2005 Award Winner
Secretaria Municipal de Saude e Acao Social, Sobral, Brazil
The Public Management and Citizenship Programme in Brazil
The Public Management and Citizenship Programme in Brazil

The municipality of Sobral has a tradition of innovative health practices. Considered one of the birthplaces of the Community Health Agent Program and the Family Health Program, since the 1990s, the town has worked to reduce infant mortality rates. The Four-Leaf Clover Program, established in 2001, operates a network of several service providers to improve access to services and the quality of life of Sobral’s mothers and children.

The Program’s strategy is to link and reorganize several entities offering pre- and post-natal treatment to provide integral and cross-sector service. Participants include public and private hospitals, Family Health Program teams, local health clinics, preschools, the Catholic Church (by means of the Pastoral da Criança), civil society groups, and the community at large.

There are two basic lines of action: 1) to reorganize and improve the quality of care given to infants, and 2) to guarantee that women have the support they need from pregnancy throughout the child’s first year of life. The Program is organized into four phases: Management of Prenatal Care; Management of Care at Birth and Postpartum; Management of Postpartum and Newborn Care; and Management of Care in the First Two Years of Life.

To observe and evaluate medical data, the Program initiated a series of indicators for each phase of care management. The data collected is passed on to health clinics and hospitals each month, reporting changes in quality of mother and child care at each location. Based on the information collected by the Program and distributed to its participants, local supervisors can evaluate team performance and help define improvement strategies.

Cases of maternal and infant death undergo a verbal autopsy process. The Program interviews families and collects all possible information from hospital and health clinic sources. This data is passed on to the Sobral Committee for Prevention of Maternal and Infant Mortality. The Committee meets on a monthly basis to discuss each death, organize necessary procedures and debate improvements to the system. The Committee identifies strong and weak points in care during pregnancy, childbirth, and infancy. Based on this, deaths are then classified according to possible avoidance and responsibility assigned (as defined by the SEADE Foundation). This information is passed on to pertinent departments and sectors.

In order to guarantee community involvement, the Four-Leaf Clover Program works with two civil society groups like the Social Mothers and Social Godparents. The Social Mothers provide support for the expectant mother and child. They are women from the community who are selected, trained, and paid to take over, when necessary, some of the domestic chores of the expectant mother or the mother of a child who is sick or otherwise needing additional help. This helps promote self-care during pregnancy and breastfeeding and appropriate assistance for children in need. The Social Mothers also provide support for sick children while they are hospitalized. There are currently 167 women who have been prepared to help in risk situations.

The Social Godparents are members of civil society who support the Program financially through a monthly contribution that goes towards food supplies for expectant and breastfeeding mothers and children with nutritional deficiencies. The Social Godparents also help procure basic supplies such as water filters, cooking utensils and clothing.

The Program has reduced infant mortality rates from 29.2 per thousand in 2001 to 18.7 in 2002. In 2003 and 2004, the rates were 23.1 and 26.3, due to a higher incidence of unavoidable causes (such as fetal malformation). Maternal deaths have fallen steadily from 83.3 per 100,000 in 2001 to 59 in 2004. Prenatal care has improved greatly; the number of women attended within their first trimester of pregnancy rose from 38% to 48% and the number of women with six or more prenatal consultations went from 59.8% to 75.1%.


  • By setting up a network of joint healthcare actions and procedures, the municipality of Sobral extended higher quality of service to more mothers and infants.
  • Actions to reduce infant and maternal mortality rates must span the first trimester of pregnancy to the end of the second year of life. This preventive approach includes not only monitoring of maternal and infant health but also home support.
  • By gathering and analyzing data on deaths within the municipality, the hospitals and health clinics can receive feedback necessary for improving care within their segment.
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