Bulletin of the World Health Organization

Brazil and Peru pool views of their people to set health agenda

Health policy is usually set by politicians and public health officials in consultation with statisticians and epidemiologists. But recent initiatives in Peru and Brazil have pooled the views of the public to create a health agenda that addresses people’s needs more closely.

IN FOCUS - Feature from the Bulletin
1 July 2005

A regional official casting his vote in the ballot organized by Peru’s Oficina Nacional de Procesos Electorales (ONPE) in which citizens in the Lambayeque region voted on the health issues they believed to be the most important.
A regional official casting his vote in the ballot organized by Peru’s Oficina Nacional de Procesos Electorales (ONPE).

The northern coastal region of Lambayeque in Peru held a referendum last November to ask 123 627 voters to rank health issues in order of importance. Now the authorities there are incorporating this feedback into a five-year plan. Brazil also used a ‘trickle-up’ approach in 2003–04, to craft a comprehensive health research agenda based on feedback gathered at hundreds of meetings from the grassroots to national levels.

Planners and participants in both countries said this was no mere communication exercise. Both processes have yielded results already, with new attention being paid to various conditions in Peru and with studies being done in Brazil on threats such as Chagas disease, a parasitic infection that infects 16 to 18 million people in Latin America and kills 50 000 a year.

Residents in Lambayeque ranked their top five health priorities as scarcity and deterioration of water services and waste pickup; marginalization of poor to health services; mental health problems; malnutrition; and maternal health problems.

The exercise, dubbed the “Citizens’ Consultation”, told authorities where resources would be most useful and gave often disenfranchised Peruvians a voice. It also instilled a sense of responsibility, accountability and commitment among all parties involved, according to Midori de Habich, the head technical advisor to Partners for Health Reformplus (PHRplus), a project of the US Agency for International Development (USAID) that coordinated the ballot initiative.

PHRplus worked with Lambayeque’s regional health councils, surveying residents about their health concerns in preparation for the referendum.

Then, through focus groups and workshops, they determined how to measure those needs. Civic organizations, university health experts and others also played a role.

Habich said that Peru had no background in setting policy on mental health, problems of water and sanitation, and marginalization of the poor from health services. But the vote put these concerns at the top of the priority list. Focus shifted from damages, or treatment of existing illnesses, which is costly, to prevention, which can be less expensive. It also drew officials’ attention to health-related issues outside the health sector, Habich said.

Community participation was already part of Brazil’s political system, with 100 000 people playing roles in 5000 municipal health councils, 27 state health councils and the National Health Council. In July 2003, a government-appointed committee of 20 scientists, health policy-makers and other experts identified 20 subcategories of research. Subsequent meetings were held with more than 500 experts.

The authors of a paper on the project, Setting and Implementing a Priority Agenda for Health Research in Brazil: a Report of a Two-Year Participatory Process, noted that great care was taken to achieve a gender balance as well as representation from all geographic regions in the seminars held after the government-appointed committee.

“Some scientists who were not used to debate with community representatives had a hard time [communicating] in lay terms ... But, in my opinion, the conference represented a very important democratic learning process.” Leonor Maria Pacheco Santos, coordinator at the Department of Science and Technology, the Ministry of Health, Brazil.