来自巴西的生命拯救启示 | 盖茨笔记

I’ve been a big fan of Brazil for a while. I first visited back in 1995 when Microsoft was building out our operations there, including working with one of the national banks to launch home banking. And some of my favorite family trips have been to the Amazon, whose river, basin, and rainforest come up often during conversations on climate change. But it wasn’t until I began working in public health that I started appreciating just how impressive the country’s track record in this area is—and how much the rest of the world could learn from it.

我一直是巴西的忠实粉丝。我第一次访问是在1995年，当时微软正在扩展我们在那里的业务，包括与其中一家国家银行合作推出家庭银行服务。而我最喜欢的一些家庭旅行是到亚马逊地区，其河流、流域和雨林在谈论气候变化时经常成为话题。但直到我开始在公共卫生领域工作，我才开始真正欣赏到该国在这个领域的令人印象深刻的成就，以及世界其他地方可以从中学到的东西。

In roughly three decades, Brazil has cut maternal mortality by nearly 60 percent, slashed under-five child mortality by 75 percent—far outpacing global trends—and increased life expectancy by almost a decade. None of these achievements was accidental. Instead, they’re the result of long-term, laser-focused investments Brazil has made in its primary healthcare system that other countries can learn from and emulate.

在大约三十年时间里，巴西孕产妇死亡率降低了近60%，五岁以下儿童死亡率降低了75%，远远超过了全球趋势，预期寿命延长了近十年。这些成就都不是偶然的。相反，它们是巴西对其基本卫生保健体系进行长期、专注投资的结果，其他国家可以学习和效仿。

The story starts in the late 1980s. Two decades under military dictatorship had turned Brazil into one of the least equitable countries in the world. In 1985, the country became a democracy; a few years later, it created a universal health system.

故事始于20世纪80年代末。二十年的军事独裁统治使巴西成为世界上最不公平的国家之一。1985年，巴西成为民主国家；几年后，巴西建立了全民医疗保健体系。

In the decade that followed, deaths from non-communicable diseases and maternal, neonatal, and nutritional causes all started to decline, and life expectancy rose. With an increase in primary healthcare services, even hospitalizations dropped.

在随后的十年中，非传染性疾病以及孕产妇、新生儿和营养原因导致的死亡人数都开始下降，预期寿命也有所延长。随着基本卫生保健服务的增加，住院率也有所下降。

But it’s one thing to guarantee healthcare. It’s another thing to fund it—and another thing entirely to make sure it reaches the people who need it most. While Brazil had been making progress, there was much more to do. So at the turn of the century, the government accelerated its efforts and took steps to close the gaps in its healthcare system, including a dramatic increase in healthcare spending. One of the most important steps was massively expanding the size and scope of its community health worker (CHW) program.

但确保医疗保健服务并不难，难的是为其提供资金，而确保它能够覆盖最需要的人群则更为困难。虽然巴西一直在取得进展，但还有许多工作要做。因此，在世纪之交，政府加快了努力，采取措施弥合医疗保健体系中的差距，包括大幅增加医疗保健支出。其中最重要的措施之一就是大幅增加社区卫生工作者（CHW）计划的规模和范围。

Community health workers are trained public health professionals who work within communities, especially in remote or underserved areas. While their roles vary around the world based on local needs, they generally include things like disease tracking, vaccine drives, and basic health screenings.

社区卫生工作者是训练有素的公共卫生专业人员，他们在社区中工作，尤其是在偏远或医疗保健服务匮乏的地区。虽然他们在世界各地的角色因当地需求而异，但通常包括疾病追踪、疫苗推广和基本健康筛查等工作。

In Brazil, CHWs had already shown they could improve public health access and outcomes during a pilot program in the Ceara state. As federal funding for primary healthcare increased, almost fivefold in fifteen years, the ratio of CHWs tripled.

在巴西，社区卫生工作者们在塞阿拉州的试点项目中已经显示出他们可以改善公共卫生服务的获取和结果。随着联邦对基本卫生保健的资助在15年内增加了近五倍，社区卫生工作者的比例也增加了三倍。

Today, Brazil has over 286,000 CHWs who serve almost two thirds of the population—almost 160 million people. Each one visits about 100-150 households a month, offering guidance on health and hygiene, advocating for preventive care, following up after medical appointments, collecting socioeconomic data, and helping people navigate other government services.

