ABSTRACT

In Amazonia, which includes regions in eight South American countries (and an enormous area in Northern Brazil) many of the inhabitants live in small communities scattered across a vast territory? Since too often they cannot be accessed by road, health services must be brought to them on specially constructed river barges, which are floating comprehensive primary care clinics. To effectively deliver health services to vulnerable populations living deep in the Amazon Rain Forest, the Municipal Health Authority of Borba, Brazil piloted the innovative technology of the Igaraçu Fluvial Mobile Clinic, a boat with full primary care services. The aim of this investigation is to do a case study of the pilot implementation of an innovative technology, Igaraçu the fluvial mobile clinic, which delivers primary care services in rural, Amazonas, Brazil. In Borba, the implementation of the Igaraçu has increased the number of people receiving primary care by over 10% and improved the quality of primary care provided, in particular, health promotion, maternal and child care, and treatment of chronic disease. Before the Igaraçu fewer people used services for the following reasons: (1) Insufficient professional healthcare staff (e. g. medical doctor and advanced practice nurses); (2) Lack of privacy during consultations; (3) Loss of exam samples; and (4) No continuity of care. Implications of this successful healthcare delivery innovation for the importance of coordination between national health authorities and local policy makers are discussed.

Key words: Amazonia, inhabitants, mobile clinic, primary care clinics.

Before Igaraçu, the healthcare team used a common wooden boat rented by the municipal health authority to deliver primary care services to people living in isolated riverbank communities. Consultations were done in community leaders' houses, churches or schools.  There was very little privacy.  To complete many exams, such as those for cervical cancer, the nurse had to do home visits and collect their specimens in patients' homes while children and other family members were present. Sometimes the specimens were lost before being analyzed. The mobile health team went to the community every 60 days, six times each year. Rarely a physician accompanied the team.

 

Dissatisfactions with this model of care delivery resulted in the Borba Health Authority to propose a pilot project to the MOH for the construction of a ship that could provide self-contained full primary care services.  In 2012, the MOH responded with additional services and within a year Igaraçu Fluvial Mobile Clinic was launched.  Currently, Igaraçu serves several river bank communities along the Madeira and its affluent. An Igaraçu roundtrip in this “liquid” territory takes 20 days. There is an interval of 40 days between trips. The health team includes one nurse unit manager, two nurse assistants, one physician, one dentist, one biomedical technician and twelve community health workers (community based). 

 

In addition, there are six crew members. The community workers have a key role planning the agenda for each Igaraçu trip and serve as a communication link between the clinic and the local population. With the nurse supervision, they also develop patient tracking maps with all of the people who must be followed-up with special services such as pregnant women, children and adults with chronic disorders.  Patient records are organized according to a therapeutic plan, e.g. maternal and child health, hypertension, diabetes, and geriatric issues (Figure 1).

 

 

The mobile health unit is 24 m in length and has two floors.  The first deck is devoted to clinical activities, which includes offices for doctor, nurses, dentist and rooms to accommodate a pharmacy, laboratory, immunization and sterilizing suites. The upper deck includes the team's bedrooms, kitchen and administrative space. A typical workday begins at 7:00 a.m. and lasts until the last patient is seen. During the night, Igaraçu travels on the river to the next community where it begins seeing patients early in the morning. 

 

Simple tests such as blood, urine, and stool analyses are completed in the Igaraçu laboratory while samples from more complex exams are sent to a laboratory in the largest community in Borba or to a clinical laboratory in Manaus.  In cases where a patient must be referred for specialized care, sometimes they can be treated in the local hospital in Borba, however, when they require more complex treatment, the municipal health authority  assists them, so that they can obtain this needed specialized care in Manaus.

 

Two constraints on this new model of primary healthcare delivery were identified. First, there had to be an increase in Federal funding (in Brazil, the MOH provides funding for primary care, which is delivered locally). Second, a more effective method of collecting and processing samples and tracking patients had to be developed.

 

The development and testing of Igaraçu was part of a regional program supported by the MOH.  Based on Borba’s outstanding success, in 2012 the MOH implemented a program to build 64 Fluvial Health Units to be used in the nine Brazilian states of the Amazonian region. Federal funding was also allocated to the local health authorities for the maintenance of these floating clinics.  Furthermore, the National Primary Care Policy was updated to address this new model of “Ribeirinha” Population Health. “Ribeirinha” is a riverside population that is deeply influenced by the cycle of waters (floods and droughts), in a type of dependence and symbiosis, traditional beliefs and subsistence family-based agriculture 

 

The cost of providing approximately 3,400 persons with comprehensive primary care including pre-natal, pediatric, chronic disease (especially hypertension and diabetes), infectious disease, immunization, health education and epidemiologic surveillance through the Igaraçu is U.S. $26,500 monthly. When this budget is broken down, 65% is for personnel, 23% is for fuel and 12% is for crew food and housing expense. Expenditures for laboratory supplies and pharmaceuticals are not additional because they are no more with the fluvial than the traditional health unit. The overall building cost for one Fluvial Health Unit was US$530,000, which is equal to the cost of constructing four traditional land-based primary care clinics.  However, because the population is spread over a vast territory, having 4 additional clinics would not substantially increase the healthcare coverage of the population.  In addition, it would cost an estimated U.S.$12,000 more per unit in maintenance expenditure. In Borba, the implementation of the Igaracu has increased the number of people receiving primary care by over 10% and improved the quality of primary care provided in particular in the areas of health promotion, maternal and child care and diagnosis and treatment of chronic disease. Before the implementation of the fluvial mobile clinic, fewer people in rural Amazonas used services because of (1) insufficient professional healthcare staff, e. g. advanced practice nurses and medical doctors; (2) lack of privacy during consultations; (3) loss of examined samples; and (4) no continuity of care.

 

The Ministry of Health of the Federal Government of Brazil had advised that a systematic evaluation of 10 fluvial mobile clinics in the state of Amazonas and Para should be conducted (MOH Communication, January,2017).

 

 

 

The Borba pilot project helped the Brazilian MOH to refine and make more effective its Fluvial Mobile Clinic initiative. Key issues that must be addressed for the sustainability of this innovative model of care had been identified.  These challenges are assumed to exist in rural areas that have similar characteristics to Amazonia, e.g. vast undeveloped rural regions and widely dispersed populations with low incomes and education levels living along navigable rivers, including other Amazonian countries in South America.

 

The scheduled predictable and more frequent arrival and functioning of the Igaraçu Fluvial Mobile Clinic dispels the community's perception of service unreliability.  Families can now return for appointments more regularly because they know they will be assisted by a complete health team, including a medical doctor who have their detailed medical histories, and will be examined and treated as required.

 

Highly bureaucratic and rigid healthcare delivery models, which often provide fragmented care, must be replaced by more accessible and flexible mobile clinics that have patient oriented highly cohesive clinical staffs (WHO, 2013).

 

This new model of care requires adjustments in work processes for providing health services (Table 1), and because of crucial differences regarding traditional land- based health units; it is highly desired to  keep  the  same health team and boat crew for no less than two years. This data in the table reflects information collected by the evaluation and monitoring team at the University of the Amazonis.

 

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