Community-based care for vulnerable older people in Brazil: inter-sectoral collaboration in practice.

Synopsis:Local governments in Brazil are developing community care programmes based on partnership between health and social service agencies. We compare experiences in two cities, applying an implementation science analytical framework.

 

Background: Policymakers in Brazil are recognising the urgent need to develop and evaluate effective interventions to meet the needs of growing numbers of care-dependent older people. We present a comparative evaluation of interventions implemented in two cities from 2023.

 

Approach: We draw on a rich set of qualitative data collected over 18 months, including key informant interviews, non-participant observation and field diaries. Our overall research design included close partnerships and coproduction of analysis with national and local government stakeholders, as well as affected communities.

 

Results: The interventions followed a similar model, with paid trained “social carers” working alongside primary healthcare and community social assistance teams to support caregiving of highly dependent older people in vulnerable households. Experiences of intersectoral collaboration varied between different neighbourhoods. Among other things, this reflected (i) the speed at which implementation occurred (highly accelerated on one case; gradual in the other); (ii) previous experiences of collaboration and interpersonal relationships between the agencies in question; and (iii) differences in service infrastructure and resourcing.

 

There were also common experiences, including initial mistrust and misunderstandings between local health and social service agencies relating to the eligibility of specific older people for inclusion in the interventions. Health departments faced particular barriers to collaboration due to frequent staff rotation and a need to respond to unpredictable demands (such as local outbreaks of dengue fever). Collaboration was facilitated by monthly joint agency case review meetings, learning over time and by strong political support from the top level of municipal government (city mayors).

 

Implications: In both cities collaboration between health and social service agencies was initially challenging, and disagreements sometimes required arbitration from higher levels of government.

 

Over time, collaboration improved through processes of shared problem-solving, increased stakeholder understanding of mutual roles and recognition of the benefits of working together. Practical insights from this study are directly informing a new federal government strategy to support similar interventions in other cities. These include establishing clear parameters and expectations, as well as mechanisms for swift resolution of disputes between different agencies and adapting implementation strategies to local contexts.