The Heliopolis comprehensive public primary care center is 1 of 3 primary care clinics serving the neighborhood that consist of 50,000 to 75,000 people. It is a favella or shantytown, with narrow crooked streets, high poverty, drug trafficking, and crime.
Despite low incomes, the high-level of poverty, crime, gangs, and mafia activity, the clinic tries its best to serve the community.
Clinic staff figure out how to work with the established power structures in the community, especially the PCC, which runs drugs and engages in robberies on the thoroughfare that connects the favela to other neighborhoods.
The neighborhood is poor most residents only have a high school level of education and they engage in manual labor in order to earn an income.
All necessary preventative and primary care services operate together under one roof for vaccines, urgent care, dental eye, pharmacy, lab, social work, and mental and behavioral health, as well as family medicine and gynecology and supported by community health workers who outreach into the community and administrators and nurses who direct resources to the most vulnerable with a population health focus.
The clinic includes dentistry for teeth cleaning and preventive medicine. Diagnoses that indicate the need for x-rays, implants and crowns require a secondary level of specialization off site.
There is an urgent care center staffed by a primary care doctor. Patients arrive with back, shoulder, and other muscular skeletal injuries, respiratory conditions, infections, sprains, as well as lacerations and wounds. Diagnoses, treatment plans, prescriptions, stitches, but not more complex surgeries, are given here in the corner of the room. There’s a crash cart with a defibrillator and intubation equipment, which is available as well as a gurney to take more seriously injured and critically ill patients to an awaiting ambulance to a tertiary level hospital first emergency care.
In addition to urgent care, there’s a room where wound care is performed as well as a place for eye exams. The nurse who specializes in wound care also works to screen patients.
The facility engages in community outreach and vulnerability assessments. The clinic is home base to a team of community health workers who canvass the neighborhood each day checking in on vulnerable and at risk patients. Both the newly diagnosed, and those with chronic conditions are referred to the primary care clinic where they are encouraged to use services. Patients over 60 years old take a comprehensive psychosocial, emotional, and physical vulnerability assessment, including activities of daily living, social, isolation, mobility, and other questions in order to come up with a composite score about how much care that they need.
In the same building there’s a vaccine clinic as well where patients are seen and receive necessary shots for measles, dengue, malaria, COVID-19, influenza, and other communicable diseases. Besides seniors, at risk pregnant mothers, infants, small children and teenagers vulnerable to drug and alcohol use, and the 52 identified homeless individuals in the clinic’s area operation are priority populations for outreach for care.
The clinic also serves CAPS, a partial hospitalization program for pediatric mental health, juvenile mental health, substance and alcohol use disorders, and serious mental illnesses, both psychosis, bipolar, major depression, but also autism, anxiety and trauma related conditions. When it comes to trauma and other conditions, patients can recover and learn to manage their symptoms, both with medication, therapy, and being in a safe therapeutic environment where psychologist and other staff can support those in need in the road to recovery. Patients with intimate partner and family violence and abuse, as well as those who suffer from drug and alcohol addiction, can recover. However, it is difficult when patients leave the clinic’s care to go back to the same environment that created the trauma and fostered the abusive environment in the first place.
In a separate room there’s a waiting area, upstairs gynecologist family medicine doctors consult with patients. By the vaccine clinic there is a lab to draw blood and urine which is processed off site. There 8: a sterilization room with sterile tech equipment.
In the pharmacy, prescribed drugs are provided through prescriptions given both by private physicians and clinic doctors at no cost. In Brazil prescriptions cost pharmacies a fraction of their cost in the United States multiple sclerosis injection cost $20,000 in America but only $1000 in Brazil and it is provided to patient at no cost though they do have to wait several hours for treatment.
In addition to all the services available under one roof, there is a nutritionist who helps patients manage their diet for hypertension and diabetes and an administrative room for medical records, which are still filed on paper, kept in files by household, with specific forms for pregnant mothers. A social worker is available on site who can connect patients to benefits, such as trips to doctors appointments for mobility challenged individuals, home care, and other social services, filling out necessary paperwork and forms to connect with benefits and connecting them with the care they need to stay healthy and manage their chronic conditions outside the clinic and in the community.
The number of patients each nurse, doctor, clinic can see is managed by São Paulo’s public health department, with service areas drawn up and redrawn every few years with a fixed ratio of doctors and nurses to households and a regions population area.
As far as funding, 25% comes from the city, 25% from the state, and 50 percent from the federal government. The healthcare system is modeled on the United Kingdom national health service and was set up in the 1980s.
Healthcare was once a civil service public sector job with licensing and credential exams and job protections. Because of this, civil servants, healthcare professionals, and physicians could work their whole career in the public hospital system. Increasingly, public healthcare system healthcare workers are employed by private contractor. One of which, called Guina Conseco, employs clinic staff with service jobs such as cleaning and meal preparation.
In addition to the clinic, there are secondary specialist facilities, for example, X-rays and ultrasounds. Further specialized treatment and intensive care is provided at tertiary level hospitals with emergency care, surgeries, and infirmary wards. Thereis a large number of private hospitals, clinics, and pharmacies that also operate in São Paulo. Generally, diagnoses are quicker, and with the right insurance and enough money, patients can be seen quickly for care at private facilities. These providers, however, they have to adhere to rules, regulations, policies, and procedures prescribed by law. Patients without the right insurance, however, often wait much longer than going through the public sector healthcare network.
The primary care clinic like the two others that serve the neighborhood, offers comprehensive primary and public health services and preventive medicine with the support of specialists who do diagnostic imaging, surgeries, and hospital care, as well as other specialties at other healthcare facilities.
The US healthcare system is fractured and uncoordinated, despite high administrative costs of private health insurance companies and health systems that underinvest in prevention, seeking instead higher reimbursement rates of elective surgeries and acute care.
To ameliorate the worst elements of income inequality and provide critical life affirming services for the most vulnerable, we can learn a lot from the public healthcare clinics in São Paulo, Brazil.