Background Even with a universal public health system, the Brazilian population faces inequalities on access to healthcare. Long queues for medical appointments, caused by lack of professionals, space and equipment, are barriers for those who cannot pay for treatments. However, health professionals working in the private sector may have free hours at their clinics which they can donate.
Objectives We report the implementation of a non-governmental initiative for connecting health professionals willing to volunteer and patients needing healthcare services, and present the initial results concerning access to healthcare.
Methods The network ‘Horas da Vida’ was created in Brazil to connect health professionals and patients. We analysed the number of patients and professionals involved, specialties, visits and services provided, and economic values.
Results In 2016, 1748 professionals were involved with the network. 6967 services were provided (1831 consultations) to 1974 patients, most of whom were unemployed and with low income, and 20% were illiterate. Medical, dental, nutritional, physical therapy or psychological consults, simple therapeutic procedures, eyeglasses, and educational services were provided by psychologists (29%), dentists (6%), nutritionists (5%) and physical therapists (5%). Only 5% of physicians were general practitioners. We calculated the cost of care at R$985 979.21 in 2016 (or US$314 446.74 on 18 September 2017).
Conclusions The Horas da Vida network made it easy to organise a schedule and identify free hours in the clinics that could be used for volunteering and for providing health assistance to a large number of socially deprived and economically vulnerable patients.
- health care
- public health system
- social network
- volunteer network
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Universal health coverage is an important goal set by the WHO in all countries, regardless of national income. To protect people from the financial hardship due to the need to pay for health services, the United Nations has included universal health coverage in the development agenda of countries.1 2 The Brazilian Constitution guarantees that health is a fundamental right of all citizens and is a state duty.3 The Brazilian public health system (‘Sistema Único de Saúde’, SUS) was implemented in 1990, requiring the government to pay for all preventive care and treatments. However, as in other countries, there are enormous inequalities in the way medical assistance is provided in Brazil, with poor people facing many barriers to accessing services.4 SUS is a universalist system planned to guarantee health to all citizens using preventive and therapeutic care. In Brazil, 47.2 million citizens had access to healthcare provided by a private insurance company in June 2018, from a total population of 208 million people (22%). Therefore, more than 70% of the population relies on the public health system alone to get healthcare, but they do not always effectively reach the services.5–7
WHO recommends 2.3 physicians per 1000 inhabitants as necessary to deliver essential maternal and child health services.8 Brazil had 2.18 doctors per 1000 inhabitants in 2018, and one might think it is more than enough. However, while in one region (Southeast) there are 2.81 doctors per 1000 inhabitants, in other regions (like the Northeast) the rates can be as low as 1.16 per 1000. In the capitals, the rate can reach 7.50, while in the countryside the rate can be as low as 0.47.9 These inequalities and other infrastructural factors (such as insufficient or obsolete equipment or material resources) pose difficulties for the population in accessing healthcare, even in regions where the number of doctors is high. More than just physicians are required.
When patients eventually do access healthcare, they complain about the short time spent on medical visits and the lack of opportunity to participate in decisions (shared decision-making), both in Brazil and in other countries.10 There are problems with management of referral and counter-referral systems to different levels of care. The insufficient and badly managed human resources in healthcare lead to long queues for medical appointments and massive dissatisfaction with waiting times,11 potentially leading to worsening of health before treatment can be provided. There is a need to organise care networks to help improve users’ access to human resources in healthcare.11
Horas da Vida is an online network that links health professionals willing to volunteer and patients in need of healthcare services. This case study aims (1) to report the experience of implementing a non-governmental initiative for connecting health professionals willing to volunteer and patients in need of healthcare services; and (2) to present the initial results of this initiative concerning access to healthcare.
Design and setting
This is a descriptive case study conducted at a federal university in Brazil (Universidade Federal de São Paulo). Users of medical services signed informed consent forms to participate in this study, while health professionals signed the consent electronically. All their data were deidentified and reported in aggregate form.
The network described here is part of the activities of a non-profit, non-governmental organisation (NGO) officially instituted in São Paulo, Brazil. The NGO Horas da Vida works under the advice of a consulting board and a fiscal board that oversee the accounts as well as an external audit to ensure the best investment of resources obtained through donations (of money, eyeglasses, medications and examinations).
In 2012, we created a network named ‘Horas da Vida’ to identify and connect health professionals willing to donate hours of work and patients in need of health services. The platform of Horas da Vida network is hosted on AWS Amazon, accessible through the following domain: www.horasdavida.org.br. It is protected by logins, passwords, firewalls and encryption so that patient and volunteer data are kept confidential and secure.
