Nursing in Brazil: Trajectory, Conquests and Challenges

Historical Background

Prior to 1940

Until the 19^th century, family members, healers, and practical midwives were the primary sources of health and illness care in the home in Brazil and other Latin American countries, while religious, custodial, and philanthropic organizations delivered health care in the major cities. Early efforts to prepare personnel to care for the sick in a systematic manner were undertaken by the National Hospital for the Mentally Ill in 1890, and by the Brazilian Red Cross in 1914, 1916, and 1920.

In the early 20^th century, the growing coffee export business created a need for disease control in ports that traded with foreign countries. This resulted in a reorganization of the National Public Health Department (NPHD) in 1920. Dr. Carlos Chagas, a prominent public health physician, requested assistance from the Rockefeller Foundation. This agency established a technical mission for the development of nursing in Brazil, directed by Ethel Parsons, a nurse of The International Health Service.

The mission consisted of 31 North American nurses who analyzed the health care system and made recommendations regarding the organization of modern nursing in Brazil. Based on their recommendations, both a nursing service and a nursing school were established at the Departamento Nacional de Saúde Pública (DNSP), a national department of public health. Twenty of the North American nurses served as faculty for the nursing school, which was founded in 1923 and later named School of Nursing Anna Nery. Eleven of the nurses served in the DNSP (Fraenkel, 1997).

Ethel Parsons served during ten years in the mission, from 1921 to1931. She published an article in the American Journal of Nursing in June 1927, documenting the efforts of the technical cooperation mission to implement modern nursing in Brazil (Germano, 1997; Paiva et al., 1999).

In 1937, the School of Nursing Anna Nery was incorporated into the University of Brazil. The School developed the North American-Parsons Model which became the prototype for other nursing schools created in the country. This model was based on the Nightingale paradigm of scientific principles of hygiene and public health and a feminist perspective, and addressed political, regulatory, and economic concerns of the profession (Paiva et al., 1999).

Under Parson‘s leadership, the national association of graduated nurses, now named Associação Brasileira de Enfermagem (ABEn), was created in 1926 and affiliated to the International Council of Nurses (ICN) in 1929. Parsons participated in the ICN conference in Montreal, Canada, that year. The first Brazilian nursing journal, the Revista Brasileira de Enfermagem, premiered in 1932 as the official publication of the nurses association. Parsons also influenced the passage of the Decree no.20109/31 which regulated professional nursing practice from 1931 to 1955. The subsequent Decree no. 2604, further regulated nursing practice and education.

1940 to 1970

After 1940, a social security system of medical care shifted the focus of health care toward individualized hospital medical care, resulting in changes in nursing roles and organization. Growing hospital care needs, increasing patient complexity, and a shortage of nurses led to the creation of different categories of nursing personnel in addition to practical nurses and nurses of the armed forces. Nursing auxiliaries, who had five years of general education (equivalent to elementary school), received a one year training program from nurses before entering the nursing work force.

Applicants to nursing schools needed at least nine years of general/basic education (equivalent to junior high school). The curriculum was primarily disease-oriented, based on the medical model, with hospital-based clinical experiences. Social sciences, administration, and teaching methods for training nurse auxiliaries was included. Community nursing received little emphasis. The 36 month course of study took 3 to 4 years to complete. Physicians and other health care professionals taught the basic and clinical courses. Nurses taught the technical portion and the nursing care in each course.

After the 1960s, candidates for admission to undergraduate nursing education were required to have a 12^th grade education. This elevated nursing to the status of a liberal profession, and the nursing faculty assumed major roles in nursing education.

However, physicians continued collaborating and teaching those courses that required more specialization. Nursing schools were sponsored by both hospitals and the university system until 1972.

1970 to 1990

In the 1970s, the government‘s emphasis on technical professionals led to the development of another category of nursing personnel, the technical nurse. Candidates were admitted to an official school after eight years of general education and received nursing education in addition to basic education at senior high school level.

Due to university reform in the 1970s, applicants for admission were required to pass an admissions examination, and were placed in their professional studies according to the mean scores obtained. Candidates who did not qualify for admission to other professions such as medicine or dentistry and had indicated nursing as a lower priority would be admitted to nursing, because nursing had fewer applicants. Fortunately, this situation has changed.

