clinical practice in Delhi, India. Only 52 per cent of private-sector ‘doctors’
sampled held the required Bachelor of Medicine and Bachelor of Surgery
(MBBS) degree. In tests only 30 per cent of public-sector doctors were able to
ask the appropriate questions to gauge a medical condition from the symp-
toms declared by a patient, but less than 10 per cent then did so when observed
Education and Health 139Box 6.2 Community health care in Ceara, BrazilCeara in north-eastern Brazil introduced the Health Agent Programme
(Programa de Agentes de Saude or PAS) in the late 1980s. After a few years of
operation Ceara’s PAS had contributed to a sharp reduction in infant deaths,
from 102 per 1,000 (one of the highest in Latin America) to 65 per 1,000 in 1992.
The programme tripled vaccination coverage for measles and polio, from 25 per
cent of the population (the lowest in Brazil) to 90 per cent. By 1993 health agents
were visiting 850,000 families (roughly 65 per cent of the state’s population) in
their homes every month to provide assistance with oral rehydration therapy,
vaccination, prenatal care, breastfeeding and child growth monitoring. The
programme costs averaged US$2 per capita, compared with the approximately
US$80 per capita cost of the existing health care system. Eighty per cent of these
costs represented payments to health agents (earning the minimum wage of
US$60 per month) who worked under temporary contracts without job security
or fringe benefits.
The scheme was not based on decentralization. The central state maintained a
strict control over the hiring and payment of the health agents (the opposite
conclusion to the one we reached earlier in this chapter about the importance of
local control over teachers) who worked for nurse-supervisors hired by the local
municipality. The state government created a sense of calling around these jobs
through a rigorous process of meritocratic selection and training, constant public-
ity and regular publicized prizes for good performance. To be chosen for the job
of health agent was like being awarded an important prize in public. Newly hired
workers began their jobs strongly influenced by the prestige accorded by the
selection process. Workers often took on tasks voluntarily that fell outside their
job descriptions, an ambiguity that seems to have made supervision of workers
ev en more difficult, but now there were also pressures to perform from the
community. Central publicity campaigns empowered local communities to moni-
tor performance of the health workers. This demonstrated that effective local
monitoring is possible even with centralized hiring (which again contradicts our
discussion of education earlier). In urban clinics nurses had traditionally been
regarded as inferior to the doctors. Now each nurse was supervising/training an
av erage of 30 para-professional agents and felt herself an important local person-
age. By enhancing the status of nurses as professionals the programme turned a
large number of potential resistors into ardent advocates: ‘In creating an informed
and demanding community, in other words, the state had initiated a dynamic in
which the mayors were rewarded politically for supporting the programme. In
doing so, the state had contributed toward replacing the old patronage dynamic
with a more service-orientated one’ (Tendler and Freedheim, 1994:1776).