First, we identified NGOs that are regularly contacted by patients. These NGOs needed to be officially instituted (not merely groups of patients) and with a defined population to which they provide assistance, that is, associations created to care for a particular type of patients (eg, children with physical or mental deficiency) or that deal with social assistance for specific communities (eg, ethnic minorities or age groups). The role of the NGO was to identify and ascertain that patients were really in need of assistance and were unable to reach the public healthcare system by regular, routine ways. Figure 1 summarises the workflow of the network.
We asked the NGOs to inform us of the network of individuals in need of help through electronic forms. These patients should have low income (up to three times the official Brazilian minimum wage) and be regular users of the Brazilian public health services (identified by the identity card). Patients should also have reported difficulties accessing consultations or treatments using the public health service. Since 2015, the platform has allowed the NGOs to use the network forms to provide patient characteristics such as age, diagnosis and needs, as described later.
The network then identifies health professionals who could assist those patients, informing them of when and where the consult will take place. The patients also receive instructions on the place and time of consult, as well as an educational leaflet containing information on their condition and on what to expect from the consult. Consultations with Horas da Vida health professionals, as well as the tests ordered, optometrist evaluations and provision of eyeglasses, are all free of charge, since all these are provided through formal partnerships between laboratories and manufacturers and Horas da Vida.
Patients registered in the network can also share information among themselves and are invited to attend events scheduled to take place in public squares, schools and other public spaces organised by Horas da Vida. During these events, examinations and consultations can happen, inviting more patients to use health professional services, and therefore additional spaces are provided where patients and health professionals can connect.
Patients were included in the network through NGOs that identified their needs and which they contacted for medical or other types of assistance. The NGOs immediately referred them to the network and provided them with free internet access which they can use to register. Since many might not be familiar with computers, the social workers of these NGOs helped them with accessing the internet and the Horas da Vida website, whenever necessary.
Patients could undergo more than one consultation or technical visit within the Horas da Vida network, for example for return visits or when they were referred for additional evaluations. When the initial health problem is solved, the patient is referred back to the public health system, and he/she receives a detailed printed medical report of the case and the treatments provided. This information could then be added to the public health system.
When logging in, the patient reads the informed consent form for participation in this study; they were informed that participation would be monitored for evaluation pertaining to this study. Participation was not required in order to obtain health assistance. At this moment, a direct communication channel was opened through which the patient could ask questions, ask for help and make complaints. The online system, however, did not allow data collection for all outcomes in the first years of the network, so some outcomes data were not available during this period.
After each appointment, the patient receives a questionnaire where he/she could evaluate the quality of service, again with the help of a social worker if needed. All the results of the survey are regularly sent to the NGOs, which are committed to using them in their communities and to also communicating them individually to the users.
A partnership with a car hire company operating locally (called 99) allowed patients to use vouchers, provided by Horas da Vida, to travel to and from consultations. In some cases, the partner NGOs provided financial help for transportation directly to patients.
A fundraising platform was created and we have an employee dedicated to that. Fundraising projects include events that are designed to raise population awareness about health and which are funded by pharmaceutical companies, along with the expertise of Horas da Vida volunteers. The net profit is donated to Horas da Vida for funding of other activities and the operation as a whole. Fund raising can also be through donations, which are of two types: microdonations (of up to R$100.00 or US$26.78 in January 2019), which are individual, regular donations per month, and regular donations from companies. Finally, Horas da Vida organises contests with prizes, which also serve as fundraising opportunities.
Data extraction and collection
We evaluated the following data in this study: number of health professionals involved in 2016, their specialties, type and number of visits or services provided, the institutions, and the economic value of the services. The services provided could be individual medical, dental, nutritional, physical therapy or psychological consults, in private offices or in collective efforts (in a public event). They could also be simple therapeutic procedures, offering of eyeglasses, and educational services such as public presentations and teaching about preventive health.
We analysed the following demographic variables among patients: sex, age and schooling, professional activity, and family income. We verified the diagnosis (according to the International Classification of Diseases version 10), alcohol consumption and smoking, and physical activities. Data were collected comprising the period from October 2015 to December 2016.
We also conducted a satisfaction survey. After receiving assistance, patients could respond, if they wanted, to an online questionnaire with a scoring system ranging from 1 (terrible) to 5 (excellent).
We calculated the economic value of the connections involved in the network, including the efforts involved with triage, medical consults, examinations, eyeglasses, educational presentations and collective efforts for medical services. For this purpose, we collected information on the cost of the clinical visit or examination from each professional, in their private offices, and we counted the number of items they voluntarily provided to the programme. We multiplied the number of visits/examinations or prosthesis (such as eyeglasses) by the informed price by each professional.
