2023 Recognized Innovation
The renowned Brazilian singer Milton Nascimento’s lyrics declare how a passionate artist should always let his song reach people’s ears, by going to where the people are. This is the same sentiment that Paula Corrêa Barbosa and her team from the Municipal Health Department of Jaboatão dos Guararapes adopted. Passionate health workers can’t wait for people in need to come to them, but rather, the delivery of equitable healthcare requires taking the services directly to the people, based on their lived reality and situation.
“Todo artista tem de ir aonde o povo está
Se foi assim, assim será
Cantando me disfarço e não me canso
De viver nem de cantar”
― Milton Nascimento, famous Brazilian singer and songwriter
Jaboatão dos Gaurapapes, is a coastal city in north-east Brazil, in the state of Pernambuco. The city is home to 706 867 inhabitants (2020), of which 37% of the population live in poverty. The reasons responsible for people living with homelessness include psychiatric disease, drug and alcohol addiction, poverty, and family strife. Between 2012 – 2020, the homeless population in Brazil increased by 140% due to the worsening social and economic situation, amplified by the pandemic. A 2020 study reported 221,000 homeless people across all cities in the country, and more recent data found 33 million Brazilians experiencing food insecurity. Hunger symptoms, mimicking disease, have become a frequent presentation at health units in the country.
The Covid-19 pandemic increased the vulnerability faced by homeless people. Vaccine rollout in Brazil commenced in January 2021 for the elderly, and it was in June 2021 that the homeless population became eligible. Paula and the team from the Municipal Health Department of, were determined to give all people, including those experiencing homelessness, an equal opportunity for protection against Covid-19. Although vaccines were provided at health locations throughout the city, this access alone was not sufficient to reach the homeless population. Instead of waiting in a clinic building, Paula reached out to some individuals experiencing homelessness and asked them directly ‘how can we reach you?’. One individual told her “Don’t come to us only with the vaccination, we don’t want that. We want someone to take care of us.’”
“Don’t come to us only with the vaccination,
we don’t want that.
We want someone to take care of us.”
― Community member
As soon as the vaccination of the homeless population was approved, a technical planning group was created comprised of Paula and the team from the Municipal Health Department, civil society members, and people experiencing homelessness. Through honest conversations, Paula and the team learned that the care of the homeless population needed to be extended beyond mere medical interventions to also include food, water, and other necessities. They learned that often a limitation for the homeless population to access free health services provided by SUS (Unifed Health System) is the requirement of an identity document and a physical address – both of which many people living on the streets did not have. To ensure they have food to eat daily, people experiencing homelessness walk the streets during daytime hours, making it a challenge to attend health facilities during the working hours of 8 am to 6 pm. In addition, a lack of access to health and vaccination information and the fear of judgment at health facilities, limited people’s care-seeking behavior.
To provide vaccinations to the homeless population as well as to drug users and sex workers, based on their needs and unique characteristics, Paula and a multidisciplinary team, started delivering vaccination services between 4 pm – 4 am, with the early morning hours being the busiest. Included in the team were psychologists, nurses, nursing technicians, occupational therapists, social workers and sanitation workers. Collaborative partnerships were also established with the Municipal Social Assistance Department to assist individuals experiencing homelessness registering for their national health insurance card and for social assistance, and with civil society organizations such as the National Street People’s Movement and the Ruas Museum Initiative, to provide social support.
Through this program, vaccines have been delivered, analgesics, and supplies such as condoms, lubricants, food and water. Based on further needs raised by the population, services have been expanded to include harm reduction support and mental health care. People in need of further care e.g. pregnant women are referred to other appropriate services. The locations where this holistic care program is delivered are carefully mapped to be in settings with the highest concentration of people during the nighttime hours.
“Everyone has a different history,
a different life,
so it is much more than immunization”
― Paula Corrêa Lima Pereira Barbosa, innovation team
Paula and her team’s willingness to intentionally listen to the experiences of people living with homelessness and their humility to not design or deliver an intervention without the involvement of beneficiaries have been two factors responsible for the programs’ success. Several beneficiaries have become program volunteers, working alongside the health team at night. Two individuals, previously affected by drug and alcohol abuse have received rehabilitation and since, have been appointed by the municipal health government as program officers. Equally, the program has challenged and changed the perception many health workers held of the homeless population and instead of regarding them with fear and concern, relationships of mutual trust were established. Some health workers have continued to volunteer for the night program, despite having a new full-time job.
The outcome of the program, on health statistics, has been significant with 87.5% of the city’s estimated homeless population being immunized, all served to be able to access the SUS (Unifed Health System) and many others benefitting from harm reduction counselling, rehabilitation services, hygiene assistance and administrative support to restore their citizenship status. The factor attributed to the success of this program is not merely enhancing access to services but delivering services in a humanizing and dignified way.