University reform increased the number of nursing students and resulted in a division of the program of study into two sections, the basic and the professional components. Physicians and other health care professionals, including nurses, were hired to teach the basic courses for students. Nurse faculty taught all the professional courses. Students earned credits for courses, and were allowed flexibility in choosing courses.

The Brazilian university system established a new curriculum in 1971 that was followed for 23 years. The plan of study consisted of three sections: basic, professional and pre-specialization in areas such as community, maternal-child, medical -surgical, and pedagogical nursing.

The pre-specialization courses were optional. Such a plan of studies, in addition to biosocial basis of nursing, fundamentals of nursing, and clinical nursing, emphasized courses related to leadership and administration, teaching, and introduction to the research process. Courses in community health nursing were given each semester along with the clinical courses.

Graduate education at the master, doctoral, and clinical specialization levels expanded in the 1980s, resulting in an increase in nursing research. A National Nursing Research Seminar, sponsored by the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPQ) , National Research Council, in collaboration with ABEn, was held to evaluate current research and establish priorities for nursing research (Wright et al, 1982).

A nursing practice law was passed in the 1980s to regulate the activities of nurses, technical nurses, nursing auxiliaries, and midwives (Brasil, 1986; 1987). According to this law, nurses perform all activities in nursing care and participate actively in the health care team. Only nurses can perform activities related to direction, organization, planning and evaluation of nursing services, nursing consultation, prescription of nursing care, and activities that are complex and require scientific knowledge and immediate actions. Technical nurses can perform all activities related to nursing care excluding those that are performed only by nurses; they assist nurses in all activities, especially those related to the supervision of auxiliaries and attendants/aides. Nursing auxiliaries perform those activities related to nursing care that are simple such as those related to signs and symptoms, hygiene and comfort. Activities of nursing aides/attendants are not described in the nursing practice act. However, they do perform activities related to patients‘ hygiene and comfort, and cleaning of nursing supplies and materials.

1990 to present

A new minimum curriculum was established in 1994 after 14 years of nursing lobbying for government approval. Because of this delay, the curriculum was already outdated, and is failing to attend the societal demands of the nursing profession. Therefore, discussions are again in progress to implement changes.

The minimum curriculum eliminated pre-nursing courses, absorbing their content into the professional courses, and established an internship in the last year of study. This curriculum also proposed better integration of course content, however it maintained similarities with the previous curriculum.

The profession of nursing advanced in Brazil in the 1990s. The number of nursing journals increased from 2 in 1970 to 11 in 1990, master's programs from 8 to 15, and doctoral programs, from 3 to 8. The quality of the Brazilian publications has steadily improved and meets the criteria for nursing journals and proceedings established by the Capes Nursing Evaluation Committee (2000). The criteria for evaluating journals include indicators such as: index, editorial board, consultants, periodicity, regularity, authorship, issues/themes, and norms. The criteria for evaluating proceedings include geographical range, scope of the themes, and regularity.

The conference proceedings published by ABEn reflect a significant number of books, manuals and research articles published by nurses in the 1990s, due at least in part to the increase in nursing graduate education. The CNPq has fostered the implementation of research groups and centers in Brazilian universities, and maintains an online directory of research groups, Diretório de Grupos de Pesquisa (DGP) (www.cnpq.br/dgp.html). The DGP catalogs the research groups‘ research interests, names of the research team members, and national and international institutions that participate in the projects.

ABEn established a center for nursing research, the Centro de Estudos e Pesquisas em Enfermagem (CEPEN), which has published the Brazilian directory of nursing research and researchers since 1975, and indexes graduate dissertations and theses. ABEn/CEPEN sponsors an annual national nursing research conference, the Seminário Nacional de Pesquisa em Enfermagem.

Health Care System

Public Health Care System

The Brazilian public health care system includes government funded hospitals, clinics, and community health care agencies that provide no cost care. Since 1990, the unified health care public system, called the Sistema Unificado de Saúde (SUS), has aimed to provide primary, secondary and tertiary care at the district level, with coordination at federal and state levels.

SUS was developed as a universal system to provide access to health care services for all the Brazilian population.

Management is decentralized at state and district levels, with oversight by councils and health conferences consisting of consumers, providers, managers, and other representatives of health care workers (Antunes, 1996; Cosems-RJ, 1997). SUS strives to create better quality of life at the district level following a strategy of healthy districts proposed by Pan-American Health Organization (OPS/OMS, 1997).

