After a lengthy hiatus (I got trapped in the hamster wheel of academia), I am back to reflecting on my Brazilian adventure and finishing off the top five moments (memories?) of my trip. So #3 was learning about nursing, nursing education, and the healthcare system in Brazil. Afterall, that was the main purpose of my trip as an invited visiting scholar following my work with Maria Alice and Angela. For me, seeing how another country operationalizes both preparation of healthcare professionals and delivery of services to its peoples can be so informative in thinking about how we might do things here in Canada. In my 37 years affiliated with our own system (first as emergency medical technician on ambulance and then as nursing student and RN), my belief is that publicly funded universal health care is great but we are inefficient and wasteful in our resources - our society essentially takes the system for granted and we now have generations that assume care is "free". Canada spent about $344 billion (12.1% of our GDP) on total health spending in 2023, the majority of this (about 40%) on hospitals and physicians; our system is not comprehensive, as we would like to think it is, as we do not have a national pharmacare program in place and are only now getting dental care covered.
As I blogged about earlier, Brazil also has a publicly funded universal system that covers health care, pharmacare, and dental care. However, not being as flush in resources as we are, their deployment of services is done quite differently with more of a focus on public health and prevention. For instance, having pharmacare and dental care is actually a mechanism for facilitating better chronic disease management and ensuring better health outcomes. By having access to medications and equipment people are able to better control their blood pressure, blood glucose levels, and prevent unwanted pregnancies (family planning) or sexually transmitted infections (everyone at risk can be on PrEP). It is a no-brainer that health maintenance and illness prevention decreases the consequences to health outcomes and costs to the health system. And for those of you who may not be aware, the recipe for solid primary health care and health promotion originated here in Canada in 1986 - the Ottawa Charter for Health. How ironic that we have reports on this topic from Romanow, Epp, Kirby, and others...yet do not embrace them to alleviate the strain on our beleaguered system.
There are many reasons for this, not least of which is the dominance of medicine over the healthcare system and over all other healthcare providers. Don't get me wrong - physicians are an important part of the healthcare system but, since the majority bill the system for every little thing they do as a service, there is no check and balance (or incentives) to moderate their slice of the pie. This power, of course, plays into the political arena where the physician lobby ensures security of their piece of pie - what political party has not identified or articulated the deficiency of access to physicians? The reality is that not everyone needs a physician or should require physicians to be gatekeepers to access care. Nurses, used to their fullest scope of practice, can independently do quite a lot if supported by their provincial/territorial legislations and professional regulatory bodies.
In Brazil, nurses in primary care do exactly that - a broad generalist role with support for diagnosis and prescription to a certain level, such as independently addressing sexual health concerns, doing perinatal care, and so forth. But they are also imbedded in a true interprofessional team model with physicians, dentists, nutritionists, health outreach workers, and specialists in community health centres. All publicly funded, community-based, and accessible. These nurses would actually straddle the role of a registered nurse and a nurse practitioner here in Canada with preparation through a solid and practical 5-year baccalaureate education that has a strong community-based focus. In comparison, we generally have a 4-year baccalaureate education with (sadly) less expectation for competency and, often, only observational experiences and literally little (or no) real community health practice. And to be a nurse practitioner is another 2-year fulltime masters program on top of baccalaureate nursing but very few jurisdictions utilize nurse practitioners to full scope. A little known fact, and this is grounded in research evidence, a nurse practitioner who is competent and operating at full scope can do up to 80% of the care a family physician does at a fraction of the cost to the health system.
When I presented to the students at the Federal Institute of Santa Catarina, a student asked me (in front of 100+ students and faculty) whether Canada had the same problem in nursing education as they do - faculty with no actual nursing practice experience teaching nursing. I had to be quite honest and frank stating, yes, it is a significant problem in Canada. I shared with them that some programs fast-track students from baccalaureate to PhD with little or no practice experience who go right into academia. And, unlike medicine and other healthcare professions (including nurse practitioners), there is no requirement for registered nurses to do a minimum number of clinical-based hours to maintain their registration. In my humble opinion, this is problematic on so many levels and is slowly destroying our profession. Coupled with this is the shortage of qualified instructors and even at that level there is minimum clinical experience, often individuals who have received all their education in the same institution and never experienced nursing practice outside of their city or province. For my part, I had almost 19 years of experience as I transitioned to academia and, until I came to the University of Manitoba, always had clinical groups in community; I also had the experience of clinical practice in two different provinces and Florida spanning several hospitals and community settings.
Similar to Canada, Brazil has a two-tiered healthcare system with more privatization of basic services including hospitals. However, as there is less oversight and litigation (accountability?) compared to the USA or Canada, many people told me that privatization did not necessarily lead to better health outcomes, efficiency in costs, or better work environments. The private health institutions certainly looked rich and impressive on the outside, from what I saw but I only was able to visit a public regional hospital that had both new and old pavilions. The old pavilions did look a bit dated and in need of replacement; however, after being in some of our facilities I have to say we have structures that are in the same state of repair. I remember my time in the Health Sciences Centre for my emergency back surgery in January 2022 in a rundown, sad room on the neurosurgery unit with holes in the wall, chipped plaster, peeling pain, and dusty bunnies on the floor. Between the environment and poor quality hospital food, it was little wonder that I opted not to stay any longer than I needed to (in spite of the invitation) - even Florence Nightingale would have been appalled.
My takeaway memories and comparisons of the respective healthcare systems of Canada and Brazil really came down to three things. First, how we in Canada seem to take what we have for granted whereas, because of economic necessity, Brazil truly focuses on upstream planning to counteract potential downstream costs. Second, a well-educated and well-utilized healthcare workforce can really make a difference for access to care and health outcomes of the population; a properly integrated interprofessional community-based model can take the pressure (and cost) off the acute care system. And third, bringing up an issue that I blogged about earlier, removing barriers of portability of healthcare professionals between provinces and territories would likely assist with the movement of providers to where there are needs. As I had noted, in Brazil registration is associated with completion of a solid, practical baccalaureate with standardized exams and there is no separate regulatory body for its 26 states and 1 federal district.
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