The renowned Brazilian singer Milton Nascimento’s lyrics declare how a passionate artist should always let his song reach people’s ears, by going to where the people are. This is the same sentiment that Paula Corrêra Barbosa and her team from the Municipal Health Department of Jaboatão dos Gaurapapes adopted. Passionate health workers can’t wait for people in need to come to them, but rather, the delivery of equitable healthcare requires taking the services directly to the people, based on their lived reality and situation.
Jaboatão dos Gaurapapes, is a coastal city in north-east Brazil, in the state of Pernambuco. The city is home to 706 867 inhabitants (2020), of which 37% of the population live in poverty. The reasons responsible for people living with homelessness include psychiatric disease, drug and alcohol addiction, poverty, and family strife. Between 2012 – 2020, the homeless population in Brazil increased by 140% due to the worsening social and economic situation, amplified by the pandemic. A 2020 study reported 221,000 homeless people across all cities in the country, and more recent data found 33 million Brazilians experiencing food insecurity. Hunger symptoms, mimicking disease, have become a frequent presentation at health units in the country.
The Covid-19 pandemic increased the vulnerability faced by people experiencing homelessness. Vaccine rollout in Brazil commenced in January 2021 for the elderly, and it was in June 2021 that the homeless population became eligible. Paula and the team from the Municipal Health Department of, were determined to give all people, including those experiencing homelessness, an equal opportunity for protection against Covid-19. Although vaccines were provided at health locations throughout the city, this access alone was not sufficient to reach the homeless population. Instead of waiting in a clinic building, Paula reached out to some individuals experiencing homelessness and asked them directly ‘how can we reach you?’. One individual told her “Don’t come to us only with the vaccination, we don’t want that. We want someone to take care of us.’”
As soon as the vaccination of the homeless population was approved, a technical planning group was created comprised of Paula and the team from the Municipal Health Department, civil society members, and people experiencing homelessness. Through honest conversations, Paula and the team learned that the care of the homeless population needed to be extended beyond mere medical interventions to also include food, water, and other necessities. They learned that often a limitation for the homeless population to access free health services provided by SUS (the National Health Insurance) is the requirement of an identity document and a physical address – both of which many people living on the streets did not have. To ensure they have food to eat daily, people experiencing homelessness walk the streets during daytime hours, making it a challenge to attend health facilities during the working hours of 8 am to 6 pm. In addition, a lack of access to health and vaccination information and the fear of judgment at health facilities, limited people’s care-seeking behavior.
To provide vaccinations to the homeless population as well as to drug users and sex workers, based on their needs and unique characteristics, Paula and a multidisciplinary team, started delivering vaccination services between 4 pm – 4 am, with the early morning hours being the busiest. Included in the team were psychologists, nurses, nursing technicians, occupational therapists, social workers and sanitation workers. Collaborative partnerships were also established with the Department of Social Assistance to assist individuals experiencing homelessness registering for their national health insurance card and for social assistance, and with civil society organizations such as the National Street People’s Movement and the Ruas Museum Initiative, to provide social support.
Through this program, vaccines have been delivered, analgesics, and supplies such as condoms, lubricants, food and water. Based on further needs raised by the population, services have been expanded to include harm reduction support and mental health care. People in need of further care e.g. pregnant women are referred to other appropriate services. The locations where this holistic care program is delivered are carefully mapped to be in settings with the highest concentration of people during the nighttime hours.
Paula and her team’s willingness to intentionally listen to the experiences of people living with homelessness and their humility to not design or deliver an intervention without the involvement of beneficiaries have been two factors responsible for the programs’ success. Several beneficiaries have become program volunteers, working alongside the health team at night. Two individuals, previously affected by drug and alcohol abuse have received rehabilitation and since, have been appointed by the municipal health government as program officers. Equally, the program has challenged and changed the perception many health workers held of the homeless population and instead of regarding them with fear and concern, relationships of mutual trust were established. Some health workers have continued to volunteer for the night program, despite having a new full-time job.
The outcome of the program, on health statistics, has been significant with 87.5% of the city’s estimated homeless population being immunized, all served to be able to access the SUS (national health insurance) and many others benefitting from harm reduction counselling, rehabilitation services, hygiene assistance and administrative support to restore their citizenship status. The factor attributed to the success of this program is not merely enhancing access to services but delivering services in a humanizing and dignified way.
TEAM
This project is made possible through the creative efforts of: Paula Corrêa Lima Pereira Barbosa, Zelma de Fátima Chaves Pessôa, Jeane Tavares Torres, Marcelo Nunes Candido, Bárbara Katiene Magno Gaião, Jucelio Cavalcanti.
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ACKNOWLEDGEMENTS
This innovation profile was written by Lindi van Niekerk, PAHO consultant, based on documents supplied by Extramural Vaccination Strategy for the Homeless Population and an interview conducted by Charlotte Scott and Kathleen Agudelo, from the SIHI LAC Hub. Website design completed by Amy Clarke and Claudi van Niekerk from Chembe Collaborative.
