying this standard accountability paradigm is that it developed in the workers, it developed in these unskilled, not particularly well-educated workers, a sense of dedication, a sense of professionalism, and a sense of pride such that I would say that these workers held themselves accountable in very important ways. Now, how did they do that? How did they develop in the workers a sense of professionalism and pride? There were a couple of things. And as I said, not all of these were completely planned out, not all of them were thought through as they were designing the program, but one thing the state bureaucrats did -- and if I'm being honest I have to say the reason they did this was that they wanted to enhance their own political prestige -- but one of the things that they did is that they gave this program an enormous amount of publicity. Everywhere you went, there were ads, there were radio programs, there was a real communication campaign saying to people in the villages, "˜Your children are dying. Your children are sick. It shouldn't happen. Our infant mortality rates are too high. Our sickness rates are too high. We shouldn't put up with that and we're going to do something about it.' State bureaucrats thought, 'Yeah, that'll be good for us because now we're doing something important,' but what effect did that have on the workers? Part of the effect it had on the workers is to make them realize that they were part of something really important, that they were working for a program, working in support of a mission, that was important to their own families, to their own neighborhoods, to the whole State of Ceara, and that sense of working for something important gave them a sense of pride and a sense of commitment. The state also publicized any successes in the program and this was a program where there was actually a good likelihood that there would be successes because this was a program where there were some relatively easy things that could be done that could help improve health outcomes: dehydration treatments for kids, immunizations, pre-natal care -- all that kind of thing. And so they were able to publicize successes, they did that very regularly, and the workers gained from that a sense of pride. So that was one way in which they did it.
Another way in which they instilled a sense of dedication and professionalism was through the hiring process that they set up. I'm going to describe this hiring process. This is going to sound horrifying to you, okay? I'm going to warn you ahead of time. You're going to think, 'This is the most horrible hiring process I have ever heard of!' I'm going to describe it and then I'm going to tell you what effect it had. They decided that they were going to do a merit hiring process, that they were going to take applications from people and they were going to interview them and then they were going to choose the workers for this program as a result of their performance in the interviews. They got lots and lots of applications because even they were only paying the minimum wage in this poor part of Brazil, this was a good wage and people wanted it and people had their neighbors helping them to fill out the applications and so on. Then they held the interviews in public. They sent the folks to do the interviews of the workers in a public setting. And Tendler describes how they would be doing these interviews and there would be people looking in the windows and listening to the interview and watching the interview that was going on, and the people who were interviewing, they were pretty scared, and all of this was going on in public. And as a result of that they did it. Well, what people were hearing as they listened to these interviews were a couple of things. First of all, they were hearing the interviewer say how important this job was. Secondly, they heard the interviewer say, 'If you get this job you should be really proud because there are lots of applicants, and this is a very selective hiring process.' And then they heard the interviewer say, 'There are some requirements for the job, which you absolutely have to follow: you have to live in the village where you're working, you have to work eight hours a day, you have to visit every family once a month, and you may not distribute political information for anyone.' Those things are clear; everyone in the community heard that, everyone in the community heard those things. What did that mean? It had a couple of effects. One of the effects it had was that it, again, enhanced the sense of pride of the workers who were hired through this process, that they had indeed come through an important selection process. It also meant that the people who weren't hired and the citizens in the community knew what the requirements of the job were and kind of had their eyes on these people, so that was an important piece. The merit hiring process -- the way it was conducted -- was a very important part of leading to worker dedication.
