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A method to overcome the vicious cycle of poverty

With multiple evidence-based actions, the Dara Institute model can inspire state public policy

Camilo Martins

Despair hit Priscila de Oliveira when she arrived at Lagoa Federal Hospital, in Rio de Janeiro, with her 2-year-old son in August 2019. The child’s screams, who suffers from hypospadias, a rare genetic defect of the urethra in boys, were just one of many problems that afflicted the family. Oliveira had to leave her job in an accounting firm when she was pregnant with the boy—it was a high-risk pregnancy—and, since then, she has not been able to find another job. At that point, she had no money to buy everyday food and the expensive hypoallergenic foods that the boy needed. She was also about to be kicked out of the place she was living with the boy and her adolescent daughter.

Referred by the hospital to a nongovernmental organization, the Dara Institute (ID), Oliveira joined an intense program for people in situations of vulnerability. The so-called Family Action Plan (PAF) takes an average of two years and is based on a multidisciplinary and integrated approach to combating poverty. The families are selected in public hospitals, Social Assistance Reference Centers (CRAS), and public schools from the city, and undergo an interview to map their life conditions. The initiative offers support on five simultaneous fronts: health, housing, income, citizenship, and education. “It is of no help treating a child in hospital for them to return with a more serious illness or die from living in unhealthy conditions,” stresses family physician Vera Cordeiro, creator and director of the Dara Institute—a term meaning star in Sanskrit. “The reception was very welcoming,” says Oliveira, who had a long conversation on her first contact with the social worker about her difficulties and the depression she suffered from. “On the same day I spoke with a psychologist. She gave me her number and told me to call whenever I needed, at any time. And told me that I could call collect.”

From the beginning, the organization provides medication, special milks when necessary, and a top-up on the food card for the amount of R$200 per family. The social services check whether the children are up to date with the vaccination calendar and doctors assess the needs of the entire family. Depending on the results, they receive guidance about vaccination centers, hospitals, or specialist doctors to look for. If there is a need for consultations or exams, they are referred to the public system or to private professionals and laboratories—some of which are partners of ID that provide services with a discount or free of charge. “People don’t generally know their rights and don’t know where to go,” observes Cordeiro.

To start rebuilding income, ID verifies that government benefits are available for every family, such as programs for transferring resources, transportation vouchers, and assistance for serious illnesses. This was fundamental for Oliveira. With the support of the legal team, she requested Incapacity Benefit provided for in the Social Assistance Organic Law, granted to people with deficiencies. “It took two years to receive it, but I got retroactive payment and was able to put a deposit on an apartment, which I will finish paying in eight years,” she celebrates.

Family algorithm
Besides the medications, attorneys, and psychologists, other specialists are also involved, such as architects and engineers, who help to improve housing conditions, nutritionists and training specialists to increase income. All of their suggestions and referrals are recorded as goals in the ID computer system, which, once a month, provides an overview of the progress of the families in different areas. “The team has accumulated a large amount of data and they serve as evidence to show whether the actions work or not,” says Mexican Daniel Ortega Nieto, senior public policy specialist of the World Bank, who evaluated the PAF methodology in 2013 during a postdoctoral study at the University of Georgetown, in the USA.

For Vera Cordeiro, the computer system, produced in partnership with McKinsey, a North-American consultancy that does not charge for the service, and enhanced by companies such as Radix, is at the core of ID’s social technology. The challenge is to give meaning to the enormous set of information collected by the technical team and volunteers. She says that, using the system, all the professionals involved are able to follow the development of the families. The psychologist, for example, knows what the medication is doing, while the architect works in collaboration with the engineer.

Goals to be achieved are agreed and monitored in monthly visits that the families make to ID. The children should be vaccinated, and, if they are old enough, attend school. The parents can choose professional courses to improve their qualifications, but have to show that they are taking part in them. If they do not comply with their commitments, they run the risk of being suspended from the program to give others the opportunity. They are released—or “discharged,” as the volunteers say—after meeting well-established criteria. They should all have a regular clinical state at least. If a member suffers from a chronic illness, it must be controlled and stabilized. For income, at least one adult must be working and the per capita income of the family cannot be less than a quarter of the minimum wage. Housing has to be masonry, without leaks in the walls and with a sewage system, among other requirements.

“When I realized that I could manage by myself, I asked to be released, because I know that others need more help than I do,” says Oliveira, who, accompanied by her children and volunteers, went to Rua das Palmeiras, in the Botafogo neighborhood in Rio de Janeiro, and rang the bell at the entrance of ID at the moment she graduated from the program, a ritual to celebrate overcoming social vulnerability, her dignity, and autonomy.

The evaluation carried out by Ortega, which compared the participants at the start of the PAF and three and five years after being “discharged,” indicated that the average time of hospitalization was reduced by 86%, while their income increased 92%. The rate of having their own home rose from 26% to 50% in the period. “Making a multifaceted program in five areas work is extremely complex; and ID has managed it,” says Ortega. 127 families that completed their journey through the PAF between 2008 and 2011 were evaluated.