All the procedures and professionals that joined the network from 2012 to 2016 were analysed directly from the network databank. Data on user profiles included the period from October 2015 to December 2016, since before this period the data system did not allow specific analyses. Data were registered in datasheets and analysed descriptively as frequencies and proportions.
Until 2016, the following 10 NGOs have participated (all agreed to be identified in this report):
Johnson & Johnson Project: aims to reduce infant mortality and provide paediatric consultations and educational presentations.
Santo Agostinho Association: an institution that manages many centres for child and elderly care.
Educafro: an organisation that promotes ethnic and social equality using educational projects.
APAE (Associação de Pais e Amigos dos Excepcionais): a social organisation that offers social assistance and healthcare for intellectually challenged individuals.
Unibes: a philanthropic institution supported by the Jewish community that fosters socioeducational projects.
Lar Sírio: a charity supported by the Syrian community to shelter children in need of protection until integration to their own or new families, providing education and professional advice to teenagers.
Casa do Zezinho: a foundation for the development of children and adolescents in situations of social vulnerability.
Saúde Criança Association: a social organisation that assists hospitalised children who are living below the poverty line by promoting the economic and social self-sufficiency of their families.
Santa Fé: a non-profit and non-religious organisation that provides shelter and therapeutic care for children and adolescents at risk, pregnant teenagers, and women at risk for domestic violence.
Playing for Change: a multimedia project that builds music schools and musical events around the world.
The Horas da Vida project started by approaching professionals (mainly physicians, but also nutritionists, psychologists and physical therapists) individually, and gradually grew by making partnerships with educational and cultural institutions, such as universities, providing some incentives to volunteers such as discounts on courses or musical events. This led to an increase in the number of volunteers from 15 in 2012 to 146 in 2013, 637 in 2014, 1302 in 2015, and finally 1748 professionals from different specialties in 2016 (figure 2).
Almost one-third of volunteers (29%) were psychologists, 14% were physicians, 6% were dentists, 5% were nutritionists and 5% were physical therapists.
There was an increase of 350% on average in the services provided from 2014 to 2016. These were, for the most part, triage assessments for referrals (1609 in 2016), consultations (1831) and educational presentations (1521), as well as clinical and imaging examinations (1378). Eyeglasses were also donated. Table 1 shows the historical evolution of services provided.
We registered data on user profiles in 2015 and 2016. In both years, there was a high female predominance in the population seeking for service, as shown in table 2. Half of the population consisted of children and adolescents up to 19 years old. Almost 20% were illiterate. In the 2 years, 1354 (61.7%) users were unemployed, and 1973 (90%) had a monthly income of R$1448.00 (US$461.79 on 18 September 2017), or less than two times the Brazilian official minimum wage of R$954.00 (US$255.55 in January 2019). A health insurance plan covered only 47 individuals. Only 3.9% of patients consumed alcohol and 4.0% smoked tobacco. Only a minority did practise physical exercise (12.5%).
A total of 200 patients agreed to respond to the online satisfaction survey. They were highly satisfied with the assistance: 145 (72.5%) evaluated the waiting time as excellent (therefore short), and 200 (100%) were totally satisfied with the assistance provided and 171 (85.5%) with the consultation time. The doctor provided excellent explanation to 183 (91.5%) patients.
We calculated the economic value of the services rendered at a total of R$985 979.21 in 2016 (or US$314 446.74 on 18 September 2017). Table 3 shows that most of the services provided were on consultations.
This study reported on the creation of a digital network that connected those providing health services voluntarily and patients in need of healthcare. The network helped patients overcome the barriers they faced when accessing healthcare, from lack of availability of a specialist to lack of money to purchase eyeglasses, for example. The initiative avoided waste of time among health professionals; health professionals’ spare time could be used to solve patients’ health problems. Horas da Vida seems to integrate public and private healthcare, even if informally.
The study shows that Brazilians struggle to get assistance from the public health system. All patients who used the Horas da Vida network had already tried hard to get public consults, examinations or treatments and were unsuccessful. It is possible to mitigate these problems using a technology that reduces the gap between people needing help and people wanting to help.
The network increased both in the number of participants and in the services provided in the 4 years of activity, and there were economic savings from providing public health services. More than 1700 professionals served more than 14 000 patients, who were highly satisfied with the service provided through the network. The network is not intended to substitute the national health system, but it did help to temporarily mitigate the problems, and maybe some of its management solutions could also help to improve government systems.