Antunes (1997) noted that, while nursing has a political interest in the implementation of the SUS, reorganizing nursing practice according to this delivery system is difficult. Nursing practice is still based on providing acute care to individuals according to a disease orientation. The SUS guidelines incorporate acute care needs, but stress population-based initiatives as well. This broader concept of health proposed by the health care reformists focuses on health determinants and conditioning factors, such as food, housing, environment, work, waste control, income, education, transportation, leisure, and access to goods and services (Antunes, 1997; Brasil, 1990).

Private Health Care System

The private system of health care includes hospitals, clinics, and physicians‘ and nurses‘ offices that provide services at established costs. Such costs are covered, totally or partially, by SUS money whenever agreements are established, or by private health care plans provided by insurance companies. However, even those plans require a co-payment from the health care consumer. The private system has become one of the major options offered to a large contingent of people due to the difficult access to public services. Unfortunately, a large contingent of the population do not have the economic resources to support the costs of the private sector, and remain unassisted.

Current commentary on the Brazilian health care system points out that the principle of universality should be associated with the principle of equity, that is the right to access should be related to the availability of resources. Instead, the SUS health care according to the resources within each district, rather than the population. The Brazilian territory is very large with 160 million inhabitants. Educational, economical, and sanitary conditions vary among the 4000 districts, further complicating delivery of care.

Nursing work force

As of May, 2000, 660,584 nursing personnel of all categories were registered with the Conselho Federal de Enfermagem/Conselhos Regionais de Enfermagem (COFEN/ CORENs) (COFEN, 2000a). Of these, 87,100 (13 percent) are nurses, 91,935 (14 percent) are technical nurses, 424,071 (64 percent) are nursing auxiliaries, 57,462 (9 percent) are aides/nursing attendants, and 16 (less than 1 percent) are practical midwives.

The proportion of nursing auxiliaries has increased due to a project developed by ABEn, universities, nursing schools, and the Ministries of Labor and Education and other funding agencies to qualify nursing aides/attendants as nursing auxiliaries. Because aides/attendants do not register in COREN since the 1986 nursing practice act, their number cannot be estimated. (The number 62,309 aides/attendants refers to registrations prior to that date.)

Nursing Organizations

There are three major active nursing organization and 23 nursing specialists associations and scientific societies (Coren - SP, 2000). The nursing organizations are ABEn, COFEN/CORENs; and professional associations which also constitute the nursing unions. Another nursing organization, the Associação Brasileira de Educação em Enfermagem , was established in 1975 as a Brazilian association of nursing education but has been inactive. Issues related to nursing education are addressed by ABEn.

ABEn is is a voluntary organization composed of nurses and technical nurses. Nursing undergraduate students and nursing auxiliaries are accepted as special members. It is organized nationally through 23 state and 21 regional sections. Every section has an elected board of directors. However, all are under the direction of a national board and regulated according to the bylaws (the latest version was approved in 1994). Major decisions are submitted to the delegates‘ national assembly during the annual Brazilian nursing association conference.

ABEn has its headquarters in Brasilia, and is affiliated with: Federación Panamericana de Profissionales de Enfermeria, a Pan American federation of professionals nurses; Sociedade Brasileira para o Progresso da Ciência, a Brazilian society for science development; Sociedade Brasileira de Editores Científicos, a Brazilian society of scientific editors; and Federação Ibero Americana de Enfermagem, a Nursing Ibero American Federation. ABEn also maintains a joint working agenda with the Forum Nacional de Enfermagem, a national nursing forum composed of state nursing unions and which is affiliated with Central Única dos Trabalhadores, a workers headquarters.

ABEn collaborates with other Brazilian nursing organizations to advance the nursing profession. ABEn‘s framework is the "defense and consolidation of nursing as a social practice - essential in health care and in the organization and functioning of health care institutions" (ABEn, 2000a).

As the only nursing organization in Brazil from 1926 to 1976, ABEn faced many challenges in pioneering nursing's causes and establishing nursing as a profession.