Camilo Martins

Social workers often visit the homes of families and notice that the situation is worse than is reported. “We attend people below the poverty line, who feel really ashamed about their situation and think it is their fault,” highlights Cordeiro. The doctor says that, besides leaks and infiltration, it is common that situations of domestic violence, unemployment, and depression, among other vulnerabilities come to light. In the case of domestic violence, the psychologists and legal team offer guidance to women about their rights and the measures they can take. In some cases, the solution involves giving an option to work. The ID offers the participants courses in cooking, hairdressing, and manicure, which quickly provide a source of income, but there are other possibilities. Oliveira received professional consultancy about finances and income management, bought a computer, installed an internet connection, and started earning money working from home for her old office. Another mother wanted to work as a security guard: ID paid for a course and she was employed at Tom Jobim International Airport. A third person learned to fix air-conditioning units. “Self-sufficiency and autonomy help women to be in control of their own destiny, often leaving toxic relationships,” stresses Cordeiro.

To break the isolation and make up for the lack of support networks, the mothers meet under the guidance of a psychologist to share information about domestic violence, teenage pregnancy, work, and other relevant topics. There are even WhatsApp groups that advertise job vacancies and courses. “The work of entities like ID encourages the formation of local solidarity networks, fundamental for treating health and poverty,” observes pathologist Paulo Saldiva, of the School of Medicine of the University of São Paulo (FM-USP) and coordinator of the FAPESP Public Policy Research Program.

Cordeiro estimates that ID assists between 300 and 400 family units every month, almost all headed by women. As each one has around four individuals, the total number of people reaches 1,600 per month. In the last 30 years, it is estimated that the NGO has directly impacted the lives of 85,000 people and, indirectly, more than 1 million, since it has inspired organizations from several countries to adopt strategies from the PAF. The Institute has provided consultation about its social technology to members of the University of Baltimore, in Maryland, USA, and to the Girl Move Academy, for actions in Mozambique.

From 2017 to 2022, ID was elected the best NGO from Latin America and was close to the best 20 in the world for all the years, according to the list by thedotgood, an independent media organization based in Geneva, Switzerland. The demand for the ID method could grow, since the number of Brazilians in poverty reached 47.3 million at the end of 2021, an increase of almost 11 million over the course of the last year. Around 6,3 million of them have reached extreme poverty.

“Vera Cordeiro is an attentive physician who has recognized, in practice, that it is necessary to treat health in an integral manner. Her work is impressive,” praises British epidemiologist Michael Marmot, of University College London (UCL), in the UK, who presided over the World Health Organization (WHO) Commission of Social Determinants of Health and has led research into inequalities in this area for 40 years. The researcher claims to know few initiatives in the world that take the social factors that affect health into account so comprehensively.

The PAF was created in 1991, when Cordeiro, who worked at Lagoa Federal Hospital, in Rio de Janeiro, decided to monitor children and their families in highly vulnerable situations after discharge and investigate the conditions that caused their frequent return and often death. To receive them, she set up an improvised space in a stable in Parque Lage, also in the Jardim Botânico neighborhood, where she founded the NGO, called Associação Saúde Criança Renascer at the time. “The poor are not all the same: each vulnerable family has one or more factors that debilitate them. In some cases, one of the responsible adults is involved with drugs, in others the home is extremely unhealthy. And there are situations in which domestic violence is a factor that worsens the living conditions,” stresses Cordeiro, who tells the story of the NGO in the book A Cobertura do Mundo (Covering the world), coauthored with Roberta Pennafort (published by Batel, 2021)

“When governments and ministries speak about spending in health, they are generally referring to the public health system. But the real determinants are outside this system,” highlights Marmot, who was one of the four global leaders, along with Cordeiro, honored in a special about inequality in health produced by the scientific journal Scientific American and by the periodical Nature, published in June. “ID deals with the social conditions that make people sick.”

A frequent problem faced by public policies is that they deal with populations in extremely heterogeneous conditions. “The risk of a myocardial infarction, for example, can vary tenfold in the same city, depending on the region,” explains Saldiva. For him, when an individual’s address helps predict this risk more accurately than the level of cholesterol—because they live in an extremely unhealthy location—public policies become necessary that take into account the specific conditions of groups or territories, not just the individuals. “Entities like ID make precise public policies,” he says, adapting the term “precision medicine”—which customizes treatment in accordance with the patient’s personal information, such as genetic data.

“The work of ID could be implemented on a larger scale, in partnership with private institutions,” says Saldiva. Something similar has happened in Belo Horizonte, since 2009. With funding from the Avina Foundation, based in Panama, ID worked in cooperation with the CRASs, of the municipal government, and developed a service similar to the PAF.

The positive results helped Cordeiro to attract funding from six international philanthropic entities, her main backers: the Linde Foundation (White Martins, in Brazil), the Ursula Zindel-Hilti Foundation, based in Lichtenstein, the NGO Ashoka Social Entrepreneurship and the Skoll Foundation, both based in the USA, the Schwab Foundation, partner of the World Economic Forum, based in Switzerland, and the Avina Foundation; in addition to companies and national entities, and donations from people that make one-off or regular contributions, making up a budget that sustains the organization and helps maintain the standard of service.