When a doctor in a private clinic has 1 or 2 vacant hours in their schedule for the week, for example, he/she is not scheduled to go to a public hospital to offer services, for safety and also administrative or bureaucratic reasons, he/she can provide those 1 or 2 hours to a patient for free, since the infrastructure required for this work (a room, equipment, reception personnel and so on) is already paid for. As a higher number of primary care physicians is associated with better health outcomes, such as reduced neonatal mortality as well as heart disease and cancer mortality,12 it seems obvious that access to first medical visit is vital. Also, a broader primary care offer is associated with lower healthcare costs.12 The primary care physician also acts as the coordinator of a specialist care that a patient needs. Horas da Vida network provided this first contact with a health professional who could take care of the problem or refer the patient to a proper specialist. These simple measures changed the lives of patients who otherwise would have to wait weeks or months to get evaluated.
This bypass filled a gap and gave patients the opportunity to receive humanised care, that is, provided by professionals who wanted to help. When there are not enough resources (both human and logistic) for a public health system to really be universal, the waiting lines get so long that the time available for a health consult (anamnesis, physical examination and other procedures) is no longer enough. This makes all health professionals work in a hurry, with no time available for more humane, respectful care—and this goes from the time a patient sits to wait for a medical consult, to the time a patient waits for a free bed for hospital admission. Unfortunately, this is the reality of the public health system in most parts of Brazil. So when a patient gets a private consultation for free in a private office, this means he/she is going to have access to appropriate space for the consult or procedure, with enough time to be heard.
The volunteers found a way to help even with limited time or space. Instead of committing the whole day to volunteering (which is usually required by volunteering contracts), they could help to offer only a few hours. Similar initiatives in the USA are the Emergency System for Advance Registration of Volunteer Health Professionals, focused on disaster situations and medical emergencies,13 and the Share the Care programme, aimed at severely ill people, their caregivers and family members.14 15 Meanwhile, the Horas da Vida is a generalist programme and to our knowledge is a pioneering network in Brazil.
Although voluntary, the work provided by health professionals can be valued, as it is capable of delivering social, economic and political benefits.16 The Horas da Vida value was calculated at R$985 979.21 in 2016 (or US$308 504.13 in January 2017). In addition to patients receiving the medical care that they otherwise would have not received, the volunteers involved gained personal and professional experiences, along with a potential reduction in state costs associated with healthcare.5 17
This project was carried out in the largest and most populous metropolis in Brazil, São Paulo. Therefore, these results can probably be generalised only to cities of similar size or of similar health services structure, since smaller cities likely experience different healthcare needs. Nevertheless, the principles, the motivation and the tool (the network) used here can be easily implemented in any location where obstacles to accessing healthcare services are an issue.
The online platform adopted by the Horas da Vida presents some limitations. It was gradually built during the first year of the programme and was not initially planned with a format that would allow data analyses—something we can now do today. This is why information for some outcomes is available only for some periods, which resulted in missing data. In future reports of the programme, this could be avoided with the involvement of information technology and specialists, statisticians, and health economists, resources that we did not have when Horas da Vida was created.
Although we have different sources for fund raising, future projects like this should take care to secure a regular, permanent source of funding so that the natural seasonality of spending would not affect the organisation’s financial health. This is why we have been putting efforts to get regular donors (from individuals and companies).
We also believe that to increase access to healthcare, it is necessary to respect geography. This means that the volunteers need to be well distributed in the area. If this is not entirely possible, telemedicine resources (ie, consults via teleconference) should be obtained and used, especially in large areas where transportation can be an issue.
By year 2016, 14 024 consultations have been carried out through the Horas da Vida network, involving 1748 professionals from different specialties in 10 NGOs assisted by the institute. The value of the services provided in 2016 was calculated at US$314 000, mainly from medical consultations. Users were mostly female and children up to 9 years old, with family income of up to US$461.00 per month, with incomplete secondary education and were unemployed. This model should be further tested in other settings.
We acknowledge and thank for the precious work of the volunteers participating in the network.
Contributors JPNR designed the study, collected the data, wrote the manuscript, and revised and gave final approval for the version to be published. RR interpreted/analysed the data, reviewed the text critically and gave final approval for the version to be published.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests JPNR is the founder of the NGO Horas da Vida.
Patient consent for publication Not required.
Ethics approval The institutional review board approved the study protocol (CAAE: 55652516.3.0000.5505).
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No data are available. Because it would be difficult to deidentify patients and volunteers, the researchers cannot share data publicly at this time.