Their achievements included the establishment of nursing practice and education regulations; the establishment of the first nursing ethical code; the creation of federal and regional nursing councils; a national research survey on the resources and needs of nursing; the construction of the headquarters building in Brasília; the promotion of scholarly discourse through journals, newsletters and directory of nursing research and researchers; the establishmentof the Brazilian Nursing Week (May 12th - 20^th); the implementation of the CEPEn; annual national conferences in which four to six thousand nurses participate; annual regional meetings and conferences; and affiliation to the International Nursing Council (ICN) from 1929 to 1995. In 1995, ABEn was replaced by COFEN at the ICN.

The COFEN/CORENs were created by federal law no. 5905/73 (Brasil, 1973) to develop and oversee norms, regulations, ethical codes, and guidelines for professional practice of nurses and other categories of nursing personnel. Therefore, professionals from different categories must register in the CORENs' state and regional councils to practice as established in the nursing practice act (Brasil, 1986).

The CORENs located in each state are subordinate to the COFEN, the national nursing council in Rio de Janeiro. COFEN is composed of nine nurse counselors and an equal number of substitutes elected by a national assembly of regional delegates. The COFEN board of directors is elected by the elected counselors in the first meeting. CORENs are composed of 5 to 21 members and respective substitutes, maintaining a proportion of 3/5 of nurses and 2/5 of other categories of nursing personnel. The members are elected by their peers in a secret and mandatory voting process according to norms established by COFEN. All nursing personnel registered at the councils are required to vote. Fees are charged in cases of no show for voting. The counselor's term is three years (Brasil, 1973).

Major accomplishments of COFEN include: federal law that regulates professional nursing practice (Brasil, 1986; 1987; 1990); national research survey on the nursing practice in health care institutions - 1982/83 (COFEN, 1985; 1986); Ethical Code for Nursing Professionals (COFEN, 1993); and the Ethical Process Code (COFEN, 1995).

COFEN establishes resolutions to regulate professional practice. Previous resolutions have included: nursing ethics committees in health care institutions; norms for registration of Brazilian and foreign nursing professionals; technical responsibility of professional nurses in health care settings; norms for establishing nursing staff/patient ratios according to acuity; norms for registration of nurse specialists; pay scales for activities performed by nursing personnel; elementary nursing activities performed by nursing aides/attendants; norms for recognizing alternative therapies as a specialty/qualification of nurses; and regulation of nursing practice in caring for women during the maternity cycle, chemotherapy, blood centers, bone marrow transplants, and radiation therapy (COFEN, 2000b).

Nursing unions started in 1962. Today there are 12 nursing unions in the country affiliated with the Federação Nacional de Enfermagem (FNE).

The purpose of the FNE is to unify nurses‘ efforts to foster appreciation of the profession and to acquire better working conditions and working relationships with other categories of health care personnel to transform society as a whole (FNE, 1999).

According to data collected by the FNE (1999) 12,669 of the country's 56,294 nurses (23%) were affiliated with the state unions in 1999. The nursing unions are located in Alagoas, Bahia, Ceará, Distrito Federal, Espírito Santo, Goiás , Pará, Pernambuco, Rio de Janeiro, Rio Grande do Sul, São Paulo, and Sergipe.

The FNE works in a joint effort with ABEn. FNE sponsors biannual national nursing union conferences, and participates in the forum of health care professionals/workers, and in the national lobbying at the Ministry of Health and National Health Council.

Nursing specialists associations/societies have existed since 1986 with the purpose of promoting clinical professional growth. The organizations are encouraged to affiliate with ABEn as institutional members in order to avoid the fragmentation of the profession. Societies affiliated to ABEn are those related to stoma therapy, continuing education, midwives and obstetrical nurses, trauma and orthopaedic nursing (ABEn, 1999). According to COREN-SP (2000), there are other associations/societies that work cooperatively with ABEn and COFEN/ CORENs but are not affiliated. Those are related to nursing scientific societies in the following areas: pediatrics, nephrology, operating room, oncology, intensive care, management, natural therapies, endoscopy, psychiatric and mental health, auditors, informatics, hemodynamics, home care, cardiovascular, image diagnostic, dermatology, parenteral and enteral nutrition, and occupational health. ABEn state sections provide physical space and logistic support to these organizations.