如今，巴西有超过28.6万名社区卫生工作者，为近三分之二的人口（近1.6亿人）提供服务。每名工作人员每月走访约100-150户家庭，提供健康和卫生指导，倡导预防保健，在就诊后进行跟踪，收集社会经济数据，并帮助人们了解其他政府服务。

In Brazil, CHWs act as the front door to the world’s largest universal free public healthcare system, and their impact has been transformative. They’re credited with further cutting child mortality and pushing immunization coverage to near-universal levels. (Unfortunately, the pandemic impacted vaccination rates, but there are efforts underway to bring them back up.)

在巴西，社区卫生工作者活跃在世界上最大的全民免费公共医疗保健体系的第一线。他们的影响是变革性的。他们进一步降低了儿童死亡率，并将免疫接种率提高到接近普及的水平。(不幸的是，大流行影响了疫苗接种率，但正在进行努力恢复。）

The country’s Bolsa Familia program—which provides cash transfers to poor families if they meet certain conditions, including vaccination for children and prenatal care—deserves credit too. Expanded in tandem with primary healthcare, Bolsa Familia is just one of the many social programs Brazil has built out over the past few decades that have helped lift almost a fifth of the country’s population out of poverty. But it’s also helped broaden healthcare access and usage by giving people an incentive to enter the healthcare system—which is how Bolsa Familia has contributed to reductions in child mortality as well.

该国的“家庭补助计划”（Bolsa Familia）也同样值得称赞，该计划向符合特定条件的贫困家庭提供现金补助，包括儿童疫苗接种和产前护理。与基本卫生保健同步扩大，家庭补助计划只是过去几十年来巴西建立的众多社会项目之一，这些项目帮助巴西近五分之一的人口摆脱了贫困。但它也通过激励人们加入医疗保健体系，帮助扩大了医疗保健获取和使用范围——这也是家庭补助计划对降低儿童死亡率的贡献所在。

I’ve been able to learn about these initiatives through the Gates Foundation's partnership with Brazil's Ministry of Health—which has focused on combatting malaria, improving vaccine production, leveraging local brainpower to address global health issues, and documenting the impact of social and health programs through data sciences. And I’ve been really impressed.

通过盖茨基金会与巴西卫生部的合作，我了解到了这些项目，其重点是抗击疟疾、提高疫苗产量、利用当地人才解决全球健康问题，以及通过数据科学记录社会和健康项目的影响。这给我留下了深刻印象。

Of course, despite all the progress that’s been made in recent decades, Brazil still faces challenges. Financial crises and austerity budgets have led to cuts in healthcare spending, for example, and there are still districts where poorer residents have no access to CHWs.

当然，尽管在过去几十年取得了很多进展，巴西仍然面临挑战。例如，财政危机和紧缩预算导致了医疗保健支出的削减，仍然有一些地区的贫困居民无法获得社区卫生工作者的服务。

But Brazil’s healthcare system doesn’t have to be perfect to serve as proof of what happens when a country invests strategically in care for its most vulnerable: The returns are often far-reaching and life-changing. 

但是，巴西的医疗保健体系并不一定要完美无缺，它可以证明当一个国家对其最弱势群体的医疗保健进行战略性投资时会发生什么：回报往往意义深远，改变生命。

That is why Brazil is highlighted by the Exemplars in Global Health program, which I helped launch in 2020. The program's mission is to identify countries that have made remarkable progress on health problems, understand the keys to their success, and share those insights globally so others can make similar progress. By that standard, Brazil has a lot to teach.

这也是我在2020年帮助发起的“全球健康典范”计划重点关注巴西的原因。该计划的使命是找出在解决健康问题上取得显著进步的国家，了解其成功的关键，并在全球范围内分享这些见解，以便其他国家也能取得类似的进步。按照这个标准，巴西有很多值得学习的地方。

That’s not to say any country can or should replicate Brazil’s approach exactly, since no two countries are alike. But with the right mix of investment and innovation, Brazil has made great strides in becoming a healthier place for its people. If the country continues on that path and keeps doing what it’s done well already, and if other countries follow—or simply forge their own paths with Brazil in mind—we’ll have a healthier world, too.

这并不是说任何国家都可以或应该完全照搬巴西的做法，因为没有两个国家是相同的。但在投资和创新的正确结合下，巴西在让其人民更健康方面取得了巨大的进展。如果巴西继续沿着这条路走下去，继续做它已经做得很好的事情，同时，如果其他国家也能效仿——或者直接以巴西为蓝本开辟自己的道路——我们也将拥有一个更健康的世界。