They did a couple of other things in terms of enhancing professionalism and worker dedication that were very important. One was they provided the workers with three months of training to be health agents and to be health aides and they provided the workers with continuing training as they were doing their jobs, continuing training and professional education. Now, it turns out that many of the workers left these health agent jobs and went to work for hospitals or went to the city to work for health organizations and so on. So some people said, "˜Gee, you're wasting this training because people aren't using it here for this job,' but they were smart enough to realize two things. They were smart enough to realize that that training that they were providing was really important to this piece of the equation, they also said to themselves, "˜Gee, if we've got some better trained health professionals in the other sectors of the health system that's not so bad.' And that was a real incentive for the workers who, as I said, weren't being paid all that much, but knew that they had some prospects for mobility and that they were getting the training that they need. So that was another aspect of how they increased professional pride and responsibility. They also allowed the workers -- and to some extent they did this because they didn't have much choice, they couldn't supervise them closely -- but they allowed the workers to expand their jobs in a couple of different ways. They allowed the workers to do very minimal curative-type health work as well as preventive work, you know, putting Band-Aids on, taking sutures out, giving people aspirin, pretty simple stuff, but it was the kind of thing that allowed the workers to do something quickly for a family and therefore to be able to get the confidence of the family in order to do some of the more preventive kinds of things. Again, not something you might normally think about doing, they did it pretty much because they couldn't supervise them that closely, but it turned out to be very important. The workers also took the initiatives in generating public health programs in the community and also took the initiative in helping families in other ways.
So all of these pieces of the program led to a sense of dedication and worker pride that meant that the workers were in many ways monitoring themselves in the same way that professionals did, but from what I said about the hiring process, you can also see that there was another accountability mechanism that was very, very important that supplemented the professionalism of the workers in a way that if they were tempted to do some of the things that people were afraid of, they knew that somebody was watching. And the way it worked was because of the way the hiring process worked, the citizens and the rejected applicants knew what the requirements were for the job, and the citizens and the rejected applicants had information channels directly to the workers and directly to their supervisors and were able to communicate back when someone wasn't doing their job. Turned out they also communicated back when things were going well, when they thought the worker was doing a really good job. And that feedback mechanism, the direct framework mechanism from clients, and in this case rejected applicants to supervisors and workers, turned out to be extremely important. So what you had then in this program was an accountability paradigm, which supplemented the regular one with another arrow, which had some different relationships between the state and the citizen through which the state provided lots of information, lots of publicity, and lots of openness to enable the citizens to supervise. And so the accountability paradigm was supplemented in these various ways. I think there were some other things that probably contributed to the success of this program. I think there was probably some just dumb luck involved. I mean it was a program that was ripe to succeed. There was also a set of relationships between the state and the municipalities, which I haven't talked about because it was pretty complicated and I think not so essential to the success of the program, because what I think really was important was these different ways of getting accountability for workers who were basically unskilled workers.
So let me just close by making a couple of comments about general lessons from this case. It's interesting: usually when I teach this case, I teach it as part of a section in which I also teach a case about an agency in Sweden, which put into place a lot of teamwork, a lot of job enlargement, a lot of autonomy for relatively low-skilled workers and was very successful. And when I teach that case, first the students usually say, "˜Well Sweden, of course it'll work in Sweden. Everything's wholesome in Sweden. Nobody steals anything. Everything works really well. So you know it'll work in Sweden, but it won't work any place else.' So when they say that, then I almost immediately try to teach this case about Brazil because Brazil is not Sweden. It's not Sweden in a lot of different ways. And then they say well, "˜It'll only work in some place where you can't pay very good salaries and...'
So I actually think there are some real generalizable lessons here that one can learn about how to manage programs within government structures, within public structures in a way that can make them successful. And I think one lesson is not to underestimate the possibility, not to underestimate the potential, of even unskilled workers to act in ways that show professionalism, that show dedication, that show a real involvement in their job. That can especially be the case when the mission is indeed compelling, but that can be helped by the use of publicity, the use of information, the use of merit hiring, and the use of job expansion. So that's one lesson that I draw. A second lesson that I draw -- which I believe is generalizable and I think that you can find this in a variety of cases -- is that there are some accountability mechanisms, which involve the community and the citizens and the clients in direct ways, not indirectly through voting for elected officials and then blah, blah, blah, but directly in being able to report on, to correct and give praise and so on for the work of the workers.
So I would leave you just to think about this case and think about whether perhaps some of these lessons about worker dedication, about ways to enhance it, and about accountability mechanisms might be generalizable in some of the situations in which you work. Thank you."