Educational Nursing Programs

Undergraduate Nursing Programs

In 1996, 107 nursing schools awarded baccalaureate degrees to 3,300 nurses. Even though nursing school enrollment and the number of nursing schools have increased, the number of nurses is still insufficient. Brazil has 4 nurses and 13 physicians per 10,000 inhabitants. However, there is a shortage of job opportunities for new graduates, with disproportionate distribution in bigger cities. The growth of jobs in the health care sector has decreased in recent years. In the 1970s and 80s Brazil had an annual 10 percent increase in jobs; now the increase in jobs is only 2 percent (Paiva et al, 1996).

The distribution of nursing schools in the country are as follows: 48 percent the Southeast, 21 percent in the South, 19 percent in the Northeast, 7 percent in the North, and 5 percent in the Midwest (Paiva et al, 1999, p.30). All schools are required to follow a basic curriculum established by the Ministry of Education; however, they are allowed to include other courses to meet regional needs. In addition to curriculum guidelines, the Ministry of Education developed guidelines for opening programs and for accreditation; it also developed criteria for external evaluation according to performance indicators that are widely publish by the media. This fact has created a healthy competition among schools, thus increasing teaching standards and quality of programs.

The National Federation of Nurses (FNE, 1999) recently offered several criticisms of the educational preparation of nurses. They faulted the predominance of the disease model with a focus on individual, rather than population-based, care. They called for more content in nursing management courses on the organizational aspects of the nursing process. Finally, they stated nursing education fails to account for the diversity of preparation of persons that deliver nursing care and needs to promote better integration and articulation of teaching among health care institutions.

Graduate Nursing Education and Research

Lato sensu. Lato sensu is a pre-master's level of formal graduate study that affords specialization, special training and updating. Individuals completing the program receive a certificate in a technical or specific area of study. The course of study includes a minimum of 360 hours of classes, and approval of a monograph. There is no formal evaluation of student performance to confer the specialization certification. Specialization programs are one of the levels of education for advanced nursing practice. Such program can lead to studies for obtaining a master‘s degree; however, the credits are not transferable at the master's level. Currently, undergraduate students are encouraged to pursue specialization studies after graduation in areas that are not covered in depth in the undergraduate program, such as obstetrical, pediatrics, psychiatric, intensive care, family, cardiovascular, and oncology nursing. Specialization classes are offered in both traditional and distance learning formats. Also, certificates of specialization in an area of nursing knowledge are given to those nurses who have been working in this area for more than five years, and who submit themselves to exams promoted by associations/societies (COFEN, 1994).

Graduated nurses can pursue specialization via a nursing residency in hospitals with major specialties such as cardiology or oncology. However, because those institutions are not accredited by the Ministry of Education, the certificate given can not be accepted at the universities for educational credit. There is a project that is being submitted to the National Congress which intends to regulate nursing residencies (Paiva et al, 1996).

Stricto sensu. Stricto sensu includes master's and doctoral programs that confer professional degrees. There are 15 accredited master's programs and 8 doctoral programs (M.G.R. Gutièrrez, personal communication, May 15^th, 2000). Ten of the master's programs are located in the Southeast region, two are in the South, and three are in the Northeast. Six of the doctoral programs are located in the Southeast, one in the Northeast, and one in the South. Consortium networks among universities has led to a significant increase in the number of graduates, and has strengthened the exchange of ideas and joint research among faculty.

The demand for master's-prepared nurses is primarily in schools of nursing and health care institutions, with an increasing demand from health care institutions. The demand for doctorally-prepared nurses is predominantly from schools.

Doctoral and master's programs are authorized by the Ministério da Educação/Coordenação do Aperfeiçoamento do Pessoal de Ensino Superior (MEC/CAPES) (Ministry of Education/Coordination of High Education). They must be accredited to give professional degrees. In addition, external consultants evaluate the programs every two years according to national guidelines. The CAPES evaluations, which include a summary of results, recommendations for improvement, and placement in a ranking scale that permits comparisons, are sent to all programs. The results are used by the funding agencies to allocate federal resources for education and research.

Nursing graduate programs also conduct periodic internal evaluations, and make adjustments as needed, in order to comply with the governmental requirements. One of the indicators for graduate programs, according to national guidelines for the profession, is scientific output, which is measured by its adequacy to the research focus (what in Brazil is called "lines of investigation")and publication productivity. According to Gutiérrez and Moriya (1999) nursing graduate programs should adhere to guidelines proposed by Dias (1990) which are as follows: a unifying proposal, and an integrated effort of graduate programs in formatting and searching for solutions to scientific problems of common interests which are legitimated by the scientific community.

