The public health care system in Brazil is similar that of many other countries: it is run by the Ministry of Health, which distributes federal health funding to state and municipal governments, which in turn administer these financial resources according to the needs of its populations. Brazil also has a parallel private health care system, distinct from the public one that dispenses services at a cost.
The SARAH Network of Rehabilitation Hospitals created a new model of public health care that diverges from this traditional model, and is specific to neurorehabilitation. The Network is funded by the Brazilian Federal Government. It is managed by a non-profit administrative association (comprised of both medical and managerial personnel) that distributes, applies and oversees the funding that it receives. This entity,Associação das Pioneiras Sociais (APS), has a direct contract with the government, thanks to a unique law, lobbied for by the SARAH Network. Specific goals and standards are established, via this contract, which the Network must accomplish. A review and assessment of these attained objectives is systematically conducted by the Federal Audit Court. The Government then allocates the new yearly budget, paid to SARAH in monthly installments, according to the timetable demanded by the pre-set goals. The management of all resources at the Network (including staff, materials, space and equipment) is done in a way that maximizes quality and efficiency. Since all of SARAH’s funding is public, all of the services it renders are free. One of the building blocks of the Network’s philosophy is the belief in giving back to Brazilian citizens in the form of quality, free health care the taxes they pay.
In addition, SARAH also has a Board of Directors, which closely follows the Network’s operations, goals, and milestones. Board members are elected from a wide swath of the Brazilian population. Currently, its members include senators, international scientists and researchers, Supreme Court justices, and well-known political and cultural figures. There is also a Board of Ethics, which oversees all aspects of research, and which must first approve new studies that involve human subjects or cutting-edge methods not yet extensively assessed.
All employees at the SARAH Network are admitted through a public selection process (exam, interviews, and practical evaluations). Once hired, professionals in the health care divisions undergo intensive training, are taught the SARAH approach to patient care, and are periodically assessed by their peers and leaders. It is essential to the system’s success that all staff understand – and practice – the methodology that has consecrated the Network: that is, the patient is the focus of every aspect of the professional’s activity, be it medical, administrative or support-oriented.
SARAH professionals are encouraged to engage in research and continuing education activities. Funding is allotted to fostering these endeavors, with many staff members pursuing graduate and post-graduate degrees, or participating in international studies. These pursuits are an integral part of the goals set forth each year by SARAH.
Although the SARAH Network model may seem, at face value, very different, it is actually a simplified way of providing a population with medical services: citizens pay taxes, are entitled to good health care, and should not have to pay twice by being forced to resort to private health practitioners because they cannot otherwise get the assistance they need. A model that efficiently applies public tax money, converts it into quality care, and succeeds at not wasting or misapplying precious financial resources is actually a model that makes sense.
But how does it work on a day-to-day basis?
The SARAH Network currently comprises nine hospitals, in diverse regions of Brazil: the headquarters and International Center for Neurosciences and Rehabilitation in Brasilia (DF); hospitals in Salvador (BA), São Luis (MA), Belo Horizonte (MG), Fortaleza (CE), Macapá (AP), Belém (PA) and the latest addition, the Rio de Janeiro (RJ) Pediatric Rehabilitation Center and the new, large facilities currently under construction in Rio.
The Network hospitals, which are guided by the same principles, concepts and techniques consolidated over time by the first SARAH/Brasilia facility, have all been designed to maximize both the patient’s recovery process and the medical professional’s efforts and assistance. All the SARAH facilities are characterized by a careful integration of architectonic concepts and work organization principles with different rehabilitation programs defined according to the epidemiological indicators of the region in which each unit is located. Testimony to this integration is the hospitals’ ample airy spaces, with solariums and gardens designed to humanize the hospital environment. The wards have covered terraces where the patients can engage in socializing or even participate in rehabilitative activities, such as speech or occupational therapy. Since the rehabilitation process can be ongoing and, at times, intense, it is the Network’s belief that contact with nature can have a beneficial impact on the individual’s overall well-being.
SARAH also employs the system of “progressive care”, implanted for the first time in Brazil, and which dates back to the origins of the SARAH Project. This system is characterized by placing the patient in locations of greater or lesser concentration of human and material resources. For example, this concept enabled the creation of a “First Stage” ward for patients who require more intensive care and where the presence of family members is permitted. There is also the “Second Stage”, in which the patient no longer needs such intensive care, and begins rehabilitation; and “Third Stages”, in which the entire program is geared towards neurorehabilitation – returning home, going back to school or work.
Because the funding is channeled directly to the Network’s governing association, it can be allocated according to each hospital’s primary needs, and applied in the most efficient manner. For example, each setting is carefully prepared for patients with diverse medical and therapeutic needs, with swimming pools, gymnasiums for physical therapy, complementary diagnostic exam units, operational service stations, and many others. The contract with the Federal government holds SARAH to certain standards and expects the attainment of specific goals, on which the yearly budget depends. There is, then, a strong commitment to efficiency that permeates all aspects of the Network’s operations.
The SARAH Network hospitals have been connected by an advanced telecommunications system since 1997. This allows, for example, a physician in the Macapá facilities, near the Equator, to convene on a given case with professionals from all the other SARAH hospitals. Teams are free to discuss diagnoses, more complex cases, protocol and all types of exams by means of live video conferences; this contributes substantially to multiplying the knowledge of the medical staff. Furthermore, the patient charts can be accessed on-line in the Network’s internal system, and can be done so from any SARAH hospital, thereby promoting uniformity of services and permitting continuous co-consultations and discussions.
The SARAH/Brasília hospital, inaugurated in 1980, has 248 beds and is the Network’s administrative headquarters. This facility is a hospital as well as the Center for Teaching and Research; Center for Studies in Education and Prevention; Center for Quality Control, and Center for Training and Human Resources.
SARAH/Salvador hospital, an entirely horizontal facility, opened in 1994, and attends to the needs of patients in northeastern Brazil. Following this inauguration came the São Luis facilities, with 130 beds, in 1995; the SARAH/Belo Horizonte, which was once a general, public hospital redesigned and transformed into a Network hospital, in 1997; SARAH/Fortaleza, which opened its doors in 2001, and is dedicated exclusively to the rehabilitation of children and adults; and the SARAH/Rio de Janeiro Pediatric Rehabilitation Center inaugurated in 2002. The SARAH/North Lake, inaugurated in 2003, is an important center for advanced research in rehabilitation, and houses an intensive patient rehabilitation program that aims at re-integrating the patient back into society. These facilities were followed by the SARAH/Macapá Pediatric Rehabilitation Center in 2005, and the SARAH/Belem hospital in 2007.
The SARAH Network is always expanding, thanks to the ongoing attainment of goals and the effective use of its financial, material and human resources. The latest addition to the Network is the SARAH/Rio de Janeiro hospital. Partially inaugurated in 2002 as a pediatric rehabilitation unit, this larger facility was recently allocated funding for its completion and inauguration in 2009. This is a much-awaited hospital, as it will attend to the numerous population of the Rio de Janeiro region.