João Cláudio Lara Fernandes
BrazilFellow since 1988

Ashoka commemorates and celebrates the life and work of this deceased Ashoka Fellow.

Joao Claudio has long sought the most effective way to serve the poor: first as a Jesuit, then as a social activist, and now as a doctor developing novel ways of providing first-class health care to Brazil's slum dwellers.

#Health & Fitness#Population health#Health care#Universal health care#Medical school#Health science#Medicine#Physician#Health

The Person

Joao Claudio was at university during the highly-charged 1970s. He left medical school after his second year and entered the Jesuit order, inspired by the possibilities of community work and the Liberation Theology Movement, which then was at its height. His experience working at the grassroots level led him back to medical school, believing that he could be more effective helping poor communities as a doctor. Back at the university he became involved in the student movement, left the Jesuit order, deepened his political involvement, and worked in newspapers and on several political campaigns. He became disillusioned with party politics and left to build a career where he could have a significant impact compatible with his ethical values.

The New Idea

Joao is gradually developing ways to integrate health care for the poor, both vertically and horizontally. The vertical integration links everyone -- from local community workers to community and municipal neighborhood health posts to sophisticated major hospitals -- into an economic and unified service. Horizontal integration ensures each patient doctor-guided access to the full array of health sciences: preventative and curative, homeopathic and allopathic, and psychological, as well as medical and dental. His plan is succeeding for the people he is serving through the community health post he created in the Rio de Janeiro favela (slum) of Rocinah. Whereas most public patients served by public doctors get only a consultation of only a minute or two, the average consultation at his post is 20 minutes. He has attracted six psychologists to volunteer several hours weekly, and he has opened dental services. He organizes community education programs, including extensive use of street theatre. He has started to work with Ashoka Fellow Emilio Eigenheer to launch a community program to manage the area's wastes. He is able to get hospital lab tests back in 24 hours, although it commonly takes several weeks for the hospital's own patients. He is developing a host of service innovations, e.g., a portable medical record book that patients could carry with them. Joao Claudio has been succeeding for a number of reasons: he is recognized as first-class doctor by his profession; he understands his clients and their community and is fully accepted by them; he has an instinctive feel for human institutions and organizational change; and he combines personal balance with commitment, creativity and vision. For example, how has he been able to get the major hospitals to give his poor patients prompt service? He has carefully controlled referrals (only 7 percent of his post's cases are referred) and has convinced the hospital that he is only sending carefully screened patients that need the test or help indicated. His referrals are therefore likely to be an economic use of the hospital staff's time and resources. His careful statistical tracking system helps carry this argument with the specific institutions where he seeks help. It will also help more broadly as he tries to spread his model, which is not only more economical, but provides better care. Joao Claudio's objective is far broader than serving one community. Rocinah is his laboratory and demonstration project, but it is not where his work ends. He is increasingly attracting medical students to do part of their training with him, and already several of his "graduates" are launching new centers in other poor areas. This tie gives his ideas increased credibility and visibility in the medical community. He is drawing other favela health groups together to use his statistical and management tools. He is speaking at and writing for the major medical institutions. Joao Claudio's goal is to bring about institutional change. He is working to bring the very separate parts of Brazil's health care effort together to build a better overall system -- and he is gradually refining and demonstrating concrete steps in this direction that make sense for each of the actors.

The Problem

Brazil's 30-year old public health care system is not providing adequate care, even in quantitative, let alone qualitative, terms. It exists side by side with huge hospitals designed to house and offer the most sophisticated medical techniques and specialized services. The nature and incentives of the complicated bureaucracies that run the hospitals make primary care difficult to obtain and very expensive. Medical education in turn is designed to feed its graduates into this system: doctors are trained for highly specialized roles, and their employment options generally are limited to either the national system or a hard-to-establish private practice.

The Strategy

Joao Claudio, working out from Rocinah, is constantly experimenting to find ways of reintegrating and reorienting Brazil's fractured health care institutions. He does not have a full blueprint yet, but concrete institutional change has begun. He has medical students, young doctors, and established practitioners engaged in the work; he is beginning to make community medicine a challenging, attractive career option; and he is engaging a number of the country's premier medical institutions in experimenting with ways of serving poor neighborhoods and clients. From the start, he has recognized that he must deal with economics. He thinks he can demonstrate that his approach saves money overall. He has already demonstrated to several leading medical institutions that it rescues them from inundations of ill- or un-screened cases. He has just persuaded one of the agencies that reimburses doctors serving the poor to experiment with non-piece-rate formulas.