Currently, nursing research efforts are being examined for their alignment with the lines of research established in 1982 (Wright et al., 1982) and with national/ regional priorities for health professions established by the CNPq (1999).

The themes for research that were appointed by CNPq include: poverty, social inequality , and health priorities; new diseases; the elderly; non-transmissible diseases; health and environment; impact of accidents on occupational health; health care systems and politics; science and technology in health care; and research, development, production and quality control of vaccines and medicines.

The national forum of graduate program coordinators met in Salvador, Bahia, in June, 2000 and recommended research in the areas of nursing practice, nursing profession, and organizational nursing (M.G.R. Gutièrrez, personal communication, June 20^th, 2000). Nursing practice issues identified for investigation included the nursing caring process, nursing care in the health-illness process, and determinants of the quality of life and the health-illness process. Nursing profession issues were foundations of caring in health and nursing, philosophical and theoretical conceptions in nursing and health, technologies in health and nursing, ethics in health and nursing, and nursing history. Recommended areas for research in organizational nursing included politics and practices in health, education, and nursing, work in health and nursing, management in health care and nursing services, and information systems and communication in health and nursing. These recommendations served as a basis for establishment of the following nursing research priorities in the country: caring process in individual and collective dimension; systems and health care politics and the organization of health care and nursing services; nursing as a profession: philosophy, ethics, education, history and work; and science and technology in nursing.

Ongoing Conquests and Challenges

Despite challenges, Brazilian nursing has achieved status as a profession in society, and a leadership position among other health professions. It is time for joy and hope. However, nursing must plan wisely for the future, implementing new actions and conquering new spaces (ABEn, 2000b).

Nursing's greatest challenge is to preserve the rights of the individual and to work together with communities toward a better quality of life.

Brazilian nurses face other challenges, such as developing a body of knowledge with an interdisciplinary interface; acknowledging the existence of cultural diversity; and fighting against social exclusion and marginalization of people in a working world (Gutiérrez, Almeida & Egry, 1999).

The Authors

Eloita Pereira Neves, Ph.D. RN
Email: elop@nfr.ufsc.br

Eloita Pereira Neves obtained her B.S.N in 1963, and began her nursing career at a Children‘s Hospital in Florianópolis, SC, Brazil. Four years later she started the nursing school at The Federal University of Santa Catarina and was nominated as the first Dean, and Professor of Nursing. She has taught at the master‘s and doctoral level for more than twenty years. Although she retired from this university in 1991, she continued to work there on a voluntary basis. In Brazil she obtained professional degrees in Education and Specialization in Fundamentals of Nursing, and a Master in Nursing Science degree. In the U.S.A. she obtained a Doctoral degree in Nursing Science and completed Post Doctoral studies. She has held leadership roles in nursing education, nursing research, professional organizations, and oncology nursing practice, and has served as a national and international consultant for nursing education and research. She has published extensively, and has delivered keynote addresses and presented workshops at major conferences in Brazil, London, Venezuela, and Colombia.. She has also worked as Visiting Professor in Brazil, Venezuela, and Chile, and recently was hired as Visiting Professor at State University of Rio de Janeiro. Her most recent area of interest is that of Caring/Comforting.

Maria Yvone Chaves Mauro, Ph D, RN
Email: mycmauro@uerj.br

Maria Yvone Chaves Mauro, obtained her BSN in 1958, and started her professional career working in community health and in hospitals in various cities of the State of Amazon. In 1964 she moved to Rio de Janeiro where she held leadership positions in community health care. In Brazil she obtained specialized professional degrees, as well as, master‘s and doctoral degrees in occupational health. She served as consultant to both the nursing division and the health education division at the Health Care District of Rio de Janeiro, and participated actively in the development of the health care plan for the city of Rio de Janeiro. Since 1965 she has occupied teaching positions in the undergraduate program at Alfredo Pinto Nursing School and in the undergraduate and graduate programs at Federal University of Rio de Janeiro. She retired from the later university in 1995. In 1996 she was admitted as Professor of Nursing at the State University of Rio de Janeiro where she coordinates the graduate program. She has investigated and published extensively in the area of occupational health, and has served as public health and occupational health consultant for governmental agencies and professional organizations, nationally and internationally. She has authored a book, written in Portuguese, on proposal method